Innovation in Primary Care: Lessons Learned and Future Directions Asaf Bitton MD, MPH, FACP Associate Physician, Brigham and Women’s HospitalInstructor in Medicine and Health Care Policy, Harvard Medical School Assistant Medical Director, BWH Advanced Primary Care Associates CIMIT Investigator A*STAR-Khoo Teck Puat Hospital Forum on Primary Care Transformation March 23rd, 2012
“Every system is perfectly designed to achieve exactly the results it gets.” Don Berwick, MD MPP
Cost-Related Access Problems, 2011 Percent of adults who went without care because of cost in past year * * Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 4
A “Perfect Storm” Unsustainable costgrowth, inadequate quality, fragmentedcare, workforce shortage, aging population Michael Patmas MD, OHSU, 2006
Primary Care as a Focus forInnovation and Systems Change•Increased access and/or •Decreasedequitable distribution of care health•Prevention and early expendituresmanagement of health problems •Equal or better•Reduction of unnecessary and health outcomesharmful specialist interventions •Better patient•Coordination and integration experiences andacross multiple conditions, increasedtreatments, and medications satisfaction
Primary Care Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for: addressing a large majority of personal health care needs developing a sustained partnership with patients practicing in the context of family and communitySource: IOM, Defining Primary Care: An Interim Report. 1994.
Essential Attributes of Primary CareFirst contact carecharacterized by: Accessibility Whole Person Comprehen- Orientation siveness PRIMARY CARE Coordination/ Continuity Integration
Health Expenditures: Generalists and Specialists Compared Generalist Density and Specialist Density and Health Expenditures Health ExpendituresSource: Baicker K & Chandra A. Health Affairs. 2004. Web Exclusive. Dartmouth Atlas projects
Better Primary Care Associated with Lower Costs Primary Care Scores vs. Per Capita Health Care Costs 4000 US Per Capita Health Care Expenditures 3500 3000 Germany 2500 Canada France The Netherlands 2000 Japan Australia Denmark Belgium Finland 1500 Sweden United Spain Kingdom 1000 500 0 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Average Primary Care ScoreSource: Starfield B, Shi L. Health Policy. 2002; 60: 201-218.
Access to Primary Care Able to Get Same Day ER Use for Condition Doctor Could Appointment with Doctor Have Treated if AvailablePercent Percent75 25 55 53 20 49 1650 15 42 41 15 11 30 9 10 825 22 6 5 5 0 0 GER NZ NETH AUS UK US CAN GER NETH UK NZ AUS US CANSource: 2007 Commonwealth Fund International Health Policy Survey 11
Patients Value Primary CarePatient Attitudes Towards Primary Care PCP versus SpecialistPhysicians and Specialist Use Preference as First-Contact Physician for Selected Medical Don’t Know Agree Disagree or Uncertain Problems (%) (%) Prefer PCP Prefer Specialist (%) 90Value having one primary care 80 94 2 4physician 70 60 50Values PCP participation in 89 3 8 40decision to see specialist 30 20Can decide whether to see 10PCP or specialist for a new 46 28 26 0problem for myself Cough and Arthritis in Blood in Stool Wheezing KneeSource: Grumbach K et al., JAMA; 281(3): 261-266.
Reinventing Our Delivery System “Current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”Institute of Medicine. Crossing the Quality Chasm. 2001
“Medical Home? That sounds like a Nursing Home…” Patients not aware PCMH: different meanings to different stakeholders
Invention vs. InnovationKitty Hawk, 1903 DC-3, 1935
“Home Team, Centered Around the Patient” Connected Personal Physician through HIT Whole Enhanced Person Access Patient Quality/ Payment Safety Reform PCMH Joint Physician Care Led Practice Coordination Principles
Common Elements of PCMH Personal Physician Team-based practice Expanded access Emphasis on coordination of care Proactive population health management Care facilitation and data analysis with HIT New forms of paymentFields et al, Health Affairs, May 2010
Does HIT = Medical Home? Necessary but alone not sufficient Enables coordinating connections Current Needs: Robust decision support Registry tools Tools enabling team function and pt engagement Personal health recordsBates D and Bitton A. “The Future of HIT in the PCMH”. Health Affairs. April 2010.
