health care reform: two challenges to the primary care sector
TRANSCRIPT
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National Health Reform:The Primary Care Imperatives andStrategies for Addressing Them
Presentation to the Center for Family andCommunity Medicine
Columbia University Medical Center
Ronda Kotelchuck, Executive DirectorPrimary Care Development Corporation
Thursday, January 21, 2010
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1. Introduction: The Problems
2. Health Care Reform: The Primary Care Agenda
3. Primary Care Expansion
4. Primary Care Transformation
A. Practice Redesign
B. Health Information Technology
1. Lessons and Reflections
Overview
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1. Introduction: The Problems
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Rising Cost and the Role of Chronic Illness
The rising cost of health care is unsustainable
Cost is driven by the rising rate of chronic illness. It:
Is the single largest cause of morbidity and mortality Is the single largest driver of cost (accounts for 75% of all health
expenses)
Has the heaviest impact on low income communities
Will grow more severe as population ages
Chronic illness is overwhelmingly preventable or primarycare manageable. Prevention and management requirea robust model of primary care.
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Primary Care Today:
Insufficient and Poorly Organized
Primary care capacity is insufficient:
60 million Americans lack access to primary care
Half of primary care doctors plan to reduce or end their practices
Only 20 percent of medical students plan to practice primary care
U.S. is expected to need 46,000 primary care doctors by 2025
Most primary care is poorly organized and still practiced in anoutdated mode. It is:
Reactive and episodic Subject to long waits and delays
Uncoordinated
Inefficient
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Study: US Lags Behind other Countries
in Key Primary Care Indicators
Commonwealth Fund study of 11 countries (November 2009) Australia, Canada, France, Germany, Italy, Netherlands, New
Zealand, Norway, Sweden, UK, US US 10th out of 11 in use of Electronic Medical Records (46% - ahead of Canada) 10th of 11 in use of care teams (ahead of France)
Last in access to after-hours care
Least likely to have financial incentives for clinical outcomes
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2. Health Care ReformThe Primary Care Agenda
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Health Reform Will Drive the Need for Expanded
Primary Care Capacity
Expanded insurance coverage will put millions of newcustomers into the healthcare market
Physician shortages will increase by 25% and workload by29% over the next 15 years.
The Massachusetts experience:
97% coverage
Patients wait months for appointments
40% of family physicians are not accepting new patients
Record use of ER for non-emergencies
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Rising Costs Will Drive the Need to Transform the
Model of Primary Care
Growing evidence shows that primary care is effective in reducing costs,improving health outcomes and eliminating disparities
Employers, insurers and policymakers are looking to primary care as thenew paradigm.
A new model of care is necessary, however, to achieve theseobjectives.
Innovations in practice have been afoot for years (practice redesign,
evidence-based clinical protocols, etc.) Now these are integrated into the concept of the Patient-CenteredMedical Home (PCMH)
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PCDC: Offering Strategies for Primary Care
Expansion and Transformation
Non-profit organization founded in 1993 to address lack ofprimary care access in underserved communities
Premier public-private partnership focused on needs ofsafety net providers - community health centers, hospitals,special needs providers
Three areas of expertise Capital Financing
Performance Improvement
Policy
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3. PCDC:
Strategies for ExpandingPrimary Care Expansion
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PCDC Primary Care Expansion StrategyProblem:
Lack of capital constrains growth of long-standing, dedicated providers ofcare to the underserved; further hampered by credit crisis
Strategy: Use public funds to leverage private investment
Provide favorable-term loans to catalyze construction of new, expandedand renovated sites, modernized facilities
Provide:
Technical assistance for facility development
Provide strong oversight to ensure successful project completion andlong-term sustainability
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Results Total investments of $245 million
for 78 capital projects in New YorkState
Created capacity for 550,000 newpatients/1.7M visits annually
Leverage more than 5:1private:public investment
Cornerstone of local economic
development: 2,200 permanentjobs created; 4,400 withcommunity multipliers
Facilities operating successfully,no defaults
PCDC CapitalProjects (partial list)
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Joseph P. Addabbo Family Health Center Queens, NY
Before After $9.4 million for 22,000 SF new facility;
increased patient visits by 40%
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Callen-Lorde Community Health Center Chelsea
Before
After$9.3 million for relocation & expansionIncreased patient visits from 8,000 to
48,000 annually
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Reflections on Capital Strategy for Expansion
Partnership among stakeholders is key
Creates a permanent community infrastructure
Relative ease of raising capital Builds a baseline of knowledge and relationships that provide great
foundation stones for other initiatives (e.g., transformation; policy)
Technical assistance is critical for organizations that have littleexperience or internal capacity for undertaking a complex, expensive,
risky process Offers a replicable model to address the capacity crisis that will follownational health reform
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4. PCDC:
Strategies for Transforming thePrimary Care Model
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The Need for Transformation Origin: Initial focus on financial strength of borrowers New realization: Poor work processes
Cause much capacity to go unused Become important barrier to access
Result in inefficiency and waste Undermine financial strength Demoralize staff and patients.
