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The Foundation for Reenginering
Healthcare
Patient Centered Medical Home
Paul Grundy MD, MPH
IBM‘s Director Healthcare Transformation
President Patient Centered Primary Care Collaborative
Paul Grundy MD MPH Bio
•
•
•
•
•
•
•
•

“Godfather” of the Patient Centered Medical Home
IBM Global Director Healthcare Transformation
President of PCPCC
Member Institute of Medicine
Member Board ACGME
Professor Univ. of Utah Department Family Medicine

Winner NCQA national Quality Award
A Leader of MOH level taskforce primary care transformation 8
nations: USA, Canada, New Zealand, Australia, Holland,
Denmark, UK, Belgium,
• Univ. of California MD, John Hopkins Trained
Away from Episode of Care to Management of Population
Hospital

Population
Health

Per
Capita
Cost

System Integrator
Patient
Experience

Public Health

Community Health
The System Integrator
Creates a partnership across the
medical neighborhood
Drives PCMH primary care redesign
Offers a utility for population health
and financial management
Smarter Healthcare
36.3%
Drop in hospital days
32.2%
Drop in ER use
12.8%
Increase Chronic Medication use
-15.6%
Total cost
10.5%
Drop Inpatient specialty care costs
18.9%Ancillary costs down
15.0%Outpatient specialty down

Outcomes of Implementing Patient Centered Medical
Home Interventions: A Review of the Evidence from
Prospective Evaluation Studies in the US - PCPCC Oct 2012
Rural New York
• Commercial/ASO insurance cost decreased
from $380 per-patient-per-month in 2009 to
$316 in 2012
• Costs for Medicaid patients dropped from $334
to $266, according to a recent “risk adjusted”
analysis.

http://poststar.com/news/local/medical-home-program-gains-traction/article_5811380c
PCMH Lower Costs
Aug 5th 2013 Pennsylvania
• 44% reduction in hospital costs
• 21% reduction in overall medical costs.
• 160 PCMH practices Pennsylvania from 2008 to 12
• Number of patients with poorly controlled diabetes
declined by 45%.
Jeffrey Bendix

modernmedicine.com/
I reland feb  2014
PCMH Michigan –
Aug 11th 2013
• 19.1% lower rate of adult hospitalization.
• 8.8% lower rate of adult ER visits.
• 17.7% lower rate ER visits (children under age 17)
• 7.3% lower rate of adult high-tech radiology usage
VS other non-PCMH designated primary care
physicians.

3,017 Physicians
. Medical home physicians help patients avoid ERs
and admissions by evening hour appointments,
weekend and same-day appointments

http://www.crainsdetroit.com/article/20130811/NEWS/308119989/blue-cross-touts-155-million-in-savings-with-medical-home-project
WellPoint PCMH Preliminary Year 2 Highlights In Sept
Issue Health affairs 2012
•
•

15% decrease in total ER visits/1000, compared to
4% increase in control group

•

Specialty visits/1000 remained around flat
compared to 10% increase in control group

•

Colorado

18% decrease in acute IP admissions/1000,
compared to 18% increase in control group

Overall Return on Investment estimates
ranged between 2.5:1 and 4.5:1

NEW HAMPSHIRE

New York
Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement

Source: Hudson Valley Initiative
TODAY’S CARE

PCMH CARE

My patients are those who make
appointments to see me

Our patients are the population
community

Care is determined by today’s
problem and time available today

Care is determined by a proactive plan
to meet patient needs with or without
visits

Care varies by scheduled time and
memory or skill of the doctor

Care is standardized according to
evidence-based guidelines

I know I deliver high quality care
because I’m well trained

We measure our quality and make
rapid changes to improve it

Patients are responsible for
coordinating their own care

A prepared team of professionals
coordinates all patients’ care

It’s up to the patient to tell us what
happened to them

We track tests & consultations, and
follow-up after ED & hospital

Clinic operations center on meeting
the doctor’s needs

A multidisciplinary team works at the
top of our licenses to serve patients
11

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
• 1/3 less cardiac intervention needed
• 60% less complication Diabetes
FFM-2 Feb 2014
• 1. Pursue Electronic Patient Management and
engagement rather than Electronic Patient Records
• 2. Bring to bear upon every patient encounter what is
known rather than what a particular provider knows.
• 3. Make it easier to do it right than not to do it at all.
• 4. Continually challenge providers to improve their
performance.
• 5. Infuse new knowledge and decision-making tools
throughout an organization instantly.
• 6. Establish and promote continuity of care with
patient education, information and plans of care.
• 7. Enlist patients as partners and collaborators in
their own health improvement.
• 8. Evaluate the care of patients and populations of
patients longitudinally.
• 9. Audit provider performance based on the
Consortium for Physician Performance Improvement
Data Sets.
• 10. Create multiple case-management tools which are
integrated in an intuitive and interchangeable fashion
giving patients the benefit of expert knowledge about
specific conditions while they get the benefit of a
global approach to their total health
Build your own corporate PCMH
$805 $804
$765

