Published on February 18, 2014
The Foundation for Reenginering Healthcare Patient Centered Medical Home Paul Grundy MD, MPH IBM‘s Director Healthcare Transformation President Patient Centered Primary Care Collaborative
Paul Grundy MD MPH Bio • • • • • • • • “Godfather” of the Patient Centered Medical Home IBM Global Director Healthcare Transformation President of PCPCC Member Institute of Medicine Member Board ACGME Professor Univ. of Utah Department Family Medicine Winner NCQA national Quality Award A Leader of MOH level taskforce primary care transformation 8 nations: USA, Canada, New Zealand, Australia, Holland, Denmark, UK, Belgium, • Univ. of California MD, John Hopkins Trained
Away from Episode of Care to Management of Population Hospital Population Health Per Capita Cost System Integrator Patient Experience Public Health Community Health The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management
Smarter Healthcare 36.3% Drop in hospital days 32.2% Drop in ER use 12.8% 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
Rural New York • Commercial/ASO insurance cost decreased from $380 per-patient-per-month in 2009 to $316 in 2012 • Costs for Medicaid patients dropped from $334 to $266, according to a recent “risk adjusted” analysis. http://poststar.com/news/local/medical-home-program-gains-traction/article_5811380c
PCMH Lower Costs Aug 5th 2013 Pennsylvania • 44% reduction in hospital costs • 21% reduction in overall medical costs. • 160 PCMH practices Pennsylvania from 2008 to 12 • Number of patients with poorly controlled diabetes declined by 45%. Jeffrey Bendix modernmedicine.com/
PCMH Michigan – Aug 11th 2013 • 19.1% lower rate of adult hospitalization. • 8.8% lower rate of adult ER visits. • 17.7% lower rate ER visits (children under age 17) • 7.3% lower rate of adult high-tech radiology usage VS other non-PCMH designated primary care physicians. 3,017 Physicians . Medical home physicians help patients avoid ERs and admissions by evening hour appointments, weekend and same-day appointments http://www.crainsdetroit.com/article/20130811/NEWS/308119989/blue-cross-touts-155-million-in-savings-with-medical-home-project
WellPoint PCMH Preliminary Year 2 Highlights In Sept Issue Health affairs 2012 • • 15% decrease in total ER visits/1000, compared to 4% increase in control group • Specialty visits/1000 remained around flat compared to 10% increase in control group • Colorado 18% decrease in acute IP admissions/1000, compared to 18% increase in control group Overall Return on Investment estimates ranged between 2.5:1 and 4.5:1 NEW HAMPSHIRE New York
Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Source: Hudson Valley Initiative
TODAY’S CARE PCMH CARE My 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 I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care 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 11 Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
• 1/3 less cardiac intervention needed • 60% less complication Diabetes
FFM-2 Feb 2014 • 1. Pursue Electronic Patient Management and engagement rather than Electronic Patient Records • 2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows. • 3. Make it easier to do it right than not to do it at all. • 4. Continually challenge providers to improve their performance. • 5. Infuse new knowledge and decision-making tools throughout an organization instantly.
• 6. Establish and promote continuity of care with patient education, information and plans of care. • 7. Enlist patients as partners and collaborators in their own health improvement. • 8. Evaluate the care of patients and populations of patients longitudinally. • 9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets. • 10. Create multiple case-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health
Build your own corporate PCMH $805 $804 $765 Per Employee Per Month Health Costs Post Implementation Actual client data: Midwest Hospital with 12,135 employees 1 year selffunded for group health 17 $569 Copyright 2011 by IBM
“We do the best heart surgeries.”