Hallmarks of poorly organized processes: Long waits for appointments; lengthy cycle times; low productivity; high no-shows;
staff-focused (rather than patient-focused) processes; poor customer service
Discovery of the gap between what is possible and what is. Whats possible? Care that is safe, effective, patient-centered, timely, efficient
and equitable (six Aims of the IOMs Crossing the Quality Chasm)
The promise of a new primary care model: the medical home
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A Vision of Transformation:
The Patient-Centered Medical Home
The medical home concept: Continuity Well organized (efficient) practice
Easy access: Same day appointments, 24/7 telephone access, alternative access Responsibility for health outcomes Panel management Care coordination across settings Decision support Incorporation of evidence based practice (prevention, treatment, management)
Patient /family engagement
Formalization and the growth of a movement: Principles agreed to by major professional associations NCQA standards, measures, system of recognition
The promise: Better health outcomes, reduced disparities;lower health care cost
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A Vision of Beyond the Medical Home:Integrated Delivery Systems/Accountable CareOrganizations
Vertically integrated, comprehensive services Responsible for total care of a population
Use of value-based payment (bundled or global payments)which:
Rewards quality and outcomes Achieves savings
Examples: Kaiser, Mayo, Geisinger, Intermountain
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Strategies for Transformation:
PCDC Performance Improvement Programs
1. Medical Home Recognition Assist providers to achieve NCQArecognition and transformation (also 2 programs below)
2. Practice Redesign Improve access and efficiency by eliminatingwait times--both for appointments and during the visitincreasingthrough-put (productivity), improving patient and staff satisfaction andincreasing revenues.
3. HIT Implementation and Meaningful Use Adopt and integratetechnology to improve quality, coordinate and manage care, engagepatients and improve patient-provider communication.
4. Other PCDC Performance Improvement Programs:
Attracting and Retaining Patients
Increasing Revenue
Primary Care Emergency Preparedness
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Performance Improvement
PCDC Approach
Focus on:
System Design Implementation Measurable Results Staff Organized as Care
Teams Building Client Capability
Sustainability
Use of:
Change Teams Change Concepts & Tactics Coaching and Training Collaborative Learning Project Management Frameworks for Improvement
Model for Improvement (IHI) Chronic Care Model (Ed
Wagner) Medical Home Model
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A. Practice Redesign
The Issues: Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time). Patients often wait 3-6 weeks for an appointment; instead go to the ER No shows run as high as 50-60%; providers overbook to make up Organizations operate well below capacity (25-35%) Redesign process is complex, resource-intensive, challenging for self-implementation
Program Results: Trained 219 teams No show rates decrease by nearly 70% Appointment backlogs drop from an average of 21 to 0-5 days Providers able to hold 4-8 same-day appointments in daily schedule Cycle time reduced to an average of 51 minutes (50%+ reduction)
Provider productivity increase of 33% Improved patient and staff satisfaction
.
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B. Implementation and Meaningful Use of HIT
The Issues: Difficult, expensive, risky process Organizations with little experience or internal capacity, few resources Excessive, vendor-generated information; little ability to evaluate
The Program:TA for all stages of HIT adoption (38 teams) HIT vendor selection and contracting (23 teams) Planning and readiness (11 teams)
Internal capacity: team building, staff training, project management Design (workflow, decision support) Budgeting
Implementation and go-live (6 teams) Effective use (Assure meaningful use compliance)
Data reporting (Quality, compliance, panel management) (2 teams) Health information exchange (6 teams)
Remediation (1 team)
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The Challenge of the Next Five Years
2 simultaneous, highly-interrelated, time-limited initiatives
Both improve care, provide financial incentives NCQA medical home recognition: NYS Medicaid Incentive Pool
FFS: $5.50/$11.25/$16.75 per visit for Levels 1/2/3 Managed Care: $2/$4/$6 pmpm for Levels 1/2/3
Level I phased out after December 2012
HIT meaningful use compliance
Medicaid: Up to $63,750 over 6 years
Medicare: Up to $48,000; penalties beginning in 2015
Both are complex, expensive, a challenge for self-implementation Current focus on PCDC programdevelopment
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5. Lessons & Reflections
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5. Reflections: The Nature of Organizational Change The under-appreciation of implementation
People know what needs to be changed. They lack knowledge of how tochange
Transforming the model of primary care requires major, thorough-goingorganizational and cultural change.
Myths:
It can been done fast and cheap
Its a project. Once done, we can move on to other things.
It can be delegated from the top The importance of technical assistance, willingness to invest in the change
process
The under-appreciation of everyday operations
Practice redesign, HIT as preconditions for clinical improvements, quality
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Reflections on Safety Net Settings Private practice
Strong on continuity, access and efficiency
Isolation raises concerns about quality, coordination
Setting is simpler, change is easier
Small size, spare resources pose a challenge to implementing HIT, PCMH Community Health Centers
Continuity, access, efficiency not assured
FQHCs offer robust model, many PCMH functions, experience in qualityimprovement
Special Needs Providers
Already offer a care home, instinctually understand medical home
Hospital OPDs
Broad scope of service available (specialties, ancillaries)
Continuity, access, efficiency present challenge in teaching environment
Primary care is not the institutional focus or priority
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Reflections: PCDC as a Model for Expanding and
Transforming Primary Care
Leverages private investment for small investment of public resources;availability of capital (relative to expense)
Produces measurable, sustainable outcomes, able to reach scale;
builds lasting community infrastructure; delivers important communitydevelopment benefits Works across wide range of provider types (community health centers,
hospitals, private practitioners) Is adaptable to localities, states, foundations Offers excellent platform upon which to build additional programs and
services Value of an organization dedicated solely to primary care Builds a strong community of interest in the success of primary care.
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Contact
Ronda Kotelchuck
Executive DirectorPrimary Care Development Corporation
Phone: (212) 437-3917
E-Mail: [email protected]: www.pcdcny.org
mailto:[email protected]:[email protected]