Innovation in Primary Care: Lessons Learned and Future Directions Asaf Bitton MD, MPH, FACP Associate Physician, Brigham and Women’s Hospital Instructor in Medicine and Health Care Policy, Harvard Medical School Assistant Medical Director, BWH Advanced Primary Care Associates CIMIT Investigator A*STAR-Khoo Teck Puat Hospital Forum on Primary Care Transformation March 23 rd , 2012
Dr Asaf Bitton @ A*STAR-KTPH Forum on Primary Care (23-Mar-12)
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Innovation in Primary Care: Lessons Learned and Future Directions
Asaf Bitton MD, MPH, FACP
Associate Physician, Brigham and Women’s HospitalInstructor in Medicine and Health Care Policy, Harvard Medical School
Assistant Medical Director, BWH Advanced Primary Care AssociatesCIMIT Investigator
A*STAR-Khoo Teck Puat Hospital Forum on Primary Care Transformation
March 23rd, 2012
“Every system is perfectly designed to achieve exactly the results it gets.”
Don Berwick, MD MPP
Singapore
Cost-Related Access Problems, 2011
4
Percent of adults who went without care because of cost in past year *
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
* Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.
A “Perfect Storm” Unsustainable cost growth, inadequate quality, fragmented care, workforce shortage, aging population
Michael Patmas MD, OHSU, 2006
Primary Care as a Focus for Innovation and Systems Change
•Increased access and/or
equitable distribution of care
•Prevention and early
management of health problems
•Reduction of unnecessary and
harmful specialist interventions
•Coordination and integration
across multiple conditions,
treatments, and medications
•Decreased
health
expenditures
•Equal or better
health outcomes
•Better patient
experiences and
increased
satisfaction
Primary Care
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for:
addressing a large majority of personal health care needs
developing a sustained partnership with patients
practicing in the context of family and community
Source: IOM, Defining Primary Care: An Interim Report. 1994.
Essential Attributes of Primary Care
Whole Person
Orientation
ContinuityCoordination/
Integration
Comprehen-
siveness
Accessibility
PRIMARY
CARE
First contact care
characterized by:
Health Expenditures: Generalists and Specialists Compared
Specialist Density and
Health Expenditures
Generalist Density and
Health Expenditures
Source: Baicker K & Chandra A. Health Affairs. 2004. Web Exclusive. Dartmouth Atlas projects
Better Primary Care Associated with Lower Costs
0
500
1000
1500
2000
2500
3000
3500
4000
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
Average Primary Care Score
Per
Cap
ita H
ealt
h C
are
Exp
en
dit
ure
s
France
US
Germany
Belgium
The Netherlands
Finland
Spain
Denmark
Canada
Australia
Sweden
Japan
United
Kingdom
Source: Starfield B, Shi L. Health Policy. 2002; 60: 201-218.
Primary Care Scores vs. Per Capita Health Care Costs
11
22
30
4142
495355
0
25
50
75
GER NZ NETH AUS UK US CAN
Percent
Source: 2007 Commonwealth Fund International Health Policy Survey
Able to Get Same Day
Appointment with Doctor
89
11
56
1516
0
5
10
15
20
25
GER NETH UK NZ AUS US CAN
ER Use for Condition Doctor Could
Have Treated if Available
Percent
Access to Primary Care
Patients Value Primary Care
Patient Attitudes Towards Primary Care
Physicians and Specialist Use
Agree
(%)
Disagree
(%)
Don’t Know
or Uncertain
(%)
Value having one primary care
physician94 2 4
Values PCP participation in
decision to see specialist89 3 8
Can decide whether to see
PCP or specialist for a new
problem for myself
46 28 26
Source: Grumbach K et al., JAMA; 281(3): 261-266.
0
10
20
30
40
50
60
70
80
90
Cough and
Wheezing
Arthritis in
Knee
Blood in Stool
Prefer PCP Prefer Specialist
PCP versus Specialist
Preference as First-Contact
Physician for Selected Medical
Problems
Reinventing Our Delivery System
“Current care systems cannot do the job. Trying harder will not work. Changing systems
of care will.”
Institute of Medicine. Crossing the Quality Chasm. 2001
What is a Patient Centered Medical Home?
