Primary Care and ACOs: From Medical Homes

to Medical Neighborhoods

National ACO Congress November 2, 2011

David Nace, MDMcKesson Corporation/Relay Health

Patient Centered Primary Care Collaborative

Kevin Grumbach, MDUCSF Department of Family and Community Medicine

PatientPatient

Health Care: A Perilous Journey*Health Care: A Perilous Journey*

OrthopedistCardiologist

Radiologist

Gastroenterologist

Chestpain

Stomach

Ache

Knee

ache

Physical Therapist

SNF

*From Tom Bodenheimer, NEJM 2008;358(10):1064

The Delivery System Reform Imperative

•

Patients need–

A medical home

•

High performing, patient-centered primary care

–

A cohesive medical neighborhood•

Care integrated across the diverse components of the health delivery system

Primary Care: The Cardinal 4 C’s

first ContactComprehensive

Continuity

Coordination

–

“Ample research concludes in recent years that the nation’s over

reliance on specialty care services at the expense of primary care leads to a health system that is less efficient…research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings.”

But the Primary Care Foundation in 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

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$450,000A

nnua

l Inc

ome

Year

The Widening Physician Payment Gap

Diagnostic Radiology

Orthopedic Surgery

Primary Care

Family Medicine

Source: Robert Graham Center

Partly a Payment Issue

Partly a Systems Issue

•

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)

Tom Daschle, Health Policy Advisor to Barack Obama, testifying to Senate Health Committee, Jan 2009: “Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out.”

3°

Care

1°

Care

2°

Care

3°

Care

2°

Care

1°

Care

… “We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”

Senator Orrin Hatch Senate 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?”

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 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

•

Health professionals

The Patient-Centered Primary Care Collaborative

ACP

Providers 333,000 primary care

Purchasers –Most of the Fortune 500

Payers Patients

AAPAAFP AOAABIM ACCACOI AHI

IBM Goodyear

General ElectricFedEx

Microsoft

Dow

StatesBusiness Coalitions

BCBSAUnited

Aetna

CIGNAHumana

WellPoint

Kaiser Permanente

AARP AFL-CIONational Consumers LeagueSEIUFoundation for Informed Decision Making

> 800 Members with Broad Stakeholder Support & Participation

The Patient-Centered Medical Home 80 Million lives

14

Geisinger

McKesson

Where we are and why primary care mattersUS Healthcare system 

fraught with issues

Uncontrollable Spending  $2.4 trillion (17% of GDP)

Low Quality compared with EU 

Counterparts

Poor Access to PCPs  Due to worsen in 2014 with expansion of Medicaid and Exchanges

Below average Population 

Health judged by life expectancy 

and mortality rates

PPACA and ARRA legislationQuality Reporting InitiativesValue Based Reimbursement Patient Centered Medical HomeEHR/HIE InvestmentDisease Management PilotsAlternate Care SettingsPatient EngagementCare Coordination PilotsHealth Insurance ExchangesTop of License PracticeTelemedicine Pilots

Many experiments underway in an 

attempt to improve system

Primary Care has the single‐most 

ability to deliver the quality, cost 

and population health ambitions 

embedded within the IHI’s Triple 

Aim

Primary Care centric projects 

have proven results

Government financial crisis, an aging population, an already‐high and growing incidence of chronic disease and an expanding  

physician shortage (primary care and specialists) only make matters worse

15

The primary care environment 

Active Physicians in the United States

2008 2018All Physicians 661,400 805,500Primary Care (32%) 211,648 257,760

Sources: US Bureau of Labor Statistics, Health Care Advisory Board

Current State of Primary Care

*CDC, CMS, HD and AF Analysis

Source: Health Care Advisory Board

Solo Practice (32%)

3‐5 Physicians (32%) Two Physicians 

(14%)

6‐10 Physicians (11%)

11+ Physicians (7%)

Upwards of 75% of PCPs are in practices with fewer 

than five physicians

Total PCP Revenue* $131,504,945,024

Total Healthcare Costs $2,400,000,000,000

PCP Spend as % of NHE 5.48%

Economics driving PCP shortage and trend toward employment

16

Primary care today is reactive, focused on acute                 care and fragmented, leading to high costs and low quality

17

Rates for NAMCS/NAHMCS data from Pitts, Health Affairs 29, no 9 (2010) Where Americans Get Acute Care: 

Increasingly it’s not at their doctor’s office (NAMCS data, ‘initial visit’

identifier; applied to 2008 NAMCS data; UCC: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685126/#B5;  Estimates of % of acute care visits for UCC and RCOnline data from Manhatan research, Social Media from Pew

“Primary care”

visits by provider in the US ‐

2008

Source: Binns et al, Ann Fam Med 

2007;5:39‐47. 

