PCPCC on the Patient-Centered Medical Home


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Presentation by PCPCC to the American Academy of Family Care, May 2008

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  • PCPCC on the Patient-Centered Medical Home

    1. 1. Working with Large Employers and Employer Coalitions to get to Patient Centered Primary Care Or how do you start to fix the foundational issues around why our healthcare system is so broken ?? .
    2. 2. Patient-Doctor Relationship A long term relationship with your primary care doctor can result in better overall family health… Patient Centered PRIMARY CARE Collaborative
    3. 3. Learning Objectives: Understand… <ul><li>Why the healthcare the employer buyer now gets is frankly unacceptable!! </li></ul><ul><ul><li>Be able to explain it to employers in your community </li></ul></ul><ul><li>How to channel that POV into your effort to transform Primary Care practice into the Family Medicine of the future AAFP effort Primary </li></ul><ul><li>How comprehensive care focused on the patient’s needs is the foundation for much better healthcare delivery </li></ul><ul><li>What we the employer buyer want to buy and you the family practice physician want to deliver. </li></ul><ul><li>IF you were asked what is the foundational issue around why our healthcare system is so broken -- what would your answer be?? </li></ul>
    4. 4. Agenda <ul><li>To work with you to get to yes -- help you to understand why the coalition of buyers of healthcare and the primary care providers are working together to transform what it is you sell as providers. </li></ul><ul><li>To get you to engage and be proactive at the community level in helping us the employer buy from you the physician comprehensive primary care centered on the patients needs. </li></ul><ul><li>To get to this point </li></ul><ul><ul><li>The Payment System for Primary Care must be fundamentally changed! </li></ul></ul><ul><ul><li>The Micropractice level has to be transformed </li></ul></ul>
    5. 5. Background Information <ul><li>Employers are facing rising medical costs that have now exceeded the growth of profits. This is a “game over” scenario. </li></ul><ul><li>~ 40% of Americans do not have a Primary Care Provider or a “Medical Home.” </li></ul><ul><li>U.S. Health Care System is ranked 37 th by the W.H.O. and we spend the most per patient. </li></ul><ul><li>U.S. has the worst record of the 19 developed economies in medical interventions actually adding years of life. </li></ul><ul><li>To fix this the fundamental and foundational issue is a change in the covenant between buyer and primary care provider. </li></ul><ul><li>Follow the MONEY </li></ul>
    6. 6. Follow the Money
    7. 7. The Problem <ul><li>Employers want to buy high quality healthcare for their employees. </li></ul><ul><li>Employers cannot buy the model of care they want for their employees. </li></ul><ul><li>The reimbursement system is inadequate, the IT is insufficient, the accountability and incentives are not in place. It is not centered on the patient’s needs. </li></ul>This is why we created the PCPCC with the AAFP and want change. We think a key role is a dialogue at the community level between buyers and primary care physicians -- The CHICKEN Story
    8. 8. <ul><li> There is no doubt that we face major problems both in health care quality and costs. The crucial question for the Employer (Buyer) is how to respond to these issues. </li></ul><ul><li>There is a solution … </li></ul><ul><li>The failure we are experiencing today is, basically, our lack of a primary care system that is structured and reimbursed in a way that adds the kind of value we need out of primary care. </li></ul><ul><li>Therefore … </li></ul>“
    9. 9. <ul><li>… Therefore, any initiative that strives to improve the overall quality and cost of care must focus on the doctor patient relationship in comprehensive primary care. </li></ul><ul><li>Since the key is the comprehensive doctor patient relationship this has to be sorted out with the primary care physicians -- this transformation has to be done in collaboration with the primary care physicians. </li></ul><ul><li>The solution has to benefit the doctor , the patient , the buyer and the payer. </li></ul>” NEJM.org August 31, 2006 The impending collapse of primary care medicine and its implications for the state of the nation’s health care. Washington, D.C.: --- American College of Physicians, January 30, 2006. (Accessed August 10, 2006, at http:// www.acponline.org/hpp/statehc06_1.pdf .) Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists . JAMA 1999;282:261-6
