creating ideal primary care joseph e. scherger, md, mph june 30, 2010
TRANSCRIPT
Creating Ideal Creating Ideal Primary CarePrimary Care
Joseph E. Scherger, MD, MPHJoseph E. Scherger, MD, MPH
June 30, 2010June 30, 2010
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What is Ideal Primary What is Ideal Primary Care?Care?
Patients receive all the time they need Patients receive all the time they need and want for care with great serviceand want for care with great service
Patients receive the best carePatients receive the best care Physicians and staff enjoy their work Physicians and staff enjoy their work
and sustain high level professional and sustain high level professional satisfactionsatisfaction
Medical errors are minimizedMedical errors are minimized Physicians are supported by a team and Physicians are supported by a team and
care for the right number of patientscare for the right number of patients
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What is a Patient-Centered What is a Patient-Centered Medical Home?Medical Home?
A Patient-Centered Medical Home A Patient-Centered Medical Home (PCMH) is a model for care (PCMH) is a model for care provided by physician practices provided by physician practices that seeks to strengthen the that seeks to strengthen the physician-patient relationship by physician-patient relationship by replacingreplacing episodic careepisodic care based on based on illnesses and patient complaints illnesses and patient complaints with with coordinated carecoordinated care and a long- and a long-term healing relationship (NCQA).term healing relationship (NCQA).
Adapted from Joint Principles of the Patient-Centered Medical Home, March 2007. Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome.pdf.
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The Time Problem – The Time Problem – Current Primary Care Current Primary Care
Time Needed for Time Needed for Chronic Illness CareChronic Illness Care
Time Needed for Time Needed for Preventive CarePreventive Care
Time Needed for Time Needed for Acute CareAcute Care
Total face to face Total face to face time for 2500 time for 2500 patientspatients
Ann Fam Med 2005;3:209Ann Fam Med 2005;3:209
Am J Pub Health 2003;93:635Am J Pub Health 2003;93:635
10.6 hours a day 10.6 hours a day for 2500 patientsfor 2500 patients
7.4 hours a day7.4 hours a day
4.6 hours a day4.6 hours a day
22.6 hours/day22.6 hours/day
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The Ticking Clock in the The Ticking Clock in the Doctor’s OfficeDoctor’s Office
““Patients on routine visits to Patients on routine visits to their primary doctors often have their primary doctors often have lots of questions but not enough lots of questions but not enough time to get good answers.”time to get good answers.”Patients leave the office with an Patients leave the office with an average of 3 unanswered average of 3 unanswered questionsquestions
- - New York Times, New York Times, February 6, 2007February 6, 2007
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58 y/o female with obesity and diabetes comes 58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and in with symptoms of fatigue, insomnia and
back pain. She has a 15 minute appointmentback pain. She has a 15 minute appointment
HEDIS diabetes measures for this patientHEDIS diabetes measures for this patient::
Percent with an annual retinal exam Percent with an annual retinal exam Percent with one of more glycohemoglobin tests Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests Percent of those having glycohemoglobin tests
showing a level of <7.5 % (goal 7.0%)showing a level of <7.5 % (goal 7.0%) Percent with an annual screening test for Percent with an annual screening test for
microalbuminuria microalbuminuria Percent with two or more blood pressure checks Percent with two or more blood pressure checks
per year per year Percent of those with one or more blood pressure Percent of those with one or more blood pressure
checks having a systolic BP <135 (goal <<130/80)checks having a systolic BP <135 (goal <<130/80) Percent with an annual lipid panel Percent with an annual lipid panel Percent of those with an annual lipid panel Percent of those with an annual lipid panel
showing an LDL level <130 mg/dL (goal << 100)showing an LDL level <130 mg/dL (goal << 100)
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Case con’tCase con’t
Other Diabetes Measures:Other Diabetes Measures: Flu vaccineFlu vaccine Pneumovax vaccinePneumovax vaccine Dental visitDental visit Cardiac screening testsCardiac screening tests Lab monitoring for side effects of Lab monitoring for side effects of
medicationsmedications Annual foot examAnnual foot exam
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Case con’tCase con’t
Cancer screening needs:Cancer screening needs: Colon- needs colonoscopy (or 3 other Colon- needs colonoscopy (or 3 other
types of screening)types of screening) Cervical- needs pap if last <1-3 years Cervical- needs pap if last <1-3 years
priorprior Breast- needs annual mammogramBreast- needs annual mammogramOsteoporosis screening and preventionOsteoporosis screening and preventionDepression screening and management Depression screening and management
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Case con’tCase con’t
General health issues:General health issues: Adult DTaP vaccineAdult DTaP vaccine Weight managementWeight management Advance directivesAdvance directives Culturally-sensitive careCulturally-sensitive care Diabetic education and self management Diabetic education and self management Tobacco screenTobacco screen Alcohol screenAlcohol screen Domestic violence screenDomestic violence screen What about the fatigue, insomnia and What about the fatigue, insomnia and
back pain?back pain?