Describing Primary 

Care Encounters

PCPUrgent Care 

Center ED  Specialist Outpatient 

Clinics  Retail Clinic 

Total Visits 

2008 490M 142M 124M 466M 110M 4M

FFS‐based reimbursement  ‐ incentivizes primary care physicians (PCPs) to spend nearly 50% of their time providing reactive, acute care; leading to inappropriate preventive and chronic care

Primary Care is fragmented, provided at many different sites, not connected or coordinated; leading to inappropriate utilization and duplication of services

History of the Medical Home concept

American Academy of Pediatrics (1967) – first documentation of the “medical home” ‐ One central source of a child’s pediatric records”History of the Medical Home Concept Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba Pediatrics 2004;113;1473‐1478

Patient Centered – introduced by the Institute of Medicine

Karen Davis (Commonwealth Fund) – urges adoption of the Danish model of the Patient Centered Medical Home  

18

Joint principles of the Patient‐Centered  Medical Home (2007) 

The following principles were written and agreed upon by the four Primary Care 

Physician Organizations – the American Academy of Family Physicians, the 

American Academy of Pediatrics, the American College of Physicians, and the 

American Osteopathic Association.

Principles:

Ongoing relationship with personal physicianPhysician directed medical practiceWhole person orientationCoordinated care across the health systemQuality and safety Enhanced access to carePayment recognizes the value added

19

Patient-Centered Primary Care A Foundational Component of Accountable Care

1st contact care for health that is continuous, comprehensive & coordinated

across care continuum

Adoption of innovations such as electronic information systems

Population-based management of chronic illness

Focus on delivering evidence-based medicine

& continuous quality improvement

Extended access

to care e.g., after hours/weekends, email, other tech media

PCMH

Improving access to primary care has positive resultsPreventive care increases Immunization rates improve

ER visits & hospitalization decline Health care costs decrease

20

Case Study: 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

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

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

From Medical Homes to Medical Neighborhoods

•

High performing primary care necessary but not sufficient

•

Accountable Care Organizations as an approach to integrated medical neighborhoods

The Concept of Integrated CareIntegrated Care

•

Ann Beal, Aetna Foundation:–

“

Integrated health care starts with good primary

care and refers to the delivery of comprehensive health care services that are well coordinated with good communication among providers; includes informed and involved patients; and leads to high-quality, cost-effective care. At the center of integrated health care delivery is a high-performing primary care provider who can serve as a medical home for patients.”

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

What is Accountable Care?

Accountable care requires physicians to change how they deliver care

and to work with other providers and payors in collaborative ways

Significant care coordination between providers caring for a patientAbility to collect and share information across care givers and patientsPerformance transparency across the system and stakeholdersShifting to a primary focus on patient health & care outcomes rather than on transactions/intensity of services

Accountable care is a term that is often a proxy for the desired outcome of health reform efforts: high quality care at the best possible cost

Key Elements to Achieve Accountable Care

30

Health IT Framework

Accountable Care and PCMHTwo Sides of the Same Coin

PCMH

PCMH

PCMH

PCMHHospitals

Public Health

Community Care TeamCare CoordinatorCase Managers

Behavioral Health SpecialistCommunity Health Workers

Specialists

A Coordinated Health System

PCMH

PCMHs require resources that enable care coordination, includingAdequate primary care workforceHealth information technologyInnovative team-based care coordination models with appropriately-trained staffPayment models that compensate PCMHs for care coordination activities that fall outside the in-person, patient visit

PCMH Have a Critical Role in Care Coordination in ACOs

Care Coordination An Essential Function of Accountable Care

Targeted care coordination may involve assigning a care coordinator to specific cases, including face-to-face patient contact

Care coordination using team-based primary care models has been shown to improve health outcomes and/or reduce hospitalizations, readmissions and costs

Care coordination using team-based primary care models has been shown to improve health outcomes and/or reduce hospitalizations, readmissions and costs

33

Health Information Technology Enabling Practice Transformation

To support PCMH (practice) and ACO (enterprise) practice transformation, an interconnected HIT network with key capabilities acts to optimize

engagement and coordinate care

HIT as an enabler of Access, Care Coordination, and Care Integration

A foundational shift in Health Information Technology (HIT) must occur in order to drive widespread adoption of the Patient Centered Medical Home (PCMH) model, and support the Accountable Care Organization (ACO)

- “Better to Best : Value Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations”, March 2011, Health2Resources, Washington, D.C.

