1. Primary Care in the 21 st Century:
The New Specialty in Health Care
IHI 10 th Annual Summit on Redesigning the
Clinical Office Practice
March 24, 2009
Jack Cochran, MD,
FACS
Executive Director
The Permanente
Federation
510-271-4620
jack.h.cochran@kp.org
Learning Objectives
Participants will be able to:
° Describe how the broken health care system
has altered the quality of care in the United
States
° Describe how the proliferation of sources of
medical information has changed the doctor-
patient relationship
° Explain why Primary Care is central to
achieving high quality, affordable, patient-
centered care and identify the elements
essential for optimizing the Primary Care
experience
2
1

2. quot;Our greatest
responsibility
is to be good
ancestors.quot;
Jonas Salk
3
Critical Confluence
° Affordability
° Nursing and other health care Keys to solutions
worker shortages will be health care
led by clinicians,
° Supply and sustainability of
primary care physicians integrated with
functional IT
° More patient focus/inclusion
systems, and
° Essential major investments in staffed with
technology and systems
innovative,
(including EMRs)
enthusiastic,
° Government and public policy
computer-enabled
probing for answers
health care teams.
° Baby Boomers entering Medicare
° Worst economic crisis in decades
4
2

3. Can We AFFORD Not to Lead?
Cumulative Changes in Premiums,
Inflation, & Earnings, 2000-2006
100%
87% Health Insurance
Premiums
80%
60%
40%
20% Worker's Earnings
20%
Overall Inflation
18%
0%
2000 2001 2002 2003 2004 2005 2006
5
International Comparison of Spending on Health
1980-2004
Average spending on health Total expenditures on health
per capita ($US PPP) as percent ofGDP
7000 16
United States
Germany
Canada 14
6000 France
Australia
United Kingdom 12
5000
10
4000
8
3000
6
2000 United States
4 Germany
Canada
1000 France
2 Australia
United Kingdom
0 0
80 82 84 86 88 90 92 94 96 98 00 02 04 80 82 84 86 88 90 92 94 96 98 00 02 04
19 19 19 19 19 19 19 19 19 19 20 20 20 19 19 19 19 19 19 19 19 19 19 20 20 20
Data: OECD Health Data 2005 and 2006.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. 6
3

4. Six Nation Rankings on
Health System Performance
AUS CAN GER NZ UK US
Overall ranking 3.5 5 2 3.5 1 6
Quality care 4 6 2.5 2.5 1 5
Right Care 5 6 3 4 2 1
Safe Care 4 5 1 3 2 6
Coordinated Care 3 6 4 2 1 5
Patient-Centred Care 3 6 2 1 4 5
Access 3 5 1 2 4 6
Efficiency 4 5 3 2 1 6
Equity 2 5 4 3 1 6
Healthy Lives 1 3 2 4.5 4.5 6
Source: Commonwealth Fund (2007)
7
The Four Parts of the Quality Gap
° Overuse
° Underuse
° Misuse/Errors
° Waste
8
4

5. Closing the Gap US data collated by Professor
Bill Runciman, President,
Australian Patient Safety
Foundation from McGlynn et al;
NEJM 2006 Vol 348; p2635-45
9
Dwindling Numbers
# US grads entering
family medicine
residency
1997 2340
2006 1132
10
5

6. Dwindling Numbers
Career Choices of Third-Year Internal Medical
Residents
11
Partially
Uninsured
Insured
The statistics have The stories have
changed a little. changed a lot.
Numbers of uninsured continue to grow.
12
6

7. Change
quot;The committee is confident that Americans can
have a health care system of the quality they
need, want, and deserve. But we are also
confident that this higher level of quality cannot
be achieved by further stressing current
systems of care. The current care systems
cannot do the job. Trying harder will not work.
Changing systems of care will.quot;
Crossing the Quality Chasm, IOM
13
IOM's Six Major Challenges
quot;Organizations will need to negotiate
successfully six major challenges.quot;
° Redesigned care processes based on best evidence
° Effective use of information technology
° Knowledge and skills management
° Development of effective teams
° Coordination of care across conditions, services, and
settings
° Use of performance and outcomes measurement for
continuous improvement and accountability
14
7

8. Crossing the Chasm to
the Medical Home
15
A House is Not a Home
Picker Institute Eight Dimensions of Patient-centered Care
¢ Respect for the patient's values, preferences,
and expressed needs
¢ Access to care
¢ Emotional support to relieve fear and anxiety
¢ Physical comfort
¢ Involvement of family and friends
¢ Coordination of care
¢ Continuity and secure transition between health
care settings
¢ Information and education
16
8

9. The Old Model of
Information Flow
17
What Is a Pati nt to Do with This
The New Model of
Abundance of Information?
Inform tion Flow
Graphic Graphic
representing representing
media alternative
practitioners (e.g.
acupuncturist)
?
Graphic
representing
medical Web
sites
(WebMD?)
18
9

10. The Future is Here
Marcus Welby, MD
quot;Marcia Welbyte,quot; MD
19
Patients Need a Trusted Partner
Graphic representing
alternative practitioners
(e.g. acupuncturist)
20
10

11. Essential Roles of Health Care
Teams and Clinicians
Healer
Leader
Partner
21
Patients Need a Partner to Guide
Them Through the Gaps
Even if you can't take care of the
problem, be sure you still take
care of the patient.
22
11