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Only 27% of hypertension is adequately controlled.
27%
Only 26% of people with diabetes have blood pressures well controlled.
26%
Only 25% of people with depression receive treatment.
25%
50% of patients hospitalized with congestive heart failure (CHF) are
readmitted within 90 days.
50%
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Care Does Not Equal VisitsCare Does Not Equal Visits
Optimal care is based on deep, trustful Optimal care is based on deep, trustful relationships between practice and patientsrelationships between practice and patients
A great relationship demands that we go far A great relationship demands that we go far beyond visits in delivering care to patientsbeyond visits in delivering care to patients
An outmoded way of managing patients
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13Improved Outcomes
Informed,Activated
Patient
ProductiveInteractions
Prepared,Proactive
Practice Team
Resources and Policies
Community
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Health Care Organization
Chronic Care Modelhttp://www.improvingchroniccare.org
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Different Models of Different Models of Idealized Primary CareIdealized Primary Care
Organized Team Model – Each PCP covers Organized Team Model – Each PCP covers a large panel of patients (2000 or more) a large panel of patients (2000 or more) with one or more mid-level providers and with one or more mid-level providers and others onsite such a care manager, care others onsite such a care manager, care coordinators, pharmacist and others.coordinators, pharmacist and others.
Relationship Centered Model – Each PCP Relationship Centered Model – Each PCP is a personalized care physician and has a is a personalized care physician and has a smaller panel size (600-1200) with an smaller panel size (600-1200) with an activated medical assistant as care activated medical assistant as care coordinator and a “neighborhood” of coordinator and a “neighborhood” of team members helping to coordinate team members helping to coordinate care.care.
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Organized Team ModelOrganized Team Model
Larger panel size per physicianLarger panel size per physician Everyone works to the limit of their Everyone works to the limit of their
license, dividing the services license, dividing the services among the teamamong the team
Medical Home care coordination Medical Home care coordination payment may be as low as $4 pmpm payment may be as low as $4 pmpm to pay for care coordinatorto pay for care coordinator
Physician work schedule focuses on Physician work schedule focuses on more complex patientmore complex patient
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Relationship Centered Relationship Centered ModelModel
Smaller panel size per physicianSmaller panel size per physician Longer visits and fewer patients seen dailyLonger visits and fewer patients seen daily Activated medical assistant, often an LVN Activated medical assistant, often an LVN
or RN, serves as a patient care coordinator or RN, serves as a patient care coordinator in co-practice with the physicianin co-practice with the physician
Medical Home care coordination payment Medical Home care coordination payment larger, $30-50 pmpm, often paid by the larger, $30-50 pmpm, often paid by the patient as a “membership” to the patient as a “membership” to the physician (resembles concierge practice physician (resembles concierge practice with online communication rather than with online communication rather than cell phone)cell phone)
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HIT Functions for Ideal HIT Functions for Ideal Primary CarePrimary Care
Patient Registry – needed for proactive Patient Registry – needed for proactive care and quality measurementcare and quality measurement
eRx – needed for avoiding medication eRx – needed for avoiding medication errorserrors
EHR – needed for organizing and EHR – needed for organizing and accessing patient dataaccessing patient data
Clinical Decision Support – needed for Clinical Decision Support – needed for smart practice and avoiding medical smart practice and avoiding medical errorserrors
