Extracting ValuePatient Centered Medical Home

Paul Grundy MD, MPH - IBM Director, Healthcare Transformation

@Paul_PCPCChttps://twitter.com/Paul_PCPCC

Beyond Flexner --- Driven by Actionable - Personalized Data

Course Objectives • participant will understand/be able to discuss the important trend of PCMH in health

care • participant will understand/be able explore the rationale and supporting evidence for

PCMH • - participant will understand/be able understand the impact on patients, providers and

payers

• Disclosure: • – I am a full time Employee of IBM I WILL NOT discuss any pharmaceuticals, medical

procedures, or devices • I have gratefully had my expenses covered to do some of my talks about PCMH by

Abbvie, Merck, and Pfizer.

North Carolina Starts the movement• When Look at the Landscape CCNC was who

was called CCNC now into year 18 !! – CCNC at the first roundtable pre-PCPCC.

• Jan 2015 --Idaho Embraces Medical Home Model Statewide Programs Seek to Facilitate Innovative Care Transitions

– BUT -where the delivery system works – a Patient in a trusting relation with a healer who is a comprehensivist with data is in charge”

In much of the world, no one is in charge. And the result is the most wasteful and Unsustainable

The System Integrator

Creates a partnership across the medical neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial

management

Away from Episode of Care to Management of PopulationWITH DATA

Community Health

PopulationHealth

System Integrator

PatientExperience

Per Capita Cost

Public Health @Paul_PCPCC

https://twitter.com/Paul_PCPCC

36.3% Drop in hospital days32.2% Drop in ER use12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 18.9% Ancillary costs down 15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012

Smarter Healthcare

•9.9 percent lower rate of adult ER visits•27.5 percent lower rate of adult ambulatory care sensitive inpatient stays•11.8 percent lower rate of adult primary care sensitive ER visits•8.7 percent lower rate of adult high-tech radiology usage•14.9 percent lower rate of pediatric ER visits•21.3 percent lower rate of pediatric primary-care sensitive ER visits

24 July 2014 Michigan Blues’ patient-centered medical home program shows statewide transformation of care YEAR 6

4,022 primary care doctors at 1,422 practices around the state in its sixth year of operation. These practices care for more than 1.2 million BCBSM members.

USA 2012

Ogden UT

Wienke BoermaNivel Institute Utrecht, Holland.Amb Wos

Watson is ushering in a new era of computing

TabulatingSystems Era

ProgrammableSystems Era

CognitiveSystems Era

19001950

2011

MobileFirst Patient Consumer

PreventiveMedicine

MedicationRefills Acute Care

Nursing

Test Results

Master Builder

DOCTOR

Source: Southcentral Foundation, Anchorage AK

BehavioralHealth

CaseManager

MedicalAssistants

Chronic DiseaseMonitoring

Practice transformation away from episode of care

Source: Southcentral Foundation, Anchorage AK

PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain

MedicationRefills

ChronicDisease

Monitoring

TestResults

AcuteCare

PreventiveMedicine

Point of Care Testing

Acute Mental Health

Complaint

ChronicDisease

ComplianceBarriers

HealthcareSupport

Team Behavioral Health

MedicalAssistants

CaseManager Clinician

Healthcare Will Transform --- Family Medicine for America’s Health

Data Driven

Every person has a plan

Team based

Managing a population down to the person

.

Today’s Care PCMH CareMy patients are those who make appointments to see me

Our patients are the population community

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs with or without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

Superb Access to Care

Patient Engagement in Care

Clinical Information Systems, Registry

Care Coordination

Team Care

Communication Patient Feedback

Mobile easy to use and Available Information

Defining the Care Centered on Patient

HIT Infrastructure: EHRs and Connectivity

Primary Care Capacity: Patient Centered Medical Home

Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $

Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures

Value-Based Purchasing: Reimbursement Tied to Performance on Value (quality, appropriate utilization and patient satisfaction)

Achieve Supportive Base for ACOs and Bundled Payments with Outcome Measurement and Health Plan Involvement

Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

Source: Hudson Valley Initiative

Payment reform requires more than one method, you have dials, adjust them!!!

“fee for health”“fee for value” “fee for outcome”“fee for process” “fee for belonging“fee for service” “fee for satisfaction”

Businesses are no longer accepting cost-shifting.

40% of commercial in-network payments are value-based up from 11% -- 2012

Government and private insurers increasingly are paying for value and outcomes, not volume; they are also employing new payment models for hospitals and clinicians.

Half of these payments are “at risk” and half are upside only.

Transformation is Here • HHS to spend $840 million on readying practices for value-based pay. -- Part of the 10 Billion • The Transforming Clinical Practice Initiative will invest $840 million over four years to support

150,000 clinicians.• It will provide a combination of incentives, tools and information to encourage doctors to team

with peers and others to transition to value-based services.• Momentum building toward value-based payment methods, this initiative hopes to leverage the

success of leading practices, health systems and professional orgs to coach others in how to best move to value-based reimbursement. It fits well into the broader federal strategy.

• Transforming Clinical Practice• Group practices health systems and Medical Societies • Impact 150,000 clinicians

• AND You ARE READY!!!!!!!

Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments

% Total Healthcare

Spend

% of Members

Those who are well or think they are well

Those with chronic illness

Those with severe, acute illness or injuries

Public Health Prevention

Specialists

PCMH 2.0 in Action

Community Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

need to move from traditional care provider to health partnerif your do not choose innovation (play a better game) you will be forced into disruption ( game Changed for you). Honest you can see it coming and some places is already there

Millennials are already finding the convenience, economics and technology in powerful virtual engagement compelling so you can chose innovation or disruption.

Virtual access become a required defensive strategy Primary Care team engaged in virtual augmented relationship – or your history loss the relationship.

Thank you

Apply new insights from interactions and outcomes

to enable continuous transformation

LEARNING

Identify and influence individuals and populations, and recognize

intervention opportunities

INTERVENTION

COORDINATIONDeliver care and monitor progress across

clinical and social requirements

COLLABORATIONAssess and engage individuals and stakeholders to drive individualized care plans

Drive evidence-based andstandardized care planning

KNOWLEDGE

WELLNESS

A comprehensive approach helps reduce costs while improving care

How many patients can you see?

How many patients’ problems can you solve?

How can we encourage and convince patients to get required prevention?

How can we create systems that significantly increase that patients get required prevention?

How often should a physician see a patient to optimally monitor a condition?

What is the best way to optimally monitor a condition?

Asking New Questions

FromTo

FromTo

FromTo

*Source: 2014 Kaiser Permanente Jack Cochran

What new skills are required for the future family physician and what old skills might no longer be necessary?How can we know if the changes underway in our practices are good for patients?What are the implications for how we teach and study family medicine?What new payment models will be required for this model of care to succeed?