Extracting Value
Patient Centered Medical Home
Paul Grundy MD, MPH - IBM Director, Healthcare Transformation
@Paul_PCPCC
https://twitter.com/Paul_PCPCC
Beyond Flexner --- Driven by
Actionable - Personalized Data
Course Objectives
• participant will understand/be able to discuss the important trend of
PCMH in health care
• participant will understand/be able explore the rationale and supporting
evidence for PCMH
• - participant will understand/be able understand the impact on patients,
providers and payers
• Disclosure:
• – I am a full time Employee of IBM I WILL NOT discuss any
pharmaceuticals, medical procedures, or devices
• I have gratefully had my expenses covered to do some of my talks about
PCMH by Abbvie, Merck, and Pfizer.
North Carolina Starts the movement
• When Look at the Landscape CCNC was who
was called CCNC now into year 18 !! – CCNC at
the first roundtable pre-PCPCC.
• Jan 2015 --Idaho Embraces Medical Home
Model Statewide Programs Seek to Facilitate
Innovative Care Transitions
In much of the world, no one is in charge.
And the result is the most wasteful and Unsustainable
– BUT -where the delivery system works
– a Patient in a trusting relation with a
healer who is a comprehensivist with
data is in charge”
Away from Episode of Care to Management of Population
WITH DATA
Per
Capita
Cost
Population
Health
System Integrator
@Paul_PCPCC
https://twitter.com/Paul_PCPCC
The System Integrator
Creates a partnership across the
medical neighborhood
Drives PCMH primary care redesign
Offers a utility for population health
and financial management
Patient
Experience
Public
Health
Community Health
Smarter Healthcare
36.3%
32.2%
12.8%
-15.6%
10.5%
18.9%
15.0%
Drop in hospital days
Drop in ER use
Increase Chronic Medication use
Total cost
Drop Inpatient specialty care costs
Ancillary costs down
Outpatient specialty down
Outcomes of Implementing Patient Centered Medical
Home Interventions: A Review of the Evidence from
Prospective Evaluation Studies in the US - PCPCC Oct 2012
24 July 2014 Michigan Blues’ patient-centered medical home program
shows statewide transformation of care YEAR 6
•9.9 percent lower rate of adult ER visits
•27.5 percent lower rate of adult ambulatory care sensitive
inpatient stays
•11.8 percent lower rate of adult primary care sensitive ER
visits
•8.7 percent lower rate of adult high-tech radiology usage
•14.9 percent lower rate of pediatric ER visits
•21.3 percent lower rate of pediatric primary-care sensitive ER
visits
4,022 primary care doctors at 1,422 practices around the state
in its sixth year of operation. These practices care for more
than 1.2 million BCBSM members.
USA 2012
Ogden UT
Wienke Boerma
Nivel Institute
Utrecht, Holland.
Amb Wos
Tabulating
Systems Era
Programmable
Systems Era
Cognitive
Systems Era
Watson is ushering in a new
era of computing
2011
1900
1950
MobileFirst Patient Consumer
Practice transformation away from episode of care
Preventive
Medicine
Chronic Disease
Monitoring
Medication
Refills
Acute Care
Test Results
DOCTOR
Master Builder
Case
Manager
Source: Southcentral Foundation, Anchorage AK
Behavioral
Health
Medical
Assistants
Nursing
PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain
Chronic
Disease
Monitoring
Medication
Refills
Healthcare
Support
Team
Point of
Care Testing
Acute
Care
Test
Results
Case
Manager
Source: Southcentral Foundation, Anchorage AK
Preventive
Medicine
Clinician
Acute
Mental
Health
Complaint
Medical
Assistants
Chronic
Disease
Compliance
Barriers
Behavioral
Health
Healthcare Will Transform --- Family Medicine for America’s Health
Data Driven
Every person has a plan
Team based
Managing a population
down to the person
.
