01 asaf bitton - innovation in primary care

Innovation in Primary Care: Lessons Learned and Future Directions

Asaf Bitton MD, MPH, FACP

Associate Physician, Brigham and Women’s HospitalInstructor in Medicine and Health Care Policy, Harvard Medical School

Assistant Medical Director, BWH Advanced Primary Care AssociatesCIMIT Investigator

A*STAR-Khoo Teck Puat Hospital Forum on Primary Care Transformation

March 23rd, 2012

“Every system is perfectly designed to achieve exactly the results it gets.”

Don Berwick, MD MPP

Singapore

Cost-Related Access Problems, 2011

4

Percent of adults who went without care because of cost in past year *

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

* Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.

A “Perfect Storm” Unsustainable cost growth, inadequate quality, fragmented care, workforce shortage, aging population

Michael Patmas MD, OHSU, 2006

Primary Care as a Focus for Innovation and Systems Change

•Increased access and/or

equitable distribution of care

•Prevention and early

management of health problems

•Reduction of unnecessary and

harmful specialist interventions

•Coordination and integration

across multiple conditions,

treatments, and medications

•Decreased

health

expenditures

•Equal or better

health outcomes

•Better patient

experiences and

increased

satisfaction

Primary Care

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for:

addressing a large majority of personal health care needs

developing a sustained partnership with patients

practicing in the context of family and community

Source: IOM, Defining Primary Care: An Interim Report. 1994.

Essential Attributes of Primary Care

Whole Person

Orientation

ContinuityCoordination/

Integration

Comprehen-

siveness

Accessibility

PRIMARY

CARE

First contact care

characterized by:

Health Expenditures: Generalists and Specialists Compared

Specialist Density and

Health Expenditures

Generalist Density and

Health Expenditures

Source: Baicker K & Chandra A. Health Affairs. 2004. Web Exclusive. Dartmouth Atlas projects

Better Primary Care Associated with Lower Costs

0

500

1000

1500

2000

2500

3000

3500

4000

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

Average Primary Care Score

Per

Cap

ita H

ealt

h C

are

Exp

en

dit

ure

s

France

US

Germany

Belgium

The Netherlands

Finland

Spain

Denmark

Canada

Australia

Sweden

Japan

United

Kingdom

Source: Starfield B, Shi L. Health Policy. 2002; 60: 201-218.

Primary Care Scores vs. Per Capita Health Care Costs

11

22

30

4142

495355

0

25

50

75

GER NZ NETH AUS UK US CAN

Percent

Source: 2007 Commonwealth Fund International Health Policy Survey

Able to Get Same Day

Appointment with Doctor

89

11

56

1516

0

5

10

15

20

25

GER NETH UK NZ AUS US CAN

ER Use for Condition Doctor Could

Have Treated if Available

Percent

Access to Primary Care

Patients Value Primary Care

Patient Attitudes Towards Primary Care

Physicians and Specialist Use

Agree

(%)

Disagree

(%)

Don’t Know

or Uncertain

(%)

Value having one primary care

physician94 2 4

Values PCP participation in

decision to see specialist89 3 8

Can decide whether to see

PCP or specialist for a new

problem for myself

46 28 26

Source: Grumbach K et al., JAMA; 281(3): 261-266.

0

10

20

30

40

50

60

70

80

90

Cough and

Wheezing

Arthritis in

Knee

Blood in Stool

Prefer PCP Prefer Specialist

PCP versus Specialist

Preference as First-Contact

Physician for Selected Medical

Problems

Reinventing Our Delivery System

“Current care systems cannot do the job. Trying harder will not work. Changing systems

of care will.”

Institute of Medicine. Crossing the Quality Chasm. 2001

What is a Patient Centered Medical Home?

“Medical Home? That sounds like a Nursing Home…”

Patients not aware

PCMH: different meanings to different stakeholders

Invention vs. Innovation

Kitty Hawk, 1903 DC-3, 1935

PCMH Joint Principles

Patient

Personal Physician

Enhanced Access

Payment Reform

Care Coordination

Physician Led Practice

Quality/ Safety

Whole Person

“Home Team, Centered Around the Patient”

Connected

through HIT

Common Elements of PCMH

Personal Physician

Team-based practice

Expanded access

Emphasis on coordination of care

Proactive population health management

Care facilitation and data analysis with HIT

New forms of payment

Fields et al, Health Affairs, May 2010

Does HIT = Medical Home?

Necessary but alone not sufficient

Enables coordinating connections

Current Needs:

Robust decision support

Registry tools

Tools enabling team function and pt engagement

Personal health records

Bates D and Bitton A. “The Future of HIT in the PCMH”. Health Affairs. April 2010.

Smaller Practices Lag Behind Large Practices in HIT

49

27

75

50

7

21

0

25

50

75

100

Use electronic medical records in practice High electronic information functionality*

Solo practices

Small and medium practices (2–9 physicians)Large practices (10 or more physicians)

* To assess HIT multifunctionality, a 14-count scale was developed. The multifunctional HIT capacity summary variable,

counting the number of functions and categorized systems, includes low (0–3), middle (4–8), and high (9–14).

Source: The Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.

HITECH: Advancing the Tipping Point

TIME

Technology Adoption

2004 2012

National

Coordination

Enhanced

Trust

Grant

Programs

Payment

Incentives

Source: David Bates MD, MSc

Spurring Use of HIT“To increase the effective use of EHRs:

1. Get doctors, hospitals, and other health care providers to acquire and use electronic health records.

2. Get those electronic health records to "talk to one another" by becoming interoperable.

3. Get providers to use EHRs to improve quality and efficiency in the provision of health care services.”

(The Federal Role in Promoting Health Information Technology,Commonwealth Fund, 2009)Source: David Bates MD, MSc

2009 2011 2013 2015

HIT-Enabled Health Reform

HITECH

Policies2011 Meaningful

Use Criteria

(Capture/share

data)2013 Meaningful

Use Criteria

(Advanced care

processes with

decision support)

2015 Meaningful

Use Criteria

(Improved

Outcomes)

Meaningful Use “Ascension Path”

Report of sub-committee of Health IT Policy CommitteeSource: David Bates MD, MSc