1. Realizing the Promise of
Patient-Centered Care: What
Will It Take?
Dana Gelb Safran, ScD
Senior Vice President
Performance Measurement & Improvement
Massachusetts Healthcare Technology Leadership Council
Waltham, MA
8 June 2012

2. US Health Care Spending As a Percent of GDP
Highest Among Economically Developed Nations
Total Health Expenditures as a % of GDP, U.S. and Selected Countries (2003)
eOECD estimate. Source: Organisation for Economic Co-operation and Development. OECD Health Data 2006, from the OECD Internet subscription database
updated October 10, 2006. Copyright OECD 2006, http://www.oecd.org/health/healthdata.
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3. US Annual Growth in % GDP Devoted to Health Care
Highest Among Economically Developed Nations
Growth in Health Care Spending as a % of GDP, U.S. and Selected Countries, 1980-2003
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4. Despite Highest Per Capita Spending in the World,
US Health Lags Substantially
Per Capita Health Expenditures vs. Life Expectancy
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5. Seeds of the Quality Imperative
IOM: Scoping the extent of
medical errors and system-
related harm
2000 2001 2003
RAND: Percent of
US population
IOM: Six receiving
Pillars of appropriate
High Quality preventive and
Health Care chronic care
Blue Cross Blue Shield of Massachusetts 5

6. Twin Goals of Improving Quality & Outcomes While
Significantly Slowing Spending Growth
In 2007, leaders at BCBSMA challenged the company to develop a
new contract model that would improve quality and outcomes while
significantly slowing the rate of growth in health care spending.
18.0%
MA health reform law (2006) 16.0% 15.9%
13.1% 13.3%
caused a bright light to shine 14.0%
12.0% 13.8% 12.8%
12.1%
on the issue of unrelenting 10.0%
8.0%
double-digit increases in 6.0%
8.2%
health care spending growth 4.0%
2.0%
(“Health Care Reform II). 0.0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
BCBSMA Workers’ Earnings
Medical Trend Overall Inflation
Sources: BCBSMA, Bureau of Labor Statistics
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7. Components of the AQC Model
AQC Providers are Accountable for Quality and Cost
Performance Incentives Financial Structure
Promote
Promotes Affordability and
Quality, Safety and
Efficiency
Patient-Centered Care
Providers receive upside Providers share risk on a health
payments for performance on a status adjusted Total Medical
broad set of quality and patient Expense Budget
experience measures
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8. AQC Measure Set for Performance Incentives
AMBULATORY HOSPITAL
PROCESS • Preventive screenings • Evidence-based care elements for:
• Acute care management • Heart attack (AMI)
• Heart failure (CHF)
• Chronic care management • Pneumonia
• Depression • Surgical infection prevention
• Diabetes
• Cardiovascular disease
OUTCOME • Control of chronic conditions • Post-operative complications
• Diabetes • Hospital-acquired infections
• Cardiovascular disease • Obstetrical injury
• Hypertension • Mortality (condition –specific)
• ***Triple weighted***
PATIENT • Access, Integration • Discharge quality, Staff
EXPERIENCE • Communication, Whole-person responsiveness
care • Communication (MDs, RNs)
DEVELOPMENTAL Up to 3 measures on priority topics for which measures lacking
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9. AQC Improving Preventive and Chronic Care
The 2009 AQC cohort continues to demonstrate success improving quality –
achieving benchmarks significantly higher than non-AQC peers.
The 2010 AQC cohort made significant quality improvements in year-1 of
their contract (2009 vs. 2010).
Preventive Screenings Chronic Care Management
5 2009 AQC 2010 AQC 2009 AQC 2010 AQC
Non-AQC Non-AQC
Cohort Cohort Cohort Cohort
3.9
4 3.6
Optimal Care
3.3 3.3
3 2.7 2.5 2.6 2.7
2.5
2.3 2.2
2 2.1 1.9
2 1.8 1.7 1.8 1.7 1.7
1.2 1.1 1.1
0.9
1
0.5
0
2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010
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10. Barriers to Adherence
Cognitive
Financial Logistical
Motivational
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11. Essential Attributes of Primary Care Measured by the
Ambulatory Care Experiences Survey (ACES)
Access
 financial
14 2/7 %
 organizational
Trust
14 2/7 %
Continuity
14longitudinal
2/7 %
 visit based
Interpersonal Primary
14 2/7 %
Treatment
Care Comprehensiveness
 knowledge of
patient %
14 2/7
 preventive
Clinical Interaction
14 2/7 % counseling
 communication
 physical exams 14 2/7 %
Integration
Source: Safran DG et al. JGIM 2006; 21(1):13-21.
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12. Clinical Relationship Quality Is A Leading
Predictor of Outcomes
Business Outcomes
Loyalty to the practice (voluntary disenrollment)
Malpractice Risk
Recommending the practice
Health Outcomes
Adherence to Clinical Advice
Symptom Resolution
Improved Clinical Indicators
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13. Patient Trust as a Predictor of Adherence:
Successful Behavior Change
1996 Trust (percentile)
95th 32.9%
75th 31.7%
50th 29.9%
25th 28.0%
5th 24.3%
0 20 25 30 35
% Successful Change
Source: Safran et al. JGIM 2000; 15 (supp):116.
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14. Patient Preference for Active Involvement in
Medical
Decision-Making: Effect of Patient Intervention
30
25 24.3*
Experimental Group
Control Group
19.4 19.2
20 18.7
15
10
5
0
Pre-Intervention Post-Intervention
Source: Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:520-528 *
Blue Cross Blue Shield of Massachusetts p<0.001 14