Smaller Practices Lag Behind Large Practices in HIT Solo practices 100 Small and medium practices (2–9 physicians) Large practices (10 or more physicians) 75 75 49 50 50 27 25 21 7 0 Use electronic medical records in practice High electronic information functionality** To assess HIT multifunctionality, a 14-count scale was developed. The multifunctional HIT capacity summary variable,counting the number of functions and categorized systems, includes low (0–3), middle (4–8), and high (9–14).Source: The Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.
HITECH: Advancing the Tipping Point Technology Adoption National Grant Coordination Programs Enhanced Payment Trust Incentives 2004 2012 TIMESource: David Bates MD, MSc
Spurring Use of HIT “To increase the effective use of EHRs: 1. Get doctors, hospitals, and other health care providers to acquire and use electronic health records. 2. Get those electronic health records to "talk to one another" by becoming interoperable. 3. Get providers to use EHRs to improve quality and efficiency in the provision of health care services.” (The Federal Role in Promoting Health Information Technology,Source: David Bates MD, MSc Commonwealth Fund, 2009)
Meaningful Use “Ascension Path” Certified EHR Required 2009 2011 2013 2015 HIT-Enabled Health Reform HITECH Policies 2011 Meaningful Use Criteria (Capture/share data) 2013 Meaningful Use Criteria (Advanced care processes with 2015 Meaningful decision support) Use Criteria (Improved Outcomes)Source: David Bates MD, MSc Report of sub-committee of Health IT Policy Committee
Meaningful Use IncentivesBUT…Penalty of 1%/yr (max 5%) reimbursement starting 2015
TODAY’S CARE MEDICAL HOME CAREMy patients are those who make Our patients are those who areappointments to see me registered in our medical homeCare is determined by today’s Care is determined by a proactive planproblem and time available today to meet patient needs without visitsPatients are responsible for A prepared team of professionalscoordinating their own care coordinates all patients’ careI know I deliver high quality care We measure our quality and makebecause I’m well trained rapid changes to improve itIt’s up to the patient to tell us what We track tests & consultations, andhappened to them follow-up after ED & hospitalFocus of the clinic is the doctor’s A multidisciplinary team works at theneeds top of our licenses with a patient focusSlide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
Results for Current National Demos Practices 4,659 Physicians 14,389 Patients 4,900,000Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
Models for PCMH Payment Enhanced Fee for Service (FFS) Higher technical fees New codes for phone call and emails Higher volume with mid-level providers Capitation Comprehensive Risk Adjusted Payment Model (NY/MA) 3 part model FFS Enhanced pay for performance Care management fees (per person per month)
Payment for Current National Demos Per Person Per Month (PPPM) Payments 96% Range of PPPM Payments $0.50 to $9.00 $720 to $91,146 Range of Additional Revenue per MD/yr (median $22,834) Upfront or Start-up Payments 42%Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
PCMH Evaluation:How do you know if this works?
Early PCMH ResultsProject Hosp ER Visits Quality Pt Total $ per Experience patient/yrGroup Health -6% (all) -29% Improved Improved in -$120Cooperative (WA) -13% (ACSC) 5 / 7 scalesGeisinger (PA) -18% (all) NA NA NA -7% (+5% to -18%) -36% (re-ad) (Not Stat Significant)NDP (national) NA NA Improved Slightly *Practice Rev worse (NS) +2% to 12%Community Care of -40% NA Improved NA -$516North Carolina* asthma, DMColorado Medical -18% -16% NA NA -$169 (all)Homes for Children* -$530 (c. dz)Intermountain (UT)* -5% (all) 0% (all) NA NA -$640 -19% (c.dz) -7% (c.dz)North Dakota BCBS* -6% -24% NA NA -$530Vermont Blueprint* -11% -12% NA NA -$215*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease NS = not statistically significant re-ad = readmissions
Experienced Coordination Gaps in Past Two Years, by Medical Home Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important informationwith each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 35
Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.* Reported medical mistake, medication error, and/or lab test error or delay in past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 36
Patient Engagement in Care Management for Chronic Condition, by Medical Home Percent reporting positive patient engagement in managing chronic condition* Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care. * Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 37
Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 38
Equity-Enhancing Effects Percent of Adults 18-64 Reporting Having Received Needed Medical Care, by Racial and Ethnic Group and Source of Care Medical home Regular source of care, not a medical home 100 No regular source of care/ER 74 74 76 74 75 52 53 52 50 50 44 38 34 31 25 0 Total White African American HispanicSource: Beal AC et al. The Commonwealth Fund. June 2007. Data from Commonwealth Fund 2006 Health Care QualitySurvey.