    10. 10. The premise: Comprehensive not episodic care is key <ul><li>The problems of quality and cost are largely failures of the way care is organized and designed in the US. More specifically, failures of how primary care is organized and PAID for: </li></ul><ul><ul><li>Inadequate system design of the primary care practice </li></ul></ul><ul><ul><li>Inadequate reimbursement of primary care </li></ul></ul><ul><ul><li>Poor organization of other resources, such as hospitals and specialists around primary care. </li></ul></ul><ul><li>Primary care is not the provider or even the practice. It is a comprehensive intensive relationship between the patient and her/his primary care practice. </li></ul><ul><li>The patient is the critical part of primary care. And comprehensive not episodic care is key. </li></ul>Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med 2003;138:248-55. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic dis-eases in primary care? Ann Fam Med 2005; 3:209-14. Roter DL, Hall JA. Studies of doctor-patient interaction. Annu Rev Public Health 1989; 10:163-80. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency
    11. 11. Primary care -- focus on comprehensive care <ul><li>Many studies show that when our primary care providers focus on the comprehensive needs of our employees: </li></ul><ul><ul><li>They end up in the hospital less </li></ul></ul><ul><ul><li>They end up in the emergency room less </li></ul></ul><ul><ul><li>and their overall care costs us less . </li></ul></ul>
    12. 12. Primary care -- focus on comprehensive care <ul><li>Many studies also show that the practice of episodic care by a partialist (specialist) without someone in charge of overall care is </li></ul><ul><ul><li>dangerous </li></ul></ul><ul><ul><li>wasteful </li></ul></ul><ul><ul><li>frankly unacceptable. </li></ul></ul>Starfield B,Shi L. Policy relevant determinants of health: an international perspective. Health Policy 60 (2002) 201–218. . Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893. . Future of Family Medicine Project Leadership Committee. The future of family medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3–32. 5. The Advanced Medical Home. The American College of Physicians, 2006. 6. Grumbach K, Selby JV, Damberg C, et al: Resolving the gatekeeper conundrum. JAMA. 1999;282:261-266.
    13. 13. AHRQ: Patient Centered Primary Care would save $29B <ul><li>Congestive heart failure: $8.3 billion </li></ul><ul><li>Bacterial pneumonia: $7 billion </li></ul><ul><li>Diabetes: $3.5 billion </li></ul><ul><ul><li>Long-term complications such as kidney damage ($2.6 billion) or diabetes related foot or leg amputations </li></ul></ul><ul><ul><li>Uncontrolled, without complications ($201 million) </li></ul></ul><ul><ul><li>Short-term complications such as hypoglycemia ($764 million) </li></ul></ul><ul><li>Chronic obstructive pulmonary disease: $3.4 billion </li></ul><ul><li>Urinary tract infection: $2 billion </li></ul><ul><li>Asthma: $1.4 billion </li></ul><ul><li>Dehydration: $1.4 billion </li></ul><ul><li>High blood pressure: $509 million </li></ul><ul><li>Angina not involving a procedure: $435 million </li></ul><ul><li>http://www.hcup-us.ahrq.gov/reports/statbriefs/sb36.pdf </li></ul>
    14. 14. What do patients think about this? (Particularly the Woodstock generation) !!! .
    15. 15. What do we patients think? Are you kidding?? <ul><li>As we boomers age, you think we’re not hearing how stressed the system is?? </li></ul><ul><ul><li>We miss the family doctors of our youth, who knew us </li></ul></ul><ul><ul><li>Concern: What if an overtaxed system can’t rescue us? </li></ul></ul><ul><ul><li>Concern: What about our children? And our precious grandchildren?? </li></ul></ul><ul><ul><li>Concern: What about our share of our costs, for conditions that could have been prevented? </li></ul></ul><ul><ul><ul><li>Elders already choose between food and prescriptions. Will that be me? </li></ul></ul></ul><ul><ul><li>Bottom line: We are very, very interested in preventing problems. It’s NUTS not to! </li></ul></ul><ul><li>Patients are willing to take as much responsibility as possible </li></ul><ul><ul><li>We WANT to do everything in our power. </li></ul></ul><ul><ul><li>Just show us how, and guide us </li></ul></ul><ul><ul><li>Effective communication is key to success. </li></ul></ul>And that requires knowing each other.
