Primary Care: The Future is the
Regional Network of Care
Ronald A. Paulus, MD
President and CEO
June 22, 2012
1
National Context
Debt and Spending
2
Behind Every Decision…
3
“Grasping” the Numbers…
$1 Trillion
• How much is $1 trillion,
really?
– The US has not existed for 1
Trillion seconds…
– …Neither has Western
Civilization
– How long would it take to
spend $1 Trillion if spending
at $1 million per day?
– Would take 2,740 years,
spending $1 million/day
~ Founding of Rome 753 B.C.
4
Composition of Federal Spending
(% of Total Outlays)
Defense
Social Security
Other Discretionary
Other Mandatory
7%
Medicare and Medicaid
Net Interest
6%
20%
12%
12%
42%
15%
20%
19%
4%
20%
23%
1970
2010
5
Source: CBO, Budget and Economic Outlook: Fiscal Years 2011 Through 2021, Historical Tables
Before Year End…
• SGR Fix Required or 30% lower payment to
physicians
• Sequester scheduled for January 1 (2% cut
across the board)
• Bush era tax cuts/Payroll tax cuts end
December 31
• Many, many others…
Cumulative Change: Health Insurance
Premiums, Workers’ Contributions,
Inflation and Workers’ Earnings
(1)Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010; Bureau of Labor Statistics
7
National Context
Value
8
We Spend Too Much and Don’t Get
Enough in Return
National Healthcare Expenditures per Capita vs. Life Expectancy at Birth(1)
Rest of OECD
U.S.
(1)OECD Health Data 2011; Dataset includes most recent information available (2008, 2009 and 2010 data)
9
We Don’t Get More for Our Money…
MD Quality Index
(outcomes or % adherence to EBM)
Lower
Higher
50th %ile
Low Efficiency
High Quality
High Efficiency
High Quality
(Dream Suppliers)
50th %ile
Low Efficiency
Low Quality
(Nightmare
Suppliers)
Lower Efficiency/
Higher
Cost
MD
Longitudinal
Cost Efficiency Index
High Efficiency
Low Quality
Higher Efficiency/
Lower Cost
(total cost per case mix-adjusted treatment episode)
Adapted from Regence Blue Shield; Arnie Milstein, MD - Mercer
10
National Context
Health Reform
11
Affordable Care Act Provisions
Impacting Primary Care
• Medicare 10% increase in primary care
reimbursement rates, 2011–2016 ($3.5 billion)
• Medicaid reimbursement for primary care increased to
at least Medicare levels, 2013–2014 ($8.3 billion)
• 50 million Medicare beneficiaries in 2011 will have
free access to currently covered preventive services
including:
– Eligible for free annual wellness check-ups/personalized prevention
plans
– Free HTN screening, alcohol counseling, and colon cancer
screening
• Nearly 40 million Medicaid enrollees in 2013 will have
access to free preventive care services.
• Up to 40 million (2011) and 90 million (2013) seniors
will no longer have to make a copayment for
recommended preventive screenings
Wide Variation in Medicaid-to-Medicare Fee Ratio for
Primary Care Services (2008)
State
Ratio State
Ratio State
Ratio
Alabama
0.78
Kentucky
0.80
North Dakota
1.01
Alaska
1.40
Louisiana
0.90
Ohio
0.66
Arizona
0.97
Maine
0.53
Oklahoma
1.00
Arkansas
0.78
Maryland
0.82
Oregon
0.78
California
0.47
Massachusetts
0.78
Pennsylvania
0.62
Colorado
0.87
Michigan
0.59
Rhode Island
0.36
Connecticut
0.78
Minnesota
0.58
South Carolina
0.86
Delaware
1.00
Mississippi
0.84
South Dakota
0.85
District of Columbia
0.47
Missouri
0.65
Tennessee
N/A
Florida
0.55
Montana
0.96
Texas
0.68
Georgia
0.86
Nebraska
0.82
Utah
0.76
Hawaii
0.64
Nevada
0.93
Vermont
0.91
Idaho
1.03
New Hampshire
0.67
Virginia
0.88
Illinois
0.57
New Jersey
0.41
Washington
0.92
Indiana
0.61
New Mexico
0.98
West Virginia
0.77
Iowa
0.89
New York
0.36
Wisconsin
0.67
Kansas
0.94
North Carolina
0.95
Wyoming
1.17
Source: Adapted from S. Zuckerman, A. F. Williams, and K. E. Stockley, “Trends in Medicaid Physician Fees, 2003–2008," Health Affairs Web Exclusive,
April 28, 2009, w510–w519.
Affordable Care Act Provisions
Impacting Primary Care
• Grants/contracts to support medical homes through:
– Community Health Teams to increase coordinated care
– Community-based collaborative care networks for low-income
populations
– Primary Care Extension Center program providing technical
assistance to primary care providers
• Scholarships, loan repayment, and training
demonstration programs to invest in primary care
physicians, midlevel providers, and community
providers
• $11 billion for Federally Qualified Health Centers,
2011–2015, to serve 15-20 million patients by 2015
• ACA and ARRA support the training of more than
16,000 new primary care providers over 5 years
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American Academy of Family Practitioners
15
American Academy of Family Practitioners
16
American Academy of Family Practitioners
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Can it Work?