Patient Portal – needed for continuous Patient Portal – needed for continuous access for communication and careaccess for communication and care
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Eisenhower Primary Care Eisenhower Primary Care 365 Origins365 Origins
1998 - Idealized Design of Clinical 1998 - Idealized Design of Clinical Office Practice (IHI collaborative and Office Practice (IHI collaborative and annual conferences)annual conferences)
2001 - Crossing the Quality Chasm 2001 - Crossing the Quality Chasm (IOM Report) Care is based on a (IOM Report) Care is based on a continuous health relationship (and continuous health relationship (and not on visits)not on visits)
2001 – Launch of Greenfield Health 2001 – Launch of Greenfield Health Practice in Portland, OR by Chuck Practice in Portland, OR by Chuck Kilo and othersKilo and others
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Old Primary Care Old Primary Care ScheduleSchedule
First patient at 8 am and 12 First patient at 8 am and 12 patients each half day patients each half day sessionsession
24 patient visits24 patient visits 12 patient phone calls12 patient phone calls Done at 6:30 PMDone at 6:30 PM Patients served -- 36Patients served -- 36
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Ideal Physician ScheduleIdeal Physician Schedule Begin online message at 8 am and Begin online message at 8 am and
communicate with 10-15 patients.communicate with 10-15 patients. First patient at 9 AM – 5-6 First patient at 9 AM – 5-6
patients/sessionpatients/session 10-12 patient visits – vary in length from 10-12 patient visits – vary in length from
brief to extendedbrief to extended 6 patient phone calls (telephone visits)6 patient phone calls (telephone visits) 30 patient e-visits and messages in 2 30 patient e-visits and messages in 2
sessions lasting 30 min. eachsessions lasting 30 min. each Done at 5:30 PMDone at 5:30 PM Patients served – 46-48Patients served – 46-48
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What is an Ideal Primary What is an Ideal Primary Care Panel Size?Care Panel Size?
2000 to 3000 numbers are historic 2000 to 3000 numbers are historic and not based on any strategic and not based on any strategic analysis – origins from a time when analysis – origins from a time when people when to physicians only when people when to physicians only when they were sick - may work for they were sick - may work for organized team modelorganized team model
Greenfield Health panel size 1000Greenfield Health panel size 1000 EPC 365 panel size 900 with more EPC 365 panel size 900 with more
seniorsseniors Concierge medicine with cell phone Concierge medicine with cell phone
access – 200 to 600access – 200 to 600
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PCMH Hybrid Financial PCMH Hybrid Financial ModelModel
Payment for care coordination by a Payment for care coordination by a team outside of visits (and for team outside of visits (and for improved access, smaller panel sizes, improved access, smaller panel sizes, more time with the physician)more time with the physician)
EPC 365 - $595 annually for EPC 365 - $595 annually for individuals, $555 for couples and individuals, $555 for couples and household family, no fee for children household family, no fee for children 18 and under if parents join18 and under if parents join
Regular billing for office visitsRegular billing for office visits 60% of income comes from the fee.60% of income comes from the fee. Physician incomes of $225-250k with Physician incomes of $225-250k with
10-12 visits/day (overhead cap of 60%)10-12 visits/day (overhead cap of 60%)
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The Major Redesign The Major Redesign Elements of Ideal Primary Elements of Ideal Primary
CareCare Care becomes Care becomes continuouscontinuous
rather than episodic based rather than episodic based only on visitsonly on visits
Care becomes Care becomes proactiveproactive rather than reactiverather than reactive
Patients become activated for Patients become activated for greater greater self-managementself-management
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We’ve Only Just We’ve Only Just Begun Begun
the Redesign of the Redesign of Primary CarePrimary Care
Thank you!Thank you!
