013 Am09 Presentations Harris

RPA 2009 Annual Meeting Jeffrey P. Harris, MD, FACP Patient Centered Medical Home March 23, 2009

Three Commonly Posed Questions: Why does the ACP, with nearly equal numbers of general internists and subspecialty internists members, advocate for a system that appears more beneficial to primary care physicians? How will my practice and my patients' experiences change? Why should subspecialists support this model?

PCMH/The Central Hub of Care why is it needed what must it provide how might it be funded where should it be

Escalating Costs International Comparison of Spending on Health, 1980–2004 Data: OECD Health Data 2005 and 2006. Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 EFFICIENCY

Total outlays in billions Projected Medicare Outlays, 2008-2018 NOTE: Numbers have been rounded to nearest whole number. SOURCE: Kaiser Family Foundation, based on Congressional Budget Office, The Budget and Economic Outlook: An Update , January 2008. 16% 16% 16% 17% 17% 18% 18% 19% 20% 20% 20% 3% 3% 3% 3% 3% 3% 4% 4% 4% 4% 4% Share of: Federal Budget Gross Domestic Product

Medicare Beneficiaries and The Number of Workers Per Beneficiary Millions of beneficiaries Number of workers per beneficiary SOURCE: Kaiser Family Foundation, based on 2001 and 2008 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. www.commonwealthfund.org

Life Expectancy at Birth in 2005 Source: OEDC Data, 2007

Criteria : Overall Mission to Achieve Long, Healthy and Productive Lives Source: OEDC Data, 2007

USA: MORE ERRORS Deaths Due to Surgical or Medical Mishaps per 100,000 Population in 2004 a 2003 b 2002 a b b b b b Source: The Commonwealth Fund, calculated from OECD Health Data 2006. Cylus J and Anderson GF. Multinational Comparisons of Health Systems Data, 2006

Buyers’ remorse Statement of Peter R. Rosa. Director, Growth in Health Care Costs, Congressional Budget Office, before the Committee on the Budget United States Senate, January 31, 2008 www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthcareSlides.pdf

Primary Care Associated with Decreased Costs According to the Center for Evaluative Clinical Sciences at Dartmouth , for patients with severe chronic diseases, those who live U.S. states that relied more on primary care have: Lower Medicare spending (inpatient reimbursements and Part B payments) Lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor) Lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians) Better quality of care (fewer ICU deaths and a higher composite quality score Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006

States with red circles have PC/Specialty Ratio of < 1.0 States with green circles have PC/Specialty Ratio of >1.45 [In the last two years of life] Dartmouth atlas Quality/Cost Impact

Primary Care Score vs Health Care Expenditures 1997 Source: The Commonwealth Fund, Data from B. Starfield, “Why More Primary Care: Better Outcomes, Lower Costs, Greater Equity,” Presentation to the Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006. Quality/Cost Impact

OECD = Organization for Economic Cooperation & Development PYLL = Potential years of life lost

HPPC Examined Health Care in the USA and Systems in 12 Other Countries

Lesson : High performing systems encourage patients to be prudent purchasers and engage in healthy behaviors Cost-sharing with co-payment schedules based on income can help restrain costs while assuring that poorer individuals have access Incentives to encourage personal responsibility can be effective in influencing healthy behaviors, improved health outcomes and responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles Belgium France Japan New Zealand Switzerland Australia Belgium Japan New Zealand Netherlands Switzerland Taiwan

Lesson: High performing systems measure their own performance Performance measures, financial incentives linked to quality, and active monitoring of performance are key elements of high performing systems Australia New Zealand United Kingdom

Lesson : Primary care is the foundation of high performing delivery systems Societal investment in medical education can help achieve a well-trained workforce with the right proportion of primary care physicians and specialists and is large enough to assure access Investment in primary and preventive care can result in better health outcomes, reduce costs, and help assure an adequate supply of primary care physicians These efforts can be enhanced by assuring that all residents have equitable access to a personal physician through a patient-centered medical home model France Germany United Kingdom Australia, Canada, Denmark France NetherlandsNew Zealand Switzerland UK Denmark