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Clinical Decision Intelligence System
(CDIS)
Other Inputs
Decision
Support
EBM Guidelines
Patient Preferences
Formulary/Economics
…
Real-time Clinical Status
Effectors
EHR
Alerts
Prompts/Reminders
Order Sets
Automated care plans
Patient portal messages
Information Rx
CDIS
Clinical,
Schedule
…
…
Consumer
Portal
Claims
Finance
Ops
Normalization, Transformation,
Analytic Application
…
20
Creating Real Value: Geisinger’s Core
Care Transformation Initiatives
• Population Health Optimization
– Geisinger Medical Home
– Chronic Disease Care Optimization
• Acute Episodic Care Optimization
– (aka the “surgical warranty”)
• Transitions of Care Optimization
• Patient engagement and activation throughout all
initiatives
Geisinger Health System
Last updated 08/18/09
Geisinger ProvenHealth Navigator Sites
Contracted ProvenHealth Navigator Sites
Geisinger Medical Groups
Geisinger Specialty Clinics
Geisinger Inpatient Facilities
Ambulatory Care Facility
Geisinger Health System Hub and Spoke Market Area
Geisinger Health Plan Service Area
Careworks Convenient
Healthcare
Non-Geisinger Physicians
With EHR
Functional Components
1. Team-based, patient-centered primary care
(including embedded care management nurse)
2. Joint payor-provider population management
3. High quality, efficient specialist identification
and referral
4. Quality Outcomes Program
5. Value-based Reimbursement Program
1. Baseline FFS
2. Practice transformation stipends
3. Quality-gated gain sharing
Population Health Optimization:
Ambulatory
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Diabetes Bundle
Measures
Quality Standard
FY07
Every 6 months
X
<7
X
LDL measurement
Yearly
X
LDL control
< 100
X
< 130/80
X
HgbA1C measurement
HgbA1C control
Blood pressure control
Retinal exam
Yearly
Urine (protein) exam
Yearly
Foot exam
Yearly
Influenza immunization
Yearly
X
Pneumococcal immunization
Once
X
Non-smoker
X
Smoking status
Use of ACE/ARB for microalbuminuria/DM nephropathy
Yes
Use of ACE/ARB for hypertension
Yes
Patients who receive/achieve ALL of the above
Yearly
X
X
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DM Best Practice Alert/Order Set
32
Patient Reminder View
33
Most recent values displayed
Patient
Trend
Report
Therapeutic goals are stated
Clinical consequences are stated
34
GHP GOLD Geisinger HEDIS
Performance vs. Panel Providers
Study
Effectiveness of Care
Comprehensive Diabetes Care:
HbA1c tested
HbA1c Good control <7.0%
HbA1c Poor controlled >9.0% (Lower rate
indicates better performance)
Lipid Profile performed
LDL-C <100
Diabetic Retinal Eye Exams
BP controlled <130/80
BP controlled <140/90
Kidney Disease monitored
Breast CA Screening
Colorectal CA Screening
Cholesterol Mgmt after Acute Cardio
- LDL Screening
- LDL <100
Controlling High Blood Pressure
Antidepressant Med Mgmt
- Optimal Practitioner Contacts
Spirometry Testing for COPD
Glaucoma Screening
HEDIS 2008
Total Rate
Clinic
Results
Test of Means
or
Population Inferences
(a = .10), two tail
Panel
94.2%
51.3%
98.8%
55.8%
87.7%
45.0%
Statistically Higher
Statistically Higher
P<0.0001
P=0.0308
12.7%
92.0%
54.5%
88.1%
44.3%
69.6%
93.4%
83.5%
65.8%
5.4%
95.4%
58.3%
92.5%
52.9%
75.4%
96.7%
88.6%
70.8%
Statistically Higher
22.8%
Statistically Higher
87.1%
49.1% +/- Statistically Higher
Statistically Higher
81.9%
Statistically Higher
32.2%
Statistically Higher
61.4%
Statistically Higher
88.9%
Statistically Higher
77.6%
Statistically Higher
60.5%
P<0.0001
P=0.0023
P=0.0643
P=0.001
P<0.0001
P=0.0023
P=0.0016
P<0.0001
P=0.0324
93.0%
67.1%
67.2%
97.6%
72.6%
73.9%
88.3%
61.4%
60.1%
Statistically Higher
Statistically Higher
Statistically Higher
P=0.0003
P=0.0178
P=0.0051
16.1%
41.8%
76.7%
14.7%
59.4%
81.0%
17.0%
33.2%
71.9%
Statistically Higher
Statistically Higher
P<0.0001
P<0.0001
Diabetes Bundle Results
Primary Care Average
(n=23,404)
36
CAD Bundle Primary Care Results
Average (n=14,714)
37
Population Health Optimization:
Patient/Consumer Engagement
38
Patients Make the “Real Decisions”
39
Population by Activation Level
12% of the population
29% of the population 37% of the population
22% of the population
Source: J.Hibbard, University of Oregon
40
HTN Patients Who Engage in Selfmanagement Behaviors
Source: J.Hibbard, University of Oregon
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Going Forward from Here
Supreme Court Pending…
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“I don’t believe there’s any problem in this
country, no matter how tough it is, that
Americans, when they roll up their sleeves,
can’t completely ignore.”
-- the late comedian George Carlin
The Verdict on National Health Reform?
“Somebody has to do something, and it’s just
incredibly pathetic that it has to be us.”
-- the late Jerry Garcia of the Grateful Dead
Mission Health
We are in this, together!
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