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81%82% 82% 82%

89%91%

92% 92% 92% 92%

The Perfect Time for 30 Million New PatientsCoverage Expansion Creates Immediate Access Challenge

Source: Congressional Budget Office. “CBO‘s February 2013 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage.” February 5, 2013. http://cbo.gov/sites/default/files/cbofiles/attachments/43900_ACAInsuranceCoverageEffects.pdf (accessed March 19, 2013); Medical Group Strategy Council interviews and analysis.

Percentage of Insured Non-elderly Americans

n=267,000,000 (2010), 282,000,000 (2019)

2014 brings 12 million newly insured, largest increase in expansion over a single year

Health Care Utilization, Massachusetts Adults

Change Based on Self-Reported Data, 2006-2008

One annual doc-tor visit

Multiple doctor visits

65% 62%

2006 2008

79%

66%39% of exchange enrollees previously lacked usual source of care

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Inching Towards Population ManagementRising Volumes, Price Pressures Call for Expanded Care Services

Source: Medical Group Strategy Council interviews and analysis.1) Advisory Board Company Population Health Leaders

survey, fall 2012; n=30.

New Responsibilities of the Integrated Medical Group

Reducing Downstream Care Costs

Identify, Manage High-Risk Patients

Create Streamlined, Effective Discharge Process

Maximize Procedural Efficiency

Expand Chronic Care Access

Standardize Chronic Care Pathways

Facilitate Care Plan Compliance

Bolstering Ambulatory Services

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Doing More with LessPhysician Shortage Creates Urgency to Become More Resourceful

… Opens Our Eyes to Other Providers

Source: Dill, Michael J., and Edward S. Salsberg. AAMC Center for Workforce Studies, "The Complexities of Physician Supply and Demand: Projections Through 2025." Last modified November 2008. Accessed March 21, 2013. https://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf; Okie, Susan. “The Evolving Primary Care Physician.” New England Journal of Medicine. 366. (2012): 1849-1853. http://www.nejm.org/doi/full/10.1056/NEJMp1201526 (accessed March 20, 2013); Medical Group Strategy Council interviews and analysis.

2006 2015 2020 2025500,000

600,000

700,000

800,000

900,000

Insufficient Physician Supply…

Demand

Supply

Projected 2005-2025

Narrowing the Skill Gap

Douglas Kelling, MDInternist

“We’ve found that 98% or 99% of all patients, with our systems and pathways, can be managed by the physician assistants and nurse practitioners.”

”

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There’s no “I” in “Team”New Models Expand Physician’s Reach

Source: Naylor MD, Coburn KD, Kurtzman ET, et al. “Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care.” Health Affairs. (May 2012). http://healthaffairs.org/blog/2012/05/04/a-social-compact-for-advancing-team-based-high-value-health-care/ (accessed January 14, 2014); Green, Linda V, Sergei Savin, and Yina Lu. "Primary Care Physician Shortages Could Be Eliminated Through Use of Teams, Nonphysicians, and Electronic Communication."  Health Affairs. 32. no. 1 (January 2013): 11-19. http://content.healthaffairs.org/content/32/1/11.full.pdf+html (accessed March 19, 2013); Medical Group Strategy Council interviews and analysis.

Team-based Care in Brief

Naylor MD, Coburn KD, Kurtzman ET, et al.

“The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.”

2,1493,169

2,3133,344

Estimated Average Panel Size per PCPAssuming 20 Appointment Slots per Day,

50% Same-Day Access

Three PCPs at single practice site available to see each other’s patients

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Re-envisioning Team-based Care

Source: Medical Group Strategy Council interviews and analysis.

Key Imperatives

Maximize Team SkillsEnsure care team members work at top-of-license

Encourage CollaborationSupport coordination, communication within the care team

Engage PatientsReorient decision-making, care planning around patients and caregivers

Increasing Traditional Practice Efficiency

Realizing Patient-Centered Care

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Maximize Performance Level of All Practice StaffBringing All Practice Team Members to Highest Level of License1

Source: Health Care Advisory Board nterviews and analysis.

Maximize Team Skills

1) State law and institutional risk must be taken into consideration.

2) Such as foot screening;

• Assists with patient education• Co-leads group visits• Triages patient phone calls using protocols

• Actively owns patient management• Leveraged for same-day and after-hours access• Sees patients with minimal supervision

In Typical Primary Care Office• Spends most of visit treating acute conditions• Refers patients to specialists with minimal

follow-up• Little care standardization across patients

• Prioritizes time for patient follow-up • Reaches out to encourage patient self-

management• Conducts one-on-one patient education

• Triages incoming patient calls • Spends majority of time on acute patient

ailments

• Rooms patients, takes vital signs, assesses reason for visit

• Has down time on slower days

• Triages incoming patient calls• Provides reminder calls to patients before

scheduled appointments

• Thoroughly screens patient needs and reviews chart, labs, self-management goals in pre-visit chart review

• Performs pre-physician services2, records in chart

• Liaises with clinic nurse before appointment to check for outstanding patient needs before reminder calls

• Discusses pre-visit testing with patient

In Medical Home• Provides standardized chronic, preventive care• Manages and leads multi-level care team• Coordinates with specialists, hospital to provide

cross-continuum care continuity

• Not always found in primary care practices• Spends majority of time on acute care• Might not see patients independently

• Functions similarly to an MA

PCP

RN

Front Desk Staff

MA

How tAP

LPN

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Foster Collaboration Among ProvidersPhysician Resistance a Common Theme, but Not Insurmountable

Source: Medical Group Strategy Council interviews and analysis.

Encourage Collaboration

Educate physicians on team model, other team members’ roles

Use compensation as a motivational tool, taking steps to carefully manage change

Overcoming Physician Barriers

Skeptical

Risk Averse

Unprepared

Train physicians on team leadership

Not Ready to Let Go

Medical directorEmployed medical group

“Physicians too often just don’t want to delegate patient care to other staff—they don’t understand what they can contribute, and they don’t want to let go of the patient relationships they have built.”

”

Source of Frustration for PCPs“Having an AP and PCP both working at the top of their licenses creates some competition and leaves the physician seeing the “harder,” sicker patients. Without incentives, the PCP is not especially motivated to participate in that arrangement.”

Donna LittlepageCFO, Carilion Clinic

”

Unconvinced of care team abilities

Communication

Lack team-based management, delegation skills

Training

CompensationWary of change, particularly when own income at risk

Common Physician Trait

Performance Lever

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Breaking the Fourth Wall

Source: Medical Group Strategy Council interviews and analysis.

Putting the Patient at the Center of Care

Institute of Medicine Working Group1

“In high-functioning health care teams, patients are members of the team; not simply objects of the team’s attention; they are the reason the team exists and the drivers of all that happens.... Having patients as members of teams is more than a shift in framing.”

Meet Your Newest Team Member: The Patient

” Key Considerations

• What is the role of the patient? How does this vary and change across settings and teams?

• What processes are in place to incorporate patients? What rules and expectations do we need to formally and informally put in place?

• How can we communicate more effectively? Are we transparent with patients? Do we use plain language?

Engage Patients

1) Matthew K. Wynia, MD, Isabelle Von Kohorn, MD, Pamela H. Mitchel, RN