12. We have been making Specialty
Care more primary.
We need to make Primary Care
more special.
23
Primary Care is essential to:
° Maintain trusted, human
connectivity in the patient's chaotic,
complex world
° Manage and coordinate care
° Make care more affordable
24
12

13. Why a Patient Centered Primary
Care Practice?
Research demonstrates the value of having
regular access to preventive and primary care
¢ Higher quality of care
¢ Higher patient satisfaction
¢ Reduced health care disparities
¢ Lower per person cost
ß Lower emergency room utilization
ß Fewer hospital admissions
ß Fewer unnecessary tests and procedures
25
The Value of Primary Care
¢ States with a greater ratio of generalist
physicians to population had higher
quality and lower costs
¢ States with a greater ratio of specialist
physicians to population had lower
quality and higher costs
quot;Medicare Spending, The Physician Workforce,
And Beneficiaries' Quality Of Carequot;
Baicker and Chandra
Health Affairs Web Exclusive. April 7, 2004.
26
13

14. The Value of Primary Care
The stronger a country's primary care
system, the lower the rates of all-
cause mortality, all-cause premature
mortality, and cause-specific
premature mortality...
quot;Contribution of Primary Care to Health Systems and Healthquot;
Macinko, J., B. Starfield, and L. Shi
The Millbank Quarterly, Vol. 83, No. 3, 2005
27
How Do We Leverage Primary Care
Physicians and Teams?
Keys to making primary care more
viable, desirable, and sustainable:
° Technology and tools
° Teams, including excellent
relationships with specialty care
° Compensation
28
14

15. Technology and Tools
29
Is Technology the Answer?
OO + NT = COO
It's not the box
30
15

16. LO + NT = TO
31
Even with the best of intentions…
GAP
200 MB capacity* 150,000 articles/month**
300,000 RCTs
20,000 biomedical journals
2,618 active performance measures
100,000 genetic tests over next few years
**Ann Intern Med 2001;135:309-12
32
16

17. Technology in the Hands of
Physicians - Transforming Care
° Registries
° Prompts and Alerts
° Guideline Reminders
° Decision Support
° Predictive Modeling
33
Yesterday's Care Tomorrow's Care
Our patients are those who make Our patients are those who are in our
appointments to see us panel
Patients' chief complaints or reasons We systematically assess all our
for visit determines care patients' health needs to plan care
Care is determined by today's Care is determined by a proactive plan
problem and time available today to meet patient needs without visits
Care varies by scheduled time and Care is standardized according to
memory or skill of the doctor evidence-based guidelines
Patients are responsible for A prepared team of professionals
coordinating their own care coordinates all patients' care
I know I deliver high quality care We measure our quality and make
because I'm well trained rapid changes to improve it
Acute care is delivered in the next Acute care is delivered by open access
available appointment and walk-ins and non-visit contacts
It's up to the patient to tell us what We track tests & consultations, and
happened to them follow-up after ED & hospital
Clinic operations center on meeting A multidisciplinary team works at the
the doctor's needs top of our licenses to serve patients
34
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
17

18. Teams
(Including Excellent
Relationships with
Specialty Care)
35
The Power of Teams
Individuals collaborate and maximize their
scope of practice to provide the best
care for patients
¢ Physician
¢ Nurse
¢ Medical Assistant
¢ Pharmacist
¢ Behavioralist
¢ Specialist
36
18

19. The Kaiser Permanente 21 st Century
Care Innovation Collaborative Model
37
The KP Proactive Encounter Experience
Pre Encounter Office Encounter Post Encounter
Proactive Office Encounter Management Immediate
Identification • Vital sign collection / • After visit summary,
• Identify missing documentation after care
labs, screening • Identify and flag alerts for provider instructions, follow-
procedures, access up appointments,
management, kp.org • Room and prepare patient for Health Ed materials,
status, etc. necessary exams how to access info
• Provide member • Pre-encounter follow-up on kp.org
instructions prior to Future
visit • Follow-up contact
• Contact member and Proactive Office Support and appointments
document encounter • In-basket Management per provider
in KP
HealthConnect™
POE success relies upon strong physician and staff partnerships based on clearly defined
roles and responsibilities, team agreements, and improved communications. 38
19

20. The Kaiser Permanente Collaborative
Cardiac Care Service (CCCS)
Coordination among:
¢ Nursing team
¢ Cardiac rehabilitation program
¢ Pharmacy team
Patients enrolled in CCCS
experienced a reduced
incidence of all-cause mortality
by 89%.
39
Compensation
40
20

21. quot;A key to the sustainability of primary
care will be payment reform coupled
with innovative quality measures…quot;
quot;Primary Care: Too Important to Failquot;
David S. Meyers, MD, and Carolyn M. Clancy, MD
Annals of Internal Medicine
February 17, 2009
41
quot;Patients, specialists, and the entire health
system need a healthy primary care base…
Primary care practice is not viable without a
substantial increase in the resources
available to primary care physicians.quot;
quot;The Primary Care-Specialty Income Gap: Why It Mattersquot;
Thomas Bodenhemier, MD, Robert A. Berenson, MD; and Paul Rudolf, MD, JD
Annals of Internal Medicine
February 20, 2007
42
21

22. Never doubt that a small group of
thoughtful, committed citizens can
change the world. Indeed, it's the only
thing that ever has.
Margaret Mead
43
Jack Cochran, MD, FACS
Executive Director
The Permanente Federation
(510) 271-5886
fax: (510) 267-2194
email: jack.h.cochran@kp.org
44
22