    16. 16. Our medical home is the core of our comprehensive care <ul><li>We want a medical “home,” where they know us </li></ul><ul><li>Case study: Monique S. </li></ul><ul><ul><li>Her primary said “Get an MRI.” It found spine mets. (Asymptomatic.) </li></ul></ul><ul><ul><li>Why did he say that? “You just didn’t seem like yourself” </li></ul></ul><ul><ul><li>She says: “That’s the art of medicine.” </li></ul></ul><ul><ul><li>Continuity and the doctor-patient relationship made all the difference. </li></ul></ul><ul><li>Case study: e-Patient Dave </li></ul><ul><ul><li>An outspoken advocate and blogger on e-patient topics </li></ul></ul><ul><ul><li>Why? Lethal cancer was caught as an incidental finding as a direct consequence of on-going comprehensive care. (Asymptomatic.) </li></ul></ul><ul><ul><li>If it had waited for episodic care (when a crisis arose, 6 weeks later) it would have been too late. </li></ul></ul><ul><ul><li>The routine of comprehensive and on-going care made this outcome possible. </li></ul></ul>
    17. 17. “Participatory Medicine” can be an important part of Patient Centered Care <ul><li>Participatory medicine = patients actively participating in their own care, in an empowered way </li></ul><ul><li>“ E-patients”: equipped, empowered, enabled, engaged </li></ul><ul><ul><li>http://e-Patients.net (Read the white paper / manifesto) </li></ul></ul><ul><ul><li>White paper says: generalists see 000 conditions a week and can’t go deep; e-patients in crisis have all the time in the world to go deep. </li></ul></ul><ul><ul><li>Empowered/equipped/enabled patients can be more effective self-monitors </li></ul></ul><ul><ul><li>The key to success is wise guidance – partnership – participatory. </li></ul></ul><ul><li>This partnership works – at no incremental cost to the payer </li></ul><ul><ul><li>Research is being planned to document that participating patients cost less </li></ul></ul><ul><ul><li>Results will supplement other research in this talk </li></ul></ul><ul><li>Again, we want our medical “home” back. We’ll help maintain it. </li></ul>
    18. 18. What is a Patient Centered Medical Home ? <ul><li>Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care to adults, youth and children. </li></ul><ul><li>PCMH will broaden access to primary care, while enhancing care coordination . </li></ul>
    19. 19. Primary caregivers will: <ul><li>Take personal responsibility and accountability for the ongoing care of patients; </li></ul><ul><li>Be accessible to their patients on short notice, for expanded hours, and open scheduling; </li></ul><ul><li>Be able to conduct consultations through email and telephone; </li></ul><ul><li>Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records ; </li></ul><ul><li>(continued…) </li></ul>
    20. 20. Primary caregivers will: <ul><li>Conduct regular check-ups with patients to identify looming health crises , and initiate treatment/prevention measures before costly, last-minute emergency procedures are required; </li></ul><ul><li>Advise patients on preventive care based on environmental and genetic risk factors they face; </li></ul><ul><li>Help patients make healthy lifestyle decisions ; and </li></ul><ul><li>Coordinate care, when needed, making sure procedures are relevant, necessary, and performed efficiently. </li></ul>
    21. 21. How to get there <ul><li>The key to this model is restructuring reimbursement for primary care to encourage the patient centered medical home, including: </li></ul><ul><li>Compensation for face-to-face consultations, as well as for those conducted over email and telephone; </li></ul><ul><li>Compensation for services associated with coordination of care , and monitoring of test results and procedures performed by other providers; and </li></ul><ul><li>Implementation of a hybrid model of payment to include both fee-for-service based on hours of contact with patient; and performance based incentives , including sharing emergency room cost savings, and compensation for achieving measurable and continuous patient health improvements. </li></ul>