“Medical Home? That sounds like a Nursing Home…”
Patients not aware
PCMH: different meanings to different stakeholders
Invention vs. Innovation
Kitty Hawk, 1903 DC-3, 1935
PCMH Joint Principles
Patient
Personal Physician
Enhanced Access
Payment Reform
Care Coordination
Physician Led Practice
Quality/ Safety
Whole Person
“Home Team, Centered Around the Patient”
Connected
through HIT
Common Elements of PCMH
Personal Physician
Team-based practice
Expanded access
Emphasis on coordination of care
Proactive population health management
Care facilitation and data analysis with HIT
New forms of payment
Fields et al, Health Affairs, May 2010
Does HIT = Medical Home?
Necessary but alone not sufficient
Enables coordinating connections
Current Needs:
Robust decision support
Registry tools
Tools enabling team function and pt engagement
Personal health records
Bates D and Bitton A. “The Future of HIT in the PCMH”. Health Affairs. April 2010.
Smaller Practices Lag Behind Large Practices in HIT
49
27
75
50
7
21
0
25
50
75
100
Use electronic medical records in practice High electronic information functionality*
Solo practices
Small and medium practices (2–9 physicians)Large practices (10 or more physicians)
* To assess HIT multifunctionality, a 14-count scale was developed. The multifunctional HIT capacity summary variable,
counting the number of functions and categorized systems, includes low (0–3), middle (4–8), and high (9–14).
Source: The Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.
HITECH: Advancing the Tipping Point
TIME
Technology Adoption
2004 2012
National
Coordination
Enhanced
Trust
Grant
Programs
Payment
Incentives
Source: David Bates MD, MSc
Spurring Use of HIT“To increase the effective use of EHRs:
1. Get doctors, hospitals, and other health care providers to acquire and use electronic health records.
2. Get those electronic health records to "talk to one another" by becoming interoperable.
3. Get providers to use EHRs to improve quality and efficiency in the provision of health care services.”
(The Federal Role in Promoting Health Information Technology,Commonwealth Fund, 2009)Source: David Bates MD, MSc
2009 2011 2013 2015
HIT-Enabled Health Reform
HITECH
Policies2011 Meaningful
Use Criteria
(Capture/share
data)2013 Meaningful
Use Criteria
(Advanced care
processes with
decision support)
2015 Meaningful
Use Criteria
(Improved
Outcomes)
Meaningful Use “Ascension Path”
Report of sub-committee of Health IT Policy CommitteeSource: David Bates MD, MSc
Certified EHR Required
Meaningful Use Incentives
BUT…Penalty of 1%/yr (max 5%) reimbursement starting 2015
TODAY’S CARE MEDICAL HOME CARE
My patients are those who make
appointments to see me
Our patients are those who are
registered in our medical home
Care is determined by a proactive plan
to meet patient needs without visits
Care is determined by today’s
problem and time available today
A prepared team of professionals
coordinates all patients’ care
Patients are responsible for
coordinating their own care
We measure our quality and make
rapid changes to improve it
I know I deliver high quality care
because I’m well trained
We track tests & consultations, and
follow-up after ED & hospital
It’s up to the patient to tell us what
happened to them
A multidisciplinary team works at the
top of our licenses with a patient focus
Focus of the clinic is the doctor’s
needs
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
Patient-Centered Medical Homes Nationwide
RI
Multi-Payer pilot discussions/activity
Identified pilot activity
No identified pilot activity – 6 States
National PCMHDemonstration Activity
Source: PCPCC
NCQA Recognized Sites, 2010
Results for Current National Demos
Practices 4,659
Physicians 14,389
Patients 4,900,000
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
Models for PCMH Payment
Enhanced Fee for Service (FFS)
Higher technical fees
New codes for phone call and emails
Higher volume with mid-level providers
Capitation
Comprehensive Risk Adjusted Payment Model (NY/MA)
3 part model
FFS
Enhanced pay for performance
Care management fees (per person per month)
Payment for Current National Demos
Per Person Per Month (PPPM) Payments 96%
Range of PPPM Payments $0.50 to $9.00
Range of Additional Revenue per MD/yr$720 to $91,146
(median $22,834)
Upfront or Start-up Payments 42%
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
PCMH Evaluation: How do you know if this works?