Per Employee Per Month
Health Costs
Post Implementation

Actual client data: Midwest Hospital
with 12,135 employees 1 year selffunded for group health

17

$569

Copyright 2011 by IBM
“We do the best
heart surgeries.”
Defining the Care Centered on Patient
Superb Access
to Care
Patient Engagement
in Care
Clinical Information
Systems, Registry
Care Coordination

Team Care

Communication
Patient Feedback
Mobile easy to use
and Available
Information
OPM Carrier Letter Feb 5th 2013
Patient Centered Medical Homes (PCMH) within the
Federal Employees Health Benefits (FEHB) Program
• A growing body of evidence supports investment in

PCMH – SO we are!!

• there must be a plan for all FEHB lives
enrolled in the practice to be included in a reasonable
timeframe.

• ACA 2334
USA 2012

Ogden, Ut
I reland feb  2014
MobileFirst Patient Consumer
Remaking Blood Chemistry - continuously test
hundred different samples,
40% of today’s blood
MobileFirst Remote Sensing

Mobile Sensing emotion for mental health status -- analyzes facial expressions
Mobile Sensing position for asthma -- integrates GPS into inhalers
Mobile Sensing motion for Alzheimer’s -- monitoring gait
Mobile Sensing ingestion of medications. activated by stomach fluid

Mobile Sensing for sleep disorders -- tracks breath, heart rate, motion
Mobile Sensing for diabetes. continuous monitoring iPhone non invasive sensor.
Mobile Sensing for readmission prevention -- BP, weight, pulse, ekg
Mobile Sensing for exercise wellness -- benefit design feedback
Practice transformation away from episode of care
Master Builder
Preventive
Medicine

Chronic Disease
Monitoring

Medication
Refills

Acute Care

Test Results

DOCTOR

Master Builder

Case
Manager

Behavioral
Health

Medical
Assistants

Nursing

Source: Southcentral Foundation, Anchorage AK
PCMH Parallel Team Flow Design
The glue is real data not a doctors Brain
Chronic
Disease
Monitoring
Medication
Refills

Healthcare
Support
Team

Point of
Care Testing

Acute
Care
Test
Results

Case
Manager

Preventive
Medicine

Clinician
Provider

Chronic
Disease
Compliance
Barriers

Acute
Mental
Health
Complaint

Medical
Assistants

Behavioral
Health

Source: Southcentral Foundation, Anchorage AK
Healthcare will Transform
• Data Driven
• Every patient has a plan
• Team based
• Managing a Population
Down to the Person
Payment reform requires more than one method, you
have dials, adjust them!!!
“fee for health”
fee for value
“fee for outcome”
“fee for process”
“fee for belonging
“fee for service”
“fee for satisfaction”
New $ Dials
• Complex Chronic Care Management payment
codes. authorize payments to physicians for the
work that goes into managing complex patients
outside of their actual office visits.
• House Energy and Commerce Committee Bill
repeals SGR moving Medicare payments away
from FFS toward new, innovative models.
•
Benefit Redesign - Patient Engagement Different Strategies for
Different Healthcare Spend Segments
Those with
severe, acute
illness or injuries

Those with
chronic illness

% Total
Healthcare
Spend

Those who are well or
think they are well

% of Members
29
29
PCMH 2.0 in Action
A Coordinated
Health System
Hospitals
PCMH

Specialists

Community Care Team
Nurse Coordinator
Social Workers
Dieticians
Community Health Workers
Care Coordinators