    22. 22. Getting to PCMH in your community <ul><li>PCMH is indeed possible, and probable if certain factors are in place…. </li></ul><ul><li>The big battles are always won one community at a time. The approach will depend on the market’s demands and requirements </li></ul><ul><li>Social capital formation is necessary for leaders to identify and coalesce divergent interests in a common cause … due to fragmentation of our healthcare system and current payment policy </li></ul><ul><li>Time, commitment, charisma and honesty are required to keep a large, diverse stakeholder group at the table. </li></ul><ul><ul><li>Managing a PCMH effort is not a part-time job </li></ul></ul><ul><ul><li>Consistent execution is necessary to maintain the social capital created as part of the initial endeavor </li></ul></ul>
    23. 23. Getting to PCMH -- Early Key Findings Social capital will help communities build trust and develop consensus on policies for information sharing Strong leadership team with good business acumen is one of the key criteria for success as communities move to the implementation stage of the PCMH Rigorous analysis of the value that PCMH services provide to each customer is crucial… Need to better understand how value for each customer translates to revenue to cover the costs of the endeavor. This takes time and discipline…and business orientation Today, while many Primary care physician leaders understand this concept, it is often not well executed
    24. 24. Points of Intersection: PCMH and what employers and HHS like to talk about regarding Value-Driven Healthcare Both require leadership and multi-stakeholder collaboration at the National State and market level Value driven healthcare needs a PCMH to effectively and efficiently measure quality (particularly as we look at 2008/9 expectations) PCMH quality improvement at the same time as performance measurement…which is critical PCMH care coordination which is a necessary component of value-driven healthcare PCMH provides necessary linkages to clinical data for consumer engagement strategies to support consumer activation for healthcare improvement So…..incentives should support process, structure and outcomes…and all align with PCMH
    25. 25. Know the National Players Belong!! Play!! for example ERIC Membership for the AAFP (my adventure) This is a full contact sport !!!!
    26. 26. Know the state and local players -- National Business Coalition on Health Part of the PCPCC <ul><li>Alabama ECHO - Employers Coalition for Healthcare Options, Inc., Huntsville </li></ul><ul><li>Arkansas Employers' Health Coalition, Fort Smith </li></ul><ul><li>California Pacific Business Group on Health, San Francisco </li></ul><ul><li>Colorado Colorado Business Group on Health, Denver </li></ul><ul><li>Florida Employers Health Coalition, Tampa Florida Health Care Coalition, Orlando </li></ul><ul><li>Georgia Savannah Business Group on Health, Savannah </li></ul><ul><li>Hawaii Hawaii Business Health Council, Honolulu </li></ul><ul><li>Illinois Employer's Coalition on Health, Rockford Heartland Healthcare Coalition, Morton Midwest Business Group on Health, Chicago Tri-State Health Care Coalition, Quincy </li></ul><ul><li>Indiana Indiana Employers Quality Health Alliance, Indianapolis Tri-State Business Group on Health, Newburg </li></ul><ul><li>Louisiana Louisiana Business Group on Health, Baton Rouge </li></ul><ul><li>Maine Maine Health Management Coalition, Scarborough </li></ul><ul><li>Maryland Mid-Atlantic Business Group on Health, Greenbelt </li></ul><ul><li>Michigan AFL-CIO Employer Purchasing Coalition, Bloomfield Alliance for Health, Grand Rapids Greater Detroit Area Health Council, Detroit Michigan Purchasers Health Alliance, Ann Arbor </li></ul><ul><li>Minnesota Buyers Health Care Action Group, Bloomington Labor/Management Health Care Coalition of the Upper Midwest, St. Louis Park </li></ul>
