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Transcript of Reform and Renewal of Primary Care New York City Research and Improvement Networking Group...
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