What we are now learning……

System Level Interventions to Enhance Integration

•

eReferral in the San Francisco General Hospital clinic system as an example of a disruptive HIT-enabled innovation to promote a better functioning medical neighborhood

San Francisco General HospitalSan Francisco General Hospital

Reengineering Specialty Referrals at SFGH

•

EHR-embedded “eReferral”

system

•

Home grown product developed by SFGH- UCSF gastroenterologist, Hal Yee, MD,

expanded by Alice Chen, MD, Gen Int Med

•

Chen AH, Kushel, Yee, Grumbach. Health Affairs 2010 May;29(5):969-71.

Description of eReferral____________________________

•

HIPAA compliant web-based referral system–Linked to EHR, with auto-

population of relevant EHR data –Free text referral questions–Mandatory use for enrolled specialty

clinics and certain imaging studies

Description of eReferral____________________________

•

Individualized review and response by specialist–

Specialists can: •

Request clarification of question or additional work-up prior to specialty appointment

•

Provide information for PCP management of condition, with or without an appointment

•

Overbook appointment if clinically warranted–

Ability for iterative communication between referring and reviewing clinicians

Improved Timing of Consultations Resulting in Reduced Waiting Times

for Specialty Visits

Scheduled30%

Overbooked40%

Not Scheduled

30%

eReferral Evaluation: Specialists____________________________

Ingredients in Success of eReferral at SFGH

•

Mixed payment model (Medicaid, Medicare fee for service payments + block funding from City for uninsured)

•

Capacity constrained system•

Network-wide EHR

•

Culture of collaboration, multispecialty medical group

Regional HIE Collaboration Northern California Market

Six Health Organizations Collaborating in the SF Bay Area

•Over 3,000 connected physicians

•Over 1,000,000 connected patients

•More than 150,000 actively connected individuals

•Providers and hospital information exchange

•Reference lab collaboration

•Coordinated care across community

•Interoperability with 5 different vendors (Cerner, GE, NextGen, McKesson, Dynamic Business Solutions)

44

SpecialtyProviders

Primary Care Providers

Consumer PHRs

Loca

l Clin

ical

Inte

grat

ion

Loca

l Clin

ical

Inte

grat

ion

Reg

iona

lly C

onne

cted

Reg

iona

lly C

onne

cted

Patient Centric Platform

HospitalsHospital Lab & Radiology Centers

Home Health Services

Community Labs

Nat

iona

lly C

onne

cted

Nat

iona

lly C

onne

cted

Payers

NHIN

Regional Health Systems

State RHIOs

Patients

Extending from the Practice ……. to the Community

45

46

Internet based networks can deliver immediate value through a patient-centered strategy

Patient centricity is a paradigm shift, that can catalyze structural changes in the delivery system…….

11/1/2011 46

Patient Centricity Critical to Driving Value

PCMH is foundational for Patient Centered ACO’s

Source: Premier Healthcare Alliance 47

4 Key Pillars of Competency

I. Consumer Engagement and PCMHthe ability to actively engage patients in their care process, provide patients with access to their pertinent information, and enable a range of personal health management and health information tools.

II. Analyticsthe ability to identify and stratify populations for management, manage cost and quality, address PMPM spend, generate and act upon care gaps, understand and optimize provider performance, and support stakeholder and regulatory reporting.

III. Care Managementthe ability to leverage evidence based decisions in the delivery of care, create efficient and effective utilization management programs, and establish an integrated medical management workflow system for utilization and disease management.

IV. Financial Managementthe ability to leverage analytics to define and support care bundles and identify network / provider efficiency in preparation for undertaking bundled payment and support for additional payment mechanics.

48

The Medical Home financial rewards model

FEE FOR SERVIC E

PAY FOR PERFORMANCE

(BONUS)

SHARED INCENTIVES

FOR MEDICAL NEIGHBORHOOD

PATIENT CENTERED MEDICAL HOME ---- ACCOUNTABLE CARE ORGANIZATION

CARE MGMTFEE

(PMPM)

49

The Challenge to PCMHs and ACOs

• PCMHs - Expand care teams, conduct non-visit based care coordination, utilize health IT, focus on assuring needs assessment, goal setting, and respecting patient values and preferences

• ACOs - Invest in a solid foundation of primary care, build an HIT infrastructure, focus on care integration and care transitions, align governance and incentives to hold members of the medical neighborhood accountable to each other

Questions