PCMH in Practice:Brigham and Women’s Advanced Primary Care Associates, South Huntington
Structure: Core Clinical Team 3 Teams:•1.5 MD•1-2 Residents •2 students (MD), and other students (RN)• 1 Physician Assistant (8 session)• 1 Licensed Practical Nurse• 2 Medical Assistants• 1 Social Worker
Structure: Shared Resources • 1 Medical Director • 1 Practice Manager • 1 Pharmacist • 1 Population Manager • 1 Nutritionist • 6 Secretaries (Check-in, Check-out) • 1 Community Resource Specialist • 1 Care Coordination RN
Local Opportunity for Innovation South Huntington as a “learning laboratory” for team- based practice innovation and training Developing new training models System-wide transformation: 60% of practices transform to PCMH by 2013 100% by 2015 Docking Platform for Innovative Technology
The Medical Neighborhood Extends around PCMH “Core” and “Peripheral” neighbors Varies by community and provider network arrangement Requires formal, reciprocal care agreements Enhanced by efficient information transfer (HIT) Shared risks and incentives for outcomes Compatible with different payment structures A stepping stone to ACOsSource: Pham H, Journal of General Internal Medicine, 2010
Accountable Care Organizations:Integration Through Information and Shared Responsibility HIT Hospital Sub-Acute Care HITSub-specialty PCMH HITSub-specialty “MedicalHome Neighbor” HIT HIT Patient-CenteredSub-Specialty Medical HomeProcedural Practice HIT HIT Source: David Bates MD, MSc and Asaf Bitton MD
Accountable Care Organizations (ACO) A group of providers that has the legal structure to receive and distribute incentive payments to participating providers. 48Source: Premier Healthcare Alliance
Vermont Blueprint for Health: Integrating PCMH/ACOs with Public Health Through Community Care Teams Prevention Programs Policies and Systems Local, state, and federal; Hospitals PCMH economic/cultural; media PCMH Community Community Care Team Physical, social and cultural Nurse Coordinator environment Behavioral Social Workers PCMH Health & Dieticians Substance Community Health Workers Abuse Organizations Services Care Coordinators Schools, worksites, faith- Public Health Prevention Specialist PCMH based organizations, etc Public Health Prevention Relationships Family, peers, social networks, associations Individual Health IT Framework Knowledge, attitudes, beliefs Global Information Framework Evaluation FrameworkSource: Craig Jones MD; Director, Vermont OperationsBlueprint for Health, AcademyHealth 2009
Centers for Medicare andMedicaid Innovations (CMMI) Genesis / Funding: Affordable Care Act ($10B) Framework for Innovation: Demonstrations Dissemination: Spread if Certified Key Programs: Pioneer ACO Comprehensive Primary Care Initiative Bundled Payments Health Care Innovation Challenge
Change is Hard“Possibility derives less from effort than from redesign” Berwick and Luo, 2010
Keys to Innovation Clear Strategies Aligned Incentives Trust Across Institutions Clear Communication Embrace New Thinking Tolerate (and even celebrate) Mavericks Don’t Focus Next Quarter’s Results Only Leadership
Concluding Thoughts Enhancing primary care capacity and function is key to building a high-performing health system The medical home is about improving care through teams, HIT, and a renewed focus on the patient The medical home model is already widespread and early results are promising Innovation is not only about building new technologies, but also about where to intelligently deploy them Optimism is a strategic imperative