Lesson : The best payment systems recognize the value of care coordinated by primary care physicians Effective payment systems: Provide adequate payment for primary care services Create incentives for quality improvement and reporting Recognize geographic or local payment differences Provide incentives for care coordination Canada Denmark Germany United Kingdom Belgium United Kingdom Denmark Netherlands

Lesson: High performing systems invest in HIT, have uniform billing, and lower administrative costs Adoption of a uniform billing and electronic processing of claims improves efficiency and reduces administrative expenses An inter-operable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision-making and enhance electronic communications among treating health professionals Germany Canada Taiwan United Kingdom and most others Denmark Taiwan Netherlands

Interest in Entering Primary Care has been Declining Among Graduating Seniors (Percentages 1999-2006) Source: Association of American Medical School Graduation Questionnaires http://www.aamc.org/data/gq/allschoolsreports/2006.pdf

Bodenheimer, T. et. al. Ann Intern Med 2007;146:301-306 The Primary Care—Specialty Income Gap

Patient-Centered, Physician-Guided Care Adapted from: Defining Primary Care: An Interim Report, Institute of Medicine 1994 Physician Patient Practice Family Team Integrated Community Delivery System or Virtual Team Core of Team-Based Care NP/PA RN/LPN Medical Assistant Care Coordinator Office Staff Nutritionist/Educator Pharmacist Behavioral Health Case Manager Community resources DM companies Others… Immediate family Extended family Friends Neighbors

What must it provide/Joint Principles patient centered personal physician team approach whole person preventive/acute/chronic/end of life longitudinal care coordinated care high quality and continuous quality improvement navigation of a complex system

PCMH/Payment 1) “Bundled Care” Coordination Fee Physician/non-physician work outside of face-to-face visits (e.g. email, telephone/group visits -Promoting efficiency rather than volume-based care System infrastructure (e.g. HIT) -Encourage coordination of care Risk adjusted -Remove incentives to avoid complex or costly patients

PCMH/Payment 2) Visit based fee-for-service Incentive to physician to see patients in office when appropriate 3) Performance based component Recognize achievement of quality and efficiency

Potential New Payment Codes Care plan oversight for specified condition Communicate with provider of treatment On-going review of patients’ medical status/labs Care plan modification Physician e-mail/telephonic consultations Training and follow up of patient self management by physician/nurse

Health Care Utilization & Primary Care For population of 775,000, an increase from 35% to 40% primary care physicians could: Reduce inpatient admissions by ~2500/year At approximately $9000/admission = $23M Reduce ED utilization by 15,000 visits/year Reduce surgery by about 2500 cases/year *Kravet, S et al: Health Care Utilization and the Proportion of Primary Care Physicians. Amer J of Medicine, 2008; 121:142-148.

Why is the ACP Advocating for Stronger Primary Care and the PCMH Model: Extensively reviewed data from this country and abroad Data compellingly suggest: Better outcomes and reduced costs by expanding primary care

How Might the PCMH Benefit Primary Care Physicians: Narrowing the earnings disparities payment for care coordination performance-based component to recognize quality and efficiency visit-based fee-for-service payment to incentivize physicians to see patients in the office More time to spend with chronically ill patients

How Might the PCMH Benefit Patients: Innovative scheduling systems to minimize delays in getting appointments, Non-urgent medical advice by e-mail and telephone, Same-day care with PCMH-based non-physicians for less complex patient issues, Group teaching of patients with chronic diseases.

How Might the PCMH Benefit Patients: Time for coordinating care with family and other clinicians Evidenced-based point-of-care support tools, and Better health information technology (HIT) to efficiently coordinate all sources of the patient's care within the community and track quality and patient satisfaction measures to promote continuous improvement.

How Might the PCMH Benefit Subspecialists? May head a medical home New billing codes Fewer hassles Better referrals Improved quality of practice Efficient spending

013 Am09 Presentations Harris

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013 Am09 Presentations Harris