Defining the Care Centered on Patient 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
OPM Carrier Letter Feb 5th 2013 Patient Centered Medical Homes (PCMH) within the Federal Employees Health Benefits (FEHB) Program • A growing body of evidence supports investment in PCMH – SO we are!! • there must be a plan for all FEHB lives enrolled in the practice to be included in a reasonable timeframe. • ACA 2334
USA 2012 Ogden, Ut
MobileFirst Patient Consumer
Remaking Blood Chemistry - continuously test hundred different samples, 40% of today’s blood
MobileFirst Remote Sensing Mobile Sensing emotion for mental health status -- analyzes facial expressions Mobile Sensing position for asthma -- integrates GPS into inhalers Mobile Sensing motion for Alzheimer’s -- monitoring gait Mobile Sensing ingestion of medications. activated by stomach fluid Mobile Sensing for sleep disorders -- tracks breath, heart rate, motion Mobile Sensing for diabetes. continuous monitoring iPhone non invasive sensor. Mobile Sensing for readmission prevention -- BP, weight, pulse, ekg Mobile Sensing for exercise wellness -- benefit design feedback
Practice transformation away from episode of care Master Builder Preventive Medicine Chronic Disease Monitoring Medication Refills Acute Care Test Results DOCTOR Master Builder Case Manager Behavioral Health Medical Assistants Nursing Source: Southcentral Foundation, Anchorage AK
PCMH Parallel Team Flow Design The glue is real data not a doctors Brain Chronic Disease Monitoring Medication Refills Healthcare Support Team Point of Care Testing Acute Care Test Results Case Manager Preventive Medicine Clinician Provider Chronic Disease Compliance Barriers Acute Mental Health Complaint Medical Assistants Behavioral Health Source: Southcentral Foundation, Anchorage AK
Healthcare will Transform • Data Driven • Every patient has a plan • Team based • Managing a Population Down to the Person
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”
New $ Dials • Complex Chronic Care Management payment codes. authorize payments to physicians for the work that goes into managing complex patients outside of their actual office visits. • House Energy and Commerce Committee Bill repeals SGR moving Medicare payments away from FFS toward new, innovative models. •
Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments Those with severe, acute illness or injuries Those with chronic illness % Total Healthcare Spend Those who are well or think they are well % of Members 29 29
PCMH 2.0 in Action A Coordinated Health System Hospitals PCMH Specialists Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators PCMH Public Health Prevention HEALTH WELLNESS Public Health Prevention 35 Health IT Framework Global Information Framework Evaluation Framework Operations Copyright 2011 by IBM
FFM_2 • Practices Features -- - Emphasis on care coordination and system navigation, System Integrator, PCMH role for family physician in integrated system - Big push on population health management - Large care teams with PCP + a variety of other professions, e.g., nursing, pharmacy, public health and mental health. • Technology Use - Better population health data stemming from centralized data based EHR through integrated system. Adoption of telemedicine, Establish Primary Care Technology Center (PCTC), a research and training entity, to fuel adoption of efficacious technology in practice, patient engagement tools. Modern, flexible, sophisticated system, developed in partnership with technology providers. -Multi-modal communication w/ patients .
• Building a Workforce -- Training in the use of population health management, data management and public health tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in interprofessional collaboration, EHR data usage, and integrated practice management. • Research Focus -- Conclusive evidence about system wide quality improvement and cost savings of robust primary care.- Rise of Continuum-Based Research Networks, applied research efforts to improve clinical pathways. - Research builds case for reductions in Total Cost of Care (at system level), research into technologies most inpactful on Triple Aim. - FM becomes trusted source of best practices to meet Triple Aim, .Focus on issues that relate to patients owning their own health through patient experience and engagement research
• Collaboration -- - Family medicine’s partnership with payers and the integrated systems, to exchange ideas about how to best deploy family physicians and represent their colleagues’ interests to these systems - Subspecialists – to ensure great working relationships within systems. - Primary care professionals – to achieve the best possible outcomes in service of Triple Aim. Payers, particularly CMS – to ensure success of alternative payment pilots.- Primary Care Nurse Practitioners (to work together in pursuit of expanded role of Primary Care, Technology manufacturers) to provide advice on how to improve technology in use by FPs, • Key Investments -- Curricular overhaul and research effort to prepare residents for work in integrated systems, tools for data being made into actionable information in population management, advance clinical decision support
Reengineering for Health Care Three types of businesses undertake reengineering: • Those at the peak of their game & ambitious executives • those that reengineer to stay ahead, and • those in deep trouble. The US health care system is in trouble, and rather than single reforms, it needs and is getting reengineered. • 7 days to 4 hours # of deals increased a 100 fold JAMA - Feb 2013, Ari Hoffman, MD, Ezekiel J. Emanuel, MD, PhD
Benefit Redesign • Cost 2013 $16,351 emp on ave paying $4,565 • Federal government Final Rules wellness incentives. • Smoker --employer may increase your insurance premiums by up to 50 percent. • Overweight, you may look at a 30 percent surcharge. • And employers may also reduce premiums by up to 30 percent for normal weight.
benefit design reference pricing • California Public Employees' Retirement System (CalPERS), from 2008 to 2012. • insurer sets limits on the amount to be paid for a procedure, with employees paying any remaining difference. • Shift by Patients from high to low cost 55.7% • Hospitals reduced their prices by an ave of 20%. • Accounted for $2.8 million in savings in 2011 http://content.healthaffairs.org/content/32/8/1392.abstract Health Aff August 2013 vol. 32no. 8 1392-1397
Calcification Inhibitors in CKD and Dialysis Patients
R ESEARCH & I NNOVATION P OLICY IN I RELAND European Research Area Committee Meeting, Thursday 13 th June 2013 Professor Mark WJ Ferguson Director General,
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