    27. 27. National Business Coalition on Health Part of the PCPCC <ul><li>Missouri Mid-America Coalition on Health Care, Kansas City Missouri Consolidated Health Care Plan, Jefferson City Southeast Missouri Business Group on Health, Cape Girardeau St. Louis Area Business Health Coalition, St. Louis </li></ul><ul><li>Montana Montana Association of Health Care Purchasers, Missoula </li></ul><ul><li>Nevada Health Services Coalition, Las Vegas Nevada Health Care Coalition, Reno </li></ul><ul><li>New Jersey New Jersey Health Care Quality Institute, Trenton, </li></ul><ul><li>New York New York Business Group on Health, New York Niagara Health Quality Coalition, Buffalo </li></ul><ul><li>North Carolina Piedmont Health Coalition, Inc., Burlington Western North Carolina Health Coalition, Asheville </li></ul><ul><li>Ohio Employer Health Care Alliance, Cincinnati Employers Health Purchasing Corporation of Ohio, Canton FrontPath Health Coalition, Perrysburg Health Action Council of Northeast Ohio, Cleveland </li></ul><ul><li>Oregon Oregon Coalition of Health Care Purchasers, Portland </li></ul><ul><li>Pennsylvania Hanover Area Health Care Alliance, Inc., Hanover Lancaster County Business Group on Health, Lancaster Northeast Pennsylvania Regional Healthcare Coalition, Inc., Orwigsburg Pittsburgh Business Group on Health, Ambridge </li></ul><ul><li>Rhode Island Rhode Island Business Group on Health, Providence </li></ul><ul><li>South Carolina South Carolina Business Coalition on Health, Greenville </li></ul><ul><li>South Dakota Sioux Empire Health Care Coalition, Sioux Falls </li></ul><ul><li>Tennessee Healthcare 21 Business Coalition of East & Middle Tennessee, Knoxville Memphis Business Group on Health, Memphis </li></ul><ul><li>Texas Dallas/Fort Worth Business Group on Health, Dallas Texas Business Group on Health, Dallas </li></ul><ul><li>Virginia Virginia Business Coalition on Health, Virginia Beach </li></ul><ul><li>Washington Puget Sound Health Alliance, Seattle </li></ul><ul><li>Wisconsin Business Health Care Group of South East Wisconsin, Franklin Fond Du Lac Area Businesses on Health, Fond Du Lac Greater Milwaukee Business Foundation on Health, Inc., Sussex The Alliance (WI), Madison WisconsinRx, Madison </li></ul>
    28. 28. National awareness of the primary care value predicament has led to policies which offer foundational building blocks for PCMH <ul><li>Congressional and Executive Branch actions signal changes in PCMH Payment Policy </li></ul><ul><ul><li>March 2007 MEDPAC recommendations call for changes in payment policy specifically refers to health IT </li></ul></ul><ul><ul><li>March 2008 MedPAC, recommendations that call for an increase in Medicare payments for physicians who provide primary care services and implementation of a medical home pilot project </li></ul></ul><ul><ul><li>The Tax Relief and Health Care Act of 2006 (H.R. 6111) calls for a three year demonstration project on the “medical home” </li></ul></ul><ul><ul><li>GAO Report to the Senate Finance on PCMH </li></ul></ul><ul><ul><li>CBO Report out value of PCMH </li></ul></ul><ul><ul><li>White Paper from national consulting firm on PCMH </li></ul></ul><ul><ul><li>GET TO KNOW YOUR CONGRESSMAN !!! WELL </li></ul></ul>
    29. 29. PCMH Pilots <ul><li>The Patient-Centered Medical Home , a primary care model physicians across the country are promoting, has garnered support from the nation’s key healthcare payers. </li></ul><ul><li>Representatives from seven of the nation’s largest health benefits companies last month pledged their support to a national collaborative promoting the medical home model, which is being touted as the way to revamp healthcare. </li></ul><ul><li>IS there one near you -- if not why not? </li></ul><ul><li>Are you playing in the one near you??? Or are you asleep in the upper bedroom? </li></ul>
    30. 30. What are we saying right and wrong – from the Business POV <ul><li>http:// www.youtube.com/watch?v =auEvdd0j8ZU </li></ul><ul><li>http://video.aol.com/video-detail/2008-comcast-patient-centered-medical-home/2735020820 </li></ul>
    31. 31. What happens when Family Practice meets Toyota and 6 Sigma under the fire of PCMH buyer expectations – can you meet the expectations? OR -- Can comprehensive care focused on the patient’s needs be delivered at a SIX SIGMA Toyota level of expectations, by family medicine ?
