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
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
% Don’t Know
% Agree % Disagree or Uncertain
Value having one PCP
94
2
4
Helpful for PCP to
participate in decision
to see specialist
89
3
8
Source: Grumbach. JAMA, 1999;282:261
Percentage of Office Visits According
to Physician Specialty, By Primary Dx
90%
80%
70%
60%
Generalist
50%
Specialist
40%
30%
20%
10%
0%
HTN
DM
ASCVD
COPD
Source: L Green, Analysis of 1996 Natl Amb Med Care Survey
Mean % of Preventive Services Received
Uninsured
Insured (Medicaid or private)
100%
C
80%
60%
B
A
D
85%
F
E
90%
81%
70%
57%
42%
40%
20%
0%
No Regular Place
Regular Place
Source: Bindman, J Gen Int Med 1996;11:269
Regular Place and
Optimal Primary Care
Outcomes of Patients with Specialists
or Generalists as a Regular Physician
Relative Difference
1.2
1.0
0.8
1.0
1.0
0.77
0.81
Specialist
Generalist
0.6
0.4
0.2
0.0
Annual Costs
5 Year Mortality
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
The Widening Physician Payment Gap
$450,000
Diagnostic Radiology
$400,000
Orthopedic Surgery
Annual Income
$350,000
$300,000
$250,000
Primary Care
$200,000
$150,000
$100,000
Family Medicine
$50,000
Source: Robert Graham Center
Year
20
03
20
01
19
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
81
19
79
$0
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
97%
100%
89%
78%
80%
60%
50%
43%
40%
29%
20%
0%
US
Australia
Canada
Source: C Schoen et al, Health Affairs, 28, no. 6 (2009): w1171-w1183
France
Netherlands
UK
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 20th Century Model of Primary Care
Will Not Meet the Demands of 21st
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 MacDonald, 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:e71
Group Health PCMH Pilot:
Effect on Clinic Staff
40%
35%
34.5% 33.3%
30.0%
30%
Percent with 25%
High Level
20%
Emotional
Exhaustion 15%
p=.02
Baseline
12 Months
9.7%
10%
5%
0%
Control Sites
PCMH Site
Team-based Care: Stable Teamlets
Patient
panel
Patient
panel
Clinician/MA
teamlet
Clinician/MA
teamlet
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%
Neutral
28%
Not satisfied
61%
SFDPH Primary Care Provider Burnout
by Team Model
Maslach Burnout Inventory, n=86-87
90%
80%
80%
70%
59%
60%
50%
40%
40%
38%
30%
27%
20%
20%
15%
14%
10%
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
21%
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, 1000s of medical practices
– 5 Integrated delivery systems
• Group Health, Geisinger, HealthPartners, 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