Reform and Renewal of Primary Care New York

Reform and Renewal of Primary Care New York City Research and Improvement Networking Group Convocation September 11, 2012 Kevin Grumbach, MD Department of Family & Community Medicine University of California, San Francisco

It’s as real as it gets San Francisco General Hospital

Primary Care Is a Really Good Thing Cardinal Attributes of Primary Care as Defined by Barbara Starfield first Contact Comprehensive Continuity Coordination

Patient Attitudes Towards Primary Care Physicians Source: Grumbach. JAMA, 1999; 282: 261

Percentage of Office Visits According to Physician Specialty, By Primary Dx Source: L Green, Analysis of 1996 Natl Amb Med Care Survey

D C B A Source: Bindman, J Gen Int Med 1996; 11: 269 F E

Outcomes of Patients with Specialists or Generalists as a Regular Physician Source: Franks & Fiscella, J Fam Pract 1998; 47: 105. Data from 1987 NMES, adjusted for health status, insurance, and other covariates

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Primary Care Strength and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 Year 1990 2000 *Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R 2(within)=0. 77. Source: Macinko et al, Health Serv Res 2003; 38: 831 -65.

But the Primary Care Foundation in the US is Crumbling • Plummeting numbers of new physicians entering primary care and burnout among PCPs • Growing problems of access to primary care and “medical homelessness” • Dysfunctional systems that are not delivering the goods in primary care

Family Medicine Residency Positions and Number Filled by U. S. Medical School Graduates Bodenheimer T. N Engl J Med 2006; 355: 861 -864

Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists Bodenheimer T. N Engl J Med 2006; 355: 861 -864

April 5, 2008 In Massachusetts, Universal Coverage Strains Care Dr. Katherine J. Atkinson of Amherst, Mass. , has a waiting list for her family practice; she has added 50 patients since November.

Partly a Payment Issue

Orthopedic Surgery Primary Care Family Medicine Source: Robert Graham Center

Percentage of Positions Filled With US Seniors vs Mean Overall Income By Specialty Ebell, M. H. JAMA 2008; 300: 1131 -1132.

Partly a Medical Education and Medical Culture Issue

FP

Partly a Systems Issue

The New Math of the 15 Minute Primary Care Visit • A primary care physician with a panel of 2500 average patients would spend: – 7. 4 hours per day to deliver all recommended preventive care [Yarnall et al. Am J Public Health 2003; 93: 635] – 10. 6 hours per day to deliver all recommended chronic care services [Ostbye et al. Annals of Fam Med 2005; 3: 209]

Percent of Primary Care Physicians Reporting After-Hours Arrangement to See Doctor or Nurse Without Going to an ER Source: C Schoen et al, Health Affairs, 28, no. 6 (2009): w 1171 -w 1183

The Choice • Redesigned primary care model with teambased practice • Concierge Medicine

The Primary Care Reform Compact • To Payers, purchasers, the public: – Invest a greater share of health care resources in primary care to strengthen the primary care workforce and enhance primary care performance • To Primary care physicians and clinicians: – Embrace innovation, new models of care, and greater patient-centeredness in return for more investment in primary care

A 20 th Century Model of Primary Care Will Not Meet the Demands of 21 st Century Health Care

Joint Principles of the Patient Centered Medical Home February 2007 American Academy of Family Physicians American Academy of Pediatrics American College of Physicians American Osteopathic Association

Transforming the Delivery of Primary Care: The Patient Centered Medical Home • Rittenhouse & Shortell: 4 Cornerstones of the PCMH • Primary Care – first Contact (access) – Comprehensiveness – Continuity – Coordination • Patient-Centered • New Model Practice • Payment Reform

Building Blocks of high performing primary care practces 10 Conscious and trained leadership 8 9 Template transformation Coordination of care 5 6 7 Population management Continuity of care Prompt access to care 1 2 3 Mission and goals Data-driven improvement Empanelment Rachel Willard Tom Bodenheimer Amireh Ghorob UCSF Center for Excellence in Primary Care 4 Team-based care http: //www. chcf. org/publications/2012/04/building-blocks-primary-care

The Multistakeholder Movement for Renewal and Reform of Primary Care • Large employers/private purchasers • Consumers/patients/the public • Government

July 6, 2009

Randy Mac. Donald, Sr VP House Ways and Means Hearing April 29, 2009 • “I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -- transform it and pay differently using a model like the Patient Centered Medical Home. ” • Congressman: “And the second issue? ” • “Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue. ”

The President Wants More and Stronger Primary Care “It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors

