Reform and Renewal of Primary Care

New York City Research and Improvement Networking Group Convocation September 11, 2012

Kevin Grumbach, MDDepartment of Family & Community Medicine

University of California, San Francisco

San Francisco San Francisco General HospitalGeneral Hospital

Cardinal Attributes of Primary Care as Defined by Barbara Starfield

first ContactComprehensive

Continuity

Coordination

Primary Care Is a Really Good Thing

Patient Attitudes Towards Primary Care Physicians

% Agree

% Disagree

% Don’t Know or Uncertain

Value having one PCP

94

2

4

Helpful for PCP to participate in decision to see specialist

89 3 8

Source: Grumbach. JAMA, 1999;282:261

Percentage of Office Visits Accordingto Physician Specialty, By Primary Dx

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

HTN DM ASCVD COPD

Generalist

Specialist

Source: L Green, Analysis of 1996 Natl Amb Med Care Survey

Mean % of Preventive Services Received

42%

70%

81%

57%

85%90%

0%

20%

40%

60%

80%

100%

No Regular Place Regular Place Regular Place andOptimal Primary Care

UninsuredInsured (Medicaid or private)

Source: Bindman, J Gen Int Med 1996;11:269

B

A

EDF

C

Outcomes of Patients with Specialists or Generalists as a Regular Physician

1.0 1.0

0.77 0.81

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Annual Costs 5 Year Mortality

Rel

ativ

e D

iffe

renc

e

SpecialistGeneralist

Source: Franks & Fiscella, J Fam Pract 1998;47:105. Data from 1987 NMES, adjusted for health status, insurance, and other covariates

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Primary Care Strength and Premature Mortality in 18 OECD Countries

*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.

Source: Macinko et al, Health Serv Res 2003; 38:831-65.

Year

High PC Countries*

Low PC Countries*

10000

PYLL

1970 1980 1990 2000

0

5000

But the Primary Care Foundationin the US is Crumbling

• Plummeting numbers of new physicians entering primary care and burnout among PCPs

• Growing problems of access to primary care and “medical homelessness”

• Dysfunctional systems that are not delivering the goods in primary care

Bodenheimer T. N Engl J Med 2006;355:861-864

Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

Bodenheimer T. N Engl J Med 2006;355:861-864

Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

Dr. Katherine J. Atkinson of Amherst, Mass., has a waiting list for her family practice; she has added 50 patients since November.

In Massachusetts, Universal Coverage Strains Care 

April 5, 2008

Partly a Payment Issue

The Widening Physician Payment Gap

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$450,000

Year

An

nu

al In

com

e

Diagnostic Radiology

Orthopedic Surgery

Primary Care

Family Medicine

Source: Robert Graham Center

Ebell, M. H. JAMA 2008;300:1131-1132.

Percentage of Positions Filled With US Seniors vs Mean Overall Income By Specialty

Partly a Medical Education and Medical Culture Issue

FP

Partly a Systems Issue

The New Math of the 15 Minute The New Math of the 15 Minute Primary Care VisitPrimary Care Visit

• A primary care physician with a panel of 2500 average patients would spend:

– 7.4 hours per day to deliver all recommended preventive care [Yarnall et al. Am J Public Health 2003;93:635]

– 10.6 hours per day to deliver all recommended chronic care services [Ostbye et al. Annals of Fam Med 2005;3:209]

Percent of Primary Care Physicians Reporting After-Hours Arrangement to See Doctor or Nurse Without Going to an ER

29%

50%43%

78%

97%89%

0%

20%

40%

60%

80%

100%

US Australia Canada France Netherlands UK

Source: C Schoen et al,  Health Affairs, 28, no. 6 (2009): w1171-w1183

The Choice

• Redesigned primary care model with team-based practice

• Concierge Medicine

The Primary Care Reform Compact

• To Payers, purchasers, the public: – Invest a greater share of health care resources in

primary care to strengthen the primary care workforce and enhance primary care performance

• To Primary care physicians and clinicians:– Embrace innovation, new models of care, and greater

patient-centeredness in return for more investment in primary care

A 20th Century Model of Primary CareWill Not Meet the Demands of 21st

Century Health Care

Joint Principles of the Patient Centered Medical Home

February 2007

American Academy of Family Physicians American Academy of Pediatrics American College of Physicians

American Osteopathic Association

Transforming the Delivery of Transforming the Delivery of Primary Care:Primary Care:

The Patient Centered Medical HomeThe Patient Centered Medical Home• Rittenhouse & Shortell: 4

Cornerstones of the PCMH• Primary Care

– first Contact (access)– Comprehensiveness– Continuity– Coordination

• Patient-Centered• New Model Practice• Payment Reform

Building Blocks of high performing primary care practces

Rachel Willard Tom Bodenheimer Amireh Ghorob

UCSF Center for Excellence in Primary Care

Mission and goals

Data-driven improvemen

t

Empanelment

Team-based care

1 2 3 4

5

Populationmanageme

nt

Continuity of care

Prompt access to

care

Template transformat

ion

Coordination of care

Conscious and

trained leadership

6 7

8 9

10

http://www.chcf.org/publications/2012/04/building-blocks-primary-care

The Multistakeholder The Multistakeholder Movement for Renewal and Movement for Renewal and

Reform of Primary CareReform of Primary Care

• Large employers/private purchasers

• Consumers/patients/the public

• Government

July 6, 2009

Randy MacDonald, Sr VP House Ways and Means Hearing April 29, 2009

• “I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -- transform it and pay differently using a model like the Patient Centered Medical Home.”