PCMH Public Health Prevention
HEALTH WELLNESS

Public Health
Prevention

35

Health IT
Framework
Global Information
Framework
Evaluation
Framework
Operations

Copyright 2011 by IBM
FFM_2
• Practices Features -- - Emphasis on care coordination and
system navigation, System Integrator, PCMH role for family
physician in integrated system - Big push on population health
management - Large care teams with PCP + a variety of other
professions, e.g., nursing, pharmacy, public health and mental
health.
• Technology Use - Better population health data stemming
from centralized data based EHR through integrated system. Adoption of telemedicine, Establish Primary Care Technology
Center (PCTC), a research and training entity, to fuel adoption
of efficacious technology in practice, patient engagement tools.
Modern, flexible, sophisticated system, developed in
partnership with technology providers. -Multi-modal
communication w/ patients .
• Building a Workforce -- Training in the use of
population health management, data management
and public health tools - Dual degrees – MD + MBAs,
MPHs - .Add’l training in interprofessional
collaboration, EHR data usage, and integrated
practice management.
• Research Focus -- Conclusive evidence about
system wide quality improvement and cost savings of
robust primary care.- Rise of Continuum-Based
Research Networks, applied research efforts to
improve clinical pathways. - Research builds case for
reductions in Total Cost of Care (at system level),
research into technologies most inpactful on Triple
Aim. - FM becomes trusted source of best practices to
meet Triple Aim, .Focus on issues that relate to
patients owning their own health through patient
experience and engagement research
• Collaboration -- - Family medicine’s partnership with payers
and the integrated systems, to exchange ideas about how to
best deploy family physicians and represent their colleagues’
interests to these systems - Subspecialists – to ensure great
working relationships within systems. - Primary care
professionals – to achieve the best possible outcomes in
service of Triple Aim. Payers, particularly CMS – to ensure
success of alternative payment pilots.- Primary Care Nurse
Practitioners (to work together in pursuit of expanded role of
Primary Care, Technology manufacturers) to provide advice on
how to improve technology in use by FPs,
• Key Investments -- Curricular overhaul and research effort to
prepare residents for work in integrated systems, tools for data
being made into actionable information in population
management, advance clinical decision support
Reengineering for Health Care
Three types of businesses undertake reengineering:
• Those at the peak of their game & ambitious executives

• those that reengineer to stay ahead, and
• those in deep trouble.
The US health care system is in trouble, and rather than
single reforms, it needs and is getting reengineered.
• 7 days to 4 hours # of deals increased a 100 fold
JAMA - Feb 2013, Ari Hoffman, MD, Ezekiel J. Emanuel, MD, PhD
Benefit Redesign
• Cost 2013 $16,351 emp on ave paying $4,565
• Federal government Final Rules wellness incentives.
• Smoker --employer may increase your insurance
premiums by up to 50 percent.
• Overweight, you may look at a 30 percent surcharge.
• And employers may also reduce premiums by up to
30 percent for normal weight.
benefit design reference pricing
• California Public Employees' Retirement
System (CalPERS), from 2008 to 2012.
• insurer sets limits on the amount to be paid for
a procedure, with employees paying any
remaining difference.
• Shift by Patients from high to low cost 55.7%
• Hospitals reduced their prices by an ave of
20%.
• Accounted for $2.8 million in savings in 2011
http://content.healthaffairs.org/content/32/8/1392.abstract
Health Aff August 2013 vol. 32no. 8 1392-1397