Senator Orrin Hatch Senate Finance Committee Roundtable Reforming America’s Health Care Delivery System April 21, 2009 “The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this? ”

Affordable Care Act: Measures to Revitalize Primary Care • Physician payment reform – Medicare fees • Infrastructure investment and facilitating practice redesign – – CMS Innovations Center Medical Home pilot programs Primary Care Extension Program ARRA HIT incentives and TA • Training pipeline – NHSC – Primary Care Training Grants

Case Study of Group Health Cooperative of Puget Sound • Patient Centered Medical Home model piloted at one site in 2007 – Avg PCP panel size reduced from 2327 to 1800 – Longer face-to-face visits and scheduled time for phone and email encounters – Increased team staffing and teamwork – HIT – Panel management

Group Health PCMH Pilot: Controlled Evaluation 12 Month Outcomes • • Improved continuity of care Better patient experiences (6 of 7 measures) Better composite quality of care score Reductions in ED visits and Ambulatory Care Sensitive Hospitalizations • No difference in total costs at year 1 (lower total costs by year 2) Source: R Reid et al. Am J Managed Care 2009; 15: e 71

Group Health PCMH Pilot: Effect on Clinic Staff p=. 02

Team-based Care: Stable Teamlets Patient panel Clinician/MA teamlet Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager 1 team, 3 teamlets

SFDPH Primary Care Provider Satisfaction with Teams n=135 Teamlet (work with same MA) (n=27) Not satisfied 15% Neutral 15% Satisfied 70% Team (work with group of MAs) (n=90) Not satisfied 35% Satisfied 37% No teams (work with different MAs) (n=18) Satisfied 11% Neutral 28% Not satisfied 61%

SFDPH Primary Care Provider Burnout by Team Model Maslach Burnout Inventory, n=86 -87 90% 80% 70% 59% 60% 50% 40% 38% 27% 30% 20% 15% 14% 10% 0% High Exhaustion High Cynicism Teamlet (n=21) Team (n=55 -56) Low professional efficacy No team (n=10)

SFDPH Primary Care Provider Confidence in Panel Management: Cancer Screenings, n=129 Provider confidence that cancer screening will be done through panel management, by team model Teamlet (work with same MA) (n=26) Agree 42% Disagree 23% Neutral 35% Team (work with group of MAs) (n=88) Agree 13% Agree 20% Neutral 20% No teams (work with different MAs) (n=15) Disagree 59% Neutral 27% Disagree 60%

http: //www. pcpcc. net/content/pcmh-outcome-evidence-quality

Review of Recent Evidence on PCMH Outcomes • 14 different initiatives – >1 million patients, 1000 s of medical practices – 5 Integrated delivery systems • Group Health, Geisinger, Health. Partners, Intermountain, VHA – 3 Private health plan sponsored initiatives • BCBS South Carolina, BCBS North Dakota, Metropolitan Health Networks Florida – 2 Medicaid state initiatives • North Carolina, Colorado – 4 Other models

Examples of Cost Outcomes • • • Group Health Cooperative: 5% ↓ $PMPM Geisinger: 7% ↓ $PMPM VA: $593 ↓ cost per patient with COPD BCBS South Carolina: 6. 5% ↓ $PMPM Metropolitan Health Networks: 20% ↓ $ per patient North Carolina Medicaid/SCHIP: Cumulative savings of $974. 5 million over 6 years (2003 -2008) • Colorado Medicaid: $215 ↓ cost per child per year

Patients Need a Good Home and a Good Neighborhood Payer Hospital Specialists Home and Family Social Worker Patient PCMH Community Workplace Other Primary Care Team Caregivers Pharmacies Nurse

Challenge to Family Medicine Culture George Saba et al. The Mythology of the Lone Physician: Towards a Collaborative Alternative. Ann Fam Med (March 2012).

From “Me” to “We” • “We will need to assemble systems in which physicians can build satisfying work relationships with staff and patients and feel supported in sharing responsibility for health outcomes. In place of the currently dominant “silo” training, we will need to foster interprofessional education about collaborative communication and team building skills. Expectations for role, competence, satisfaction, and success will need to change. ” – G Saba et al. , The mythology of the lone physician.

The Shared Predicament of Family Farmers and Family Doctors • Reductionistic paradigm vs whole food/whole person care • Generalism and biodiversity • Sustainability and resource stewardship vs resource exploitation • Agribusiness and the Medical Industrial Complex • Tax subsidies and price distortions

Michael Pollan’s Guide to Nutrition • Eat food • Not too much • Mostly plants

Kevin’s Guide to Health Care • Get medical care • Not too much • Mostly primary care