Multi-Dimensional Evaluations
Transformation
Efficiency Quality Experience
Patient Staff
Education
Early PCMH ResultsProject Hosp ER Visits Quality Pt
ExperienceTotal $ per patient/yr
Group Health Cooperative (WA)
-6% (all)
-13% (ACSC)
-29% Improved Improved in 5 / 7 scales
-$120
Geisinger (PA) -18% (all)
-36% (re-ad)
NA NA NA -7% (+5% to -18%)
(Not Stat Significant)
NDP (national) NA NA Improved Slightly worse (NS)
*Practice Rev +2% to 12%
Community Care of North Carolina*
-40% NA Improved asthma, DM
NA -$516
Colorado Medical Homes for Children*
-18% -16% NA NA -$169 (all)
-$530 (c. dz)
Intermountain (UT)* -5% (all)
-19% (c.dz)
0% (all)
-7% (c.dz)
NA NA -$640
North Dakota BCBS* -6% -24% NA NA -$530
Vermont Blueprint* -11% -12% NA NA -$215
*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease
NS = not statistically significant re-ad = readmissions
35
Experienced Coordination Gaps in Past Two Years, by Medical Home
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information
with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
36Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
Patient Engagement in Care Management for Chronic Condition, by Medical Home
37Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Percent reporting positive patient engagement in managing chronic condition*
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make
treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
38Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
7476
7474
50525352
3431
38
44
0
25
50
75
100
Total White African American Hispanic
Medical home
Regular source of care, not a medical home
No regular source of care/ER
Percent of Adults 18-64 Reporting Having Received Needed
Medical Care, by Racial and Ethnic Group and Source of Care
Source: Beal AC et al. The Commonwealth Fund. June 2007. Data from Commonwealth Fund 2006 Health Care Quality
Survey.
Equity-Enhancing Effects
PCMH in Practice: Brigham and Women’s Advanced Primary Care Associates, South Huntington
Structure: Core Clinical Team
3 Teams:
•1.5 MD•1-2 Residents
•2 students (MD), and other students (RN)• 1 Physician Assistant (8 session)• 1 Licensed Practical Nurse• 2 Medical Assistants• 1 Social Worker
Structure: Shared Resources
• 1 Medical Director• 1 Practice Manager• 1 Pharmacist• 1 Population Manager• 1 Nutritionist• 6 Secretaries (Check-in, Check-out)• 1 Community Resource Specialist• 1 Care Coordination RN
Local Opportunity for Innovation
South Huntington as a “learning laboratory” for team- based practice innovation and training
Developing new training models
System-wide transformation:
60% of practices transform to PCMH by 2013
100% by 2015
Docking Platform for Innovative Technology
Innovative Primary Care Technologies
Moving Outside the PCMH
The Medical Neighborhood
Extends around PCMH “Core” and “Peripheral” neighbors
Varies by community and provider network arrangement
Requires formal, reciprocal care agreements
Enhanced by efficient information transfer (HIT)
Shared risks and incentives for outcomes
Compatible with different payment structures
A stepping stone to ACOs
Source: Pham H, Journal of General Internal Medicine, 2010
Accountable Care Organizations: Integration Through Information and Shared Responsibility
Patient-Centered
Medical Home
Sub-specialty PCMH
Sub-specialty “Medical
Home Neighbor”
Sub-Specialty
Procedural Practice
Hospital
Sub-Acute
Care
HIT
HIT
HIT
HIT
HIT
HIT
HIT
Source: David Bates MD, MSc and Asaf Bitton MD
Accountable Care Organizations (ACO)
48Source: Premier Healthcare Alliance
A group of providers thathas the legal structure toreceive and distributeincentive payments toparticipating providers.
Operations
PCMH
PCMH
PCMH
PCMHHospitals
Public Health Prevention
Community Care Team
Nurse Coordinator
Social Workers
Dieticians
Community Health Workers
Care Coordinators
Public Health Prevention Specialist
Behavioral Health & Substance Abuse
Services
Prevention Programs
Policies and SystemsLocal, state, and federal; economic/cultural; media
CommunityPhysical, social and cultural environment