15. Effect of a Patient Involvement on Clinical Outcomes:
Diabetes Control
14
12
10.59 10.61
10.26
10 9.06*
8 Experimental Group
Control Group
6
4
2
0
Glycosylated HbA1 (%) Glycosylated HbA1 (%)
Pre-Intervention Post-Intervention
Source: Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457 *
Blue Cross Blue Shield of Massachusetts p<0.001 15

16. Patient Reported Outcome Measures
(PROMs)
• Measures of a patient's health status or
health-related quality of life
• Standardized patient reported data,
collected over time in a consistent manner
so results can be measured, analyzed,
and used in research and care delivery.
• Provides information on key dimensions
of patient functional status and well-being;
inform diagnosis and treatment decisions.
• Quantifies the impact of treatments in
ways that can inform clinical practice and
quality measurement.
• Meaningful Use Phase II includes
requirement for PROMs
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17. Near- and Longer-Term Promise of PROMs
Patients and Families
• Improved clinical interactions
• Empirical basis for treatment decisions
• Meaningful data on “quality” to inform choice
PROMs
Payers/Purchasers
• Tools to promote focus on health and Clinicians/Systems
health outcomes • Monitor patient progress
• Improved evidence base on efficacy • Data to guide treatment decisions
and basis for informed decision making • Improved evidence-base for care
• Ability to measure and improve • Compete on evidence of better results
outcomes
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18. Summary & Implications
♦ A payment system that has delivered unsustainable cost growth,
unreliable quality, and inferior population health is giving way
♦ New models require accountability for quality, outcomes &
resource use
♦ Success is impossible without patient engagement
 Clinical relationship quality is on the critical path
 What role can technology play – imagine!
♦ Patient reported outcome measures (PROMs) have the potential to
revolutionize clinical encounters and value in health care
 The promise of PROMs cannot be realized without technology-based
solutions
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19. Questions and Comments
dana.safran@bcbsma.com
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20. Introducing Our Panelists
• Joshua Feast, CEO & Founder, Cogito Health
• Kamal Jethwani, MD, MPH, Lead Research
Scientist, Partners Healthcare, Center for
Connected Health
• David C. Judge, MD, Medical Director,
Ambulatory Practice of the Future, Partners
Healthcare
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