• Congressman: “And the second issue?”

• “Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue.”

The President Wants More and Stronger

Primary Care

“It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies.  How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors

Senator Orrin HatchSenate Finance Committee Roundtable

Reforming America’s Health Care Delivery System April 21, 2009

“The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?”

Affordable Care Act:Measures to Revitalize Primary Care• Physician payment reform

– Medicare fees

• Infrastructure investment and facilitating practice redesign– CMS Innovations Center– Medical Home pilot programs– Primary Care Extension Program– ARRA HIT incentives and TA

• Training pipeline– NHSC– Primary Care Training Grants

Case Study of Group Health Cooperative of Puget Sound

• Patient Centered Medical Home model piloted at one site in 2007– Avg PCP panel size reduced from 2327 to 1800– Longer face-to-face visits and scheduled time

for phone and email encounters– Increased team staffing and teamwork– HIT– Panel management

Group Health PCMH Pilot:Controlled Evaluation 12 Month Outcomes

• Improved continuity of care• Better patient experiences (6 of 7 measures)• Better composite quality of care score• Reductions in ED visits and Ambulatory

Care Sensitive Hospitalizations• No difference in total costs at year 1 (lower

total costs by year 2)

Source: R Reid et al. Am J Managed Care 2009;15:e71

Group Health PCMH Pilot:Effect on Clinic Staff

30.0%

34.5% 33.3%

9.7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Control Sites PCMH Site

Percent with High Level Emotional Exhaustion

Baseline12 Months

p=.02

Team-based Care: Stable Teamlets

Patientpanel

1 team, 3 teamlets

Clinician/MAteamlet

Patientpanel

Clinician/MAteamlet

Patientpanel

Clinician/MAteamlet

Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager

SFDPH Primary Care Provider Satisfaction with Teamsn=135

Teamlet (work with same Teamlet (work with same MA) (n=27)MA) (n=27)

Team (work with group of Team (work with group of MAs) (n=90)MAs) (n=90)

No teams (work with No teams (work with different MAs) (n=18)different MAs) (n=18)

SFDPH Primary Care Provider Burnout by Team ModelMaslach Burnout Inventory, n=86-87

SFDPH Primary Care Provider Confidence in Panel Management: Cancer Screenings, n=129

Teamlet (work with same MA) (n=26)

Team (work with group of MAs) (n=88)

No teams (work with different MAs) (n=15)

Provider confidence that cancer screening will be done through panel management, by team model

http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Review of Recent Evidence on PCMH Outcomes

• 14 different initiatives – >1 million patients, 1000s of medical practices– 5 Integrated delivery systems

• Group Health, Geisinger, HealthPartners, Intermountain, VHA

– 3 Private health plan sponsored initiatives• BCBS South Carolina, BCBS North Dakota, Metropolitan Health

Networks Florida

– 2 Medicaid state initiatives• North Carolina, Colorado

– 4 Other models

Examples of Cost Outcomes

• Group Health Cooperative: 5% ↓ $PMPM• Geisinger: 7% ↓ $PMPM• VA: $593 ↓ cost per patient with COPD• BCBS South Carolina: 6.5% ↓ $PMPM• Metropolitan Health Networks: 20% ↓ $ per patient• North Carolina Medicaid/SCHIP: Cumulative

savings of $974.5 million over 6 years (2003-2008)• Colorado Medicaid: $215 ↓ cost per child per year

Hospital Payer

Other

Caregivers

Pharmacies

Nurse

Specialists

Social Worker

PCMH

Primary Care Team

Patient

Workplace

Home and

Family

Patients Need a Good Home and a Good Neighborhood

Community

Challenge to Family Medicine Culture

George Saba et al. The Mythology of the Lone Physician: Towards a Collaborative Alternative. Ann Fam Med (March 2012).

From “Me” to “We”• “We will need to assemble systems in which

physicians can build satisfying work relationships with staff and patients and feel supported in sharing responsibility for health outcomes. In place of the currently dominant “silo” training, we will need to foster interprofessional education about collaborative communication and team building skills. Expectations for role, competence, satisfaction, and success will need to change.”– G Saba et al., The mythology of the lone physician.

The Shared Predicament of Family Farmers and Family Doctors

• Reductionistic paradigm vs whole food/whole person care

• Generalism and biodiversity• Sustainability and resource stewardship vs

resource exploitation• Agribusiness and the Medical Industrial

Complex• Tax subsidies and price distortions

Michael Pollan’s Guide to Nutrition

• Eat food

• Not too much

• Mostly plants

Kevin’s Guide to Health Care

• Get medical care

• Not too much

• Mostly primary care