    32. 32. Seeking the Ideal Payment Environment for the PCMH <ul><li>Salary : Problems with productivity </li></ul><ul><li>Fee for service: Problems with overuse </li></ul><ul><li>Capitation : Problems with underuse </li></ul><ul><li>Pay for performance: Problems with ignoring the things not attached to payment </li></ul><ul><li>A ‘blended’ payment model is the answer for primary care and the PCMH! </li></ul>
    33. 33. Key Drivers for Advancing the PCMH into Practice <ul><li>A new Payment System for Primary Care </li></ul><ul><ul><li>Updated FFS </li></ul></ul><ul><ul><li>Positive incentive for QI, patent centeredness and Performance Assessment </li></ul></ul><ul><ul><li>Care Management Fee (PMPM to the patient’s PCMH) </li></ul></ul><ul><ul><ul><li>This is NOT NEW MONEY! </li></ul></ul></ul>
    34. 34. Key Drivers for Advancing the PCMH <ul><li>Employers and consumers must recognize the value of FM and Primary Care and must be willing to support it, promote it, and pay differently and better for it! </li></ul><ul><li>Employers and Primary care physicians must press the health plans and the federal government to adopt this model as essential to improved quality and cost efficiency! </li></ul><ul><li>Employers, Family Medicine Physicians and consumers must get involved in insisting that the federal FFS payment model must be fixed – and now! </li></ul><ul><li>Join the PCPCC and move this agenda! </li></ul>
    35. 35. <ul><li>“ … studies have demonstrated that a primary care–based health care system has the potential to reduce costs while maintaining quality . </li></ul><ul><li>The hospitalization rates for diagnoses that could be addressed in ambulatory care settings are higher where access to primary care physicians is more limited . </li></ul><ul><li>States with a higher ratio of generalist to population have lower per-beneficiary Medicare expenditures and higher scores on 24 common performance measures than states with fewer generalist physicians and more specialists per capita. ” </li></ul>Primary Care — Will It Survive? Thomas Bodenheimer, M.D. Perspective August 31, 2006
    36. 36. <ul><li>“ Fixing primary care requires actions on the part of primary care practices (microsystem improvement) and the larger health care system (macrosystem reform). </li></ul><ul><li>A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.” </li></ul>Primary Care — Will It Survive? Thomas Bodenheimer, M.D. Perspective August 31, 2006
    37. 37. Conclusion: we need to move to action - walk the talk “ Knowing is not enough… We must apply.” ~Goethe
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    40. 40. PAUL GRUNDY MD, MPH, Chairman Patient Centered Primary Care Collaborative <ul><li>Director, Healthcare, Technology and Strategic Initiatives IBM Global Wellbeing Services and Health Benefits </li></ul><ul><li>Summary: </li></ul><ul><li>Paul Grundy MD, MPH, FACOEM, FACPM is IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM Global Wellbeing Services and Health Benefits, part of IBM’s Corporate Headquarters Human Resources group. </li></ul><ul><li>Chairman of the Patient Centered Primary Care Collaborative, a coalition he led IBM in creating in early 2006. The PCPCC is dedicated to advancing a new primary-care model called the Patient-Centered Medical Home as a means of fundamentally reforming healthcare delivery, which in turn is essential to maintaining US international competitiveness. Today, the PCPCC represents employers of some 50 million people across the United States as well as physician groups representing more than 330,000 medical doctors, leading consumer groups and, most recently, the top seven US health-benefits companies. </li></ul><ul><li>Prior to joining to IBM, Dr Grundy worked as a senior diplomat in the US State Department supporting the intersection of health and diplomacy. He was also the Medical Director for the International SOS, the world’s largest medical assistance company and for Adventist Health Systems, the second-largest not-for-profit medical system in the world. </li></ul><ul><li>Dr. Grundy attended medical school at the University of California San Francisco and trained at Johns Hopkins University. He has work extensively in International Aids Pandemic, including writing the United States’ first piece of legislation addressing AIDS Education in Africa. </li></ul><ul><li>Dr. Grundy presently serves on The Medical Education Futures Study National Advisory Board and is Chairman of the Patient-Centered Primary Care Collaborative (PCPCC), Dr Grundy is also the Chair of Health Policy of the ERISA Industry Committee. </li></ul>