Today’s Care
My patients are those who make appointments to see
me
Care is determined by today’s problem and time
available today
Care varies by scheduled time and memory or skill of
the doctor
I know I deliver high quality care because I’m well
trained
Patients are responsible for coordinating their own
care
PCMH Care
Our patients are the population community
Care is determined by a proactive plan to
meet patient needs with or without visits
Care is standardized according to evidence-based
guidelines
We measure our quality and make rapid changes to
improve it
A prepared team of professionals coordinates all
patients’ care
It’s up to the patient to tell us what happened to them
We track tests & consultations, and follow-up after
ED & hospital
Clinic operations center on meeting the doctor’s
needs
A multidisciplinary team works at the top of our
licenses to serve patients
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
Defining the Care Centered on Patient
Superb Access to
Care
Patient Engagement in
Care
Team Care
Communication
Patient Feedback
Clinical Information
Systems, Registry
Care Coordination
Mobile easy to use and
Available Information
Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement
Operational
Care
Coordination:
Embedded RN
Primary Care Coordinator and
Capacity:
Health Plan Care
Patient
Coordination $
Centered
Medical Home
Value/ Outcome
Measurement:
Reporting of Quality,
Utilization and Patient
Satisfaction Measures
HIT
Infrastructure:
EHRs and
Connectivity
Source: Hudson Valley Initiative
Value-Based
Purchasing:
Reimbursement
Tied to
Performance on
Value (quality,
appropriate
utilization and
patient satisfaction)
Achieve Supportive
Base for ACOs and
Bundled Payments
with Outcome
Measurement and
Health Plan
Involvement
Payment reform requires more than one method, you
have dials, adjust them!!!
“fee for health”
“fee for value”
“fee for outcome”
“fee for process”
“fee for belonging
“fee for service”
“fee for satisfaction”
Businesses are no longer accepting cost-shifting.
40% of commercial in-network payments are value-based up from 11% -- 2012
Government and private insurers increasingly are paying for value and outcomes, not
volume; they are also employing new payment models for hospitals and clinicians.
Half of these payments are “at risk” and
half are upside only.
Transformation is Here
•
•
•
•
•
HHS to spend $840 million on readying practices for value-based pay. -- Part of the 10 Billion
The Transforming Clinical Practice Initiative will invest $840 million over four years to support
150,000 clinicians.
It will provide a combination of incentives, tools and information to encourage doctors to team
with peers and others to transition to value-based services.
Momentum building toward value-based payment methods, this initiative hopes to leverage the
success of leading practices, health systems and professional orgs to coach others in how to best
move to value-based reimbursement. It fits well into the broader federal strategy.
Transforming Clinical Practice
Group practices health systems and Medical Societies
Impact 150,000 clinicians
•
AND You ARE READY!!!!!!!
•
•
Benefit Redesign - Patient Engagement
Different Strategies for Different Healthcare Spend Segments
Those with
severe, acute
illness or
injuries
% Total
Healthcare
Spend
Those with
chronic
illness
% of Members
Those who
are well or
think they
are well
PCMH 2.0 in Action
A Coordinated
Health System
Hospitals
Community Care Team
PCMH
Specialists
PCMH
Public Health
Prevention
Nurse Coordinator
Social Workers
Dieticians
Community Health Workers
Care Coordinators
Public Health Prevention
HEALTH WELLNESS
Health IT
Framework
Global Information
Framework
Evaluation
Framework
Operations
need to move from traditional care provider to health partner
if your do not choose innovation (play a better game) you will
be forced into disruption ( game Changed for you). Honest you
can see it coming and some places is already there
Millennials are already finding the convenience, economics and
technology in powerful virtual engagement compelling so you
can chose innovation or disruption.
Virtual access become a required defensive strategy Primary
Care team engaged in virtual augmented relationship – or your
history loss the relationship.
Thank you
A comprehensive approach helps reduce costs while improving care
KNOWLEDGE
INTERVENTION
Identify and influence individuals
and populations, and recognize
intervention opportunities
Drive evidence-based and
standardized care planning
LEARNING
Apply new insights from
interactions and outcomes
to enable continuous
transformation
COLLABORATION
WELLNESS
COORDINATION
Deliver care and monitor progress across
clinical and social requirements
Assess and engage
individuals and
stakeholders to drive
individualized care plans
Asking New Questions
From
To
How many patients can you see?
How many patients’ problems can you solve?
From
To
How can we encourage and convince patients to get required prevention?
From
To
How often should a physician see a patient to optimally monitor a condition?
How can we create systems that significantly increase that patients get
required prevention?
What is the best way to optimally monitor a condition?
*Source: 2014 Kaiser Permanente Jack Cochran
What new skills are required for the future
family physician and what old skills might
no longer be necessary?
How can we know if the changes underway
in our practices are good for patients?
What are the implications for how we teach
and study family medicine?
What new payment models will be required
for this model of care to succeed?