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I reland feb 2014

  • 1. The Foundation for Reenginering Healthcare Patient Centered Medical Home Paul Grundy MD, MPH IBM‘s Director Healthcare Transformation President Patient Centered Primary Care Collaborative
  • 2. Paul Grundy MD MPH Bio • • • • • • • • “Godfather” of the Patient Centered Medical Home IBM Global Director Healthcare Transformation President of PCPCC Member Institute of Medicine Member Board ACGME Professor Univ. of Utah Department Family Medicine Winner NCQA national Quality Award A Leader of MOH level taskforce primary care transformation 8 nations: USA, Canada, New Zealand, Australia, Holland, Denmark, UK, Belgium, • Univ. of California MD, John Hopkins Trained
  • 3. Away from Episode of Care to Management of Population Hospital Population Health Per Capita Cost System Integrator Patient Experience Public Health Community Health The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management
  • 4. Smarter Healthcare 36.3% Drop in hospital days 32.2% Drop in ER use 12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 18.9%Ancillary costs down 15.0%Outpatient specialty down Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012
  • 5. Rural New York • Commercial/ASO insurance cost decreased from $380 per-patient-per-month in 2009 to $316 in 2012 • Costs for Medicaid patients dropped from $334 to $266, according to a recent “risk adjusted” analysis. http://poststar.com/news/local/medical-home-program-gains-traction/article_5811380c
  • 6. PCMH Lower Costs Aug 5th 2013 Pennsylvania • 44% reduction in hospital costs • 21% reduction in overall medical costs. • 160 PCMH practices Pennsylvania from 2008 to 12 • Number of patients with poorly controlled diabetes declined by 45%. Jeffrey Bendix modernmedicine.com/
  • 8. PCMH Michigan – Aug 11th 2013 • 19.1% lower rate of adult hospitalization. • 8.8% lower rate of adult ER visits. • 17.7% lower rate ER visits (children under age 17) • 7.3% lower rate of adult high-tech radiology usage VS other non-PCMH designated primary care physicians. 3,017 Physicians . Medical home physicians help patients avoid ERs and admissions by evening hour appointments, weekend and same-day appointments http://www.crainsdetroit.com/article/20130811/NEWS/308119989/blue-cross-touts-155-million-in-savings-with-medical-home-project
  • 9. WellPoint PCMH Preliminary Year 2 Highlights In Sept Issue Health affairs 2012 • • 15% decrease in total ER visits/1000, compared to 4% increase in control group • Specialty visits/1000 remained around flat compared to 10% increase in control group • Colorado 18% decrease in acute IP admissions/1000, compared to 18% increase in control group Overall Return on Investment estimates ranged between 2.5:1 and 4.5:1 NEW HAMPSHIRE New York
  • 10. Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
  • 11. TODAY’S CARE PCMH CARE My patients are those who make appointments to see me Our patients are the population community Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs with or without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care It’s up to the patient to tell us what happened to them We track tests & consultations, and follow-up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients 11 Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
  • 12. • 1/3 less cardiac intervention needed • 60% less complication Diabetes
  • 13. FFM-2 Feb 2014 • 1. Pursue Electronic Patient Management and engagement rather than Electronic Patient Records • 2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows. • 3. Make it easier to do it right than not to do it at all. • 4. Continually challenge providers to improve their performance. • 5. Infuse new knowledge and decision-making tools throughout an organization instantly.
  • 14. • 6. Establish and promote continuity of care with patient education, information and plans of care. • 7. Enlist patients as partners and collaborators in their own health improvement. • 8. Evaluate the care of patients and populations of patients longitudinally. • 9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets. • 10. Create multiple case-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health
  • 15. Build your own corporate PCMH $805 $804 $765 Per Employee Per Month Health Costs Post Implementation Actual client data: Midwest Hospital with 12,135 employees 1 year selffunded for group health 17 $569 Copyright 2011 by IBM
  • 16. “We do the best heart surgeries.”
  • 17. Defining the Care Centered on Patient Superb Access to Care Patient Engagement in Care Clinical Information Systems, Registry Care Coordination Team Care Communication Patient Feedback Mobile easy to use and Available Information
  • 18. OPM Carrier Letter Feb 5th 2013 Patient Centered Medical Homes (PCMH) within the Federal Employees Health Benefits (FEHB) Program • A growing body of evidence supports investment in PCMH – SO we are!! • there must be a plan for all FEHB lives enrolled in the practice to be included in a reasonable timeframe. • ACA 2334
  • 22. Remaking Blood Chemistry - continuously test hundred different samples, 40% of today’s blood
  • 23. MobileFirst Remote Sensing Mobile Sensing emotion for mental health status -- analyzes facial expressions Mobile Sensing position for asthma -- integrates GPS into inhalers Mobile Sensing motion for Alzheimer’s -- monitoring gait Mobile Sensing ingestion of medications. activated by stomach fluid Mobile Sensing for sleep disorders -- tracks breath, heart rate, motion Mobile Sensing for diabetes. continuous monitoring iPhone non invasive sensor. Mobile Sensing for readmission prevention -- BP, weight, pulse, ekg Mobile Sensing for exercise wellness -- benefit design feedback
  • 24. Practice transformation away from episode of care Master Builder Preventive Medicine Chronic Disease Monitoring Medication Refills Acute Care Test Results DOCTOR Master Builder Case Manager Behavioral Health Medical Assistants Nursing Source: Southcentral Foundation, Anchorage AK
  • 25. PCMH Parallel Team Flow Design The glue is real data not a doctors Brain Chronic Disease Monitoring Medication Refills Healthcare Support Team Point of Care Testing Acute Care Test Results Case Manager Preventive Medicine Clinician Provider Chronic Disease Compliance Barriers Acute Mental Health Complaint Medical Assistants Behavioral Health Source: Southcentral Foundation, Anchorage AK
  • 26. Healthcare will Transform • Data Driven • Every patient has a plan • Team based • Managing a Population Down to the Person
  • 27. Payment reform requires more than one method, you have dials, adjust them!!! “fee for health” fee for value “fee for outcome” “fee for process” “fee for belonging “fee for service” “fee for satisfaction”
  • 28. New $ Dials • Complex Chronic Care Management payment codes. authorize payments to physicians for the work that goes into managing complex patients outside of their actual office visits. • House Energy and Commerce Committee Bill repeals SGR moving Medicare payments away from FFS toward new, innovative models. •
  • 29. Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments Those with severe, acute illness or injuries Those with chronic illness % Total Healthcare Spend Those who are well or think they are well % of Members 29 29
  • 30. PCMH 2.0 in Action A Coordinated Health System Hospitals PCMH Specialists Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators PCMH Public Health Prevention HEALTH WELLNESS Public Health Prevention 35 Health IT Framework Global Information Framework Evaluation Framework Operations Copyright 2011 by IBM
  • 31. FFM_2 • Practices Features -- - Emphasis on care coordination and system navigation, System Integrator, PCMH role for family physician in integrated system - Big push on population health management - Large care teams with PCP + a variety of other professions, e.g., nursing, pharmacy, public health and mental health. • Technology Use - Better population health data stemming from centralized data based EHR through integrated system. Adoption of telemedicine, Establish Primary Care Technology Center (PCTC), a research and training entity, to fuel adoption of efficacious technology in practice, patient engagement tools. Modern, flexible, sophisticated system, developed in partnership with technology providers. -Multi-modal communication w/ patients .
  • 32. • Building a Workforce -- Training in the use of population health management, data management and public health tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in interprofessional collaboration, EHR data usage, and integrated practice management. • Research Focus -- Conclusive evidence about system wide quality improvement and cost savings of robust primary care.- Rise of Continuum-Based Research Networks, applied research efforts to improve clinical pathways. - Research builds case for reductions in Total Cost of Care (at system level), research into technologies most inpactful on Triple Aim. - FM becomes trusted source of best practices to meet Triple Aim, .Focus on issues that relate to patients owning their own health through patient experience and engagement research
  • 33. • Collaboration -- - Family medicine’s partnership with payers and the integrated systems, to exchange ideas about how to best deploy family physicians and represent their colleagues’ interests to these systems - Subspecialists – to ensure great working relationships within systems. - Primary care professionals – to achieve the best possible outcomes in service of Triple Aim. Payers, particularly CMS – to ensure success of alternative payment pilots.- Primary Care Nurse Practitioners (to work together in pursuit of expanded role of Primary Care, Technology manufacturers) to provide advice on how to improve technology in use by FPs, • Key Investments -- Curricular overhaul and research effort to prepare residents for work in integrated systems, tools for data being made into actionable information in population management, advance clinical decision support
  • 34. Reengineering for Health Care Three types of businesses undertake reengineering: • Those at the peak of their game & ambitious executives • those that reengineer to stay ahead, and • those in deep trouble. The US health care system is in trouble, and rather than single reforms, it needs and is getting reengineered. • 7 days to 4 hours # of deals increased a 100 fold JAMA - Feb 2013, Ari Hoffman, MD, Ezekiel J. Emanuel, MD, PhD
  • 35. Benefit Redesign • Cost 2013 $16,351 emp on ave paying $4,565 • Federal government Final Rules wellness incentives. • Smoker --employer may increase your insurance premiums by up to 50 percent. • Overweight, you may look at a 30 percent surcharge. • And employers may also reduce premiums by up to 30 percent for normal weight.
  • 36. benefit design reference pricing • California Public Employees' Retirement System (CalPERS), from 2008 to 2012. • insurer sets limits on the amount to be paid for a procedure, with employees paying any remaining difference. • Shift by Patients from high to low cost 55.7% • Hospitals reduced their prices by an ave of 20%. • Accounted for $2.8 million in savings in 2011 http://content.healthaffairs.org/content/32/8/1392.abstract Health Aff August 2013 vol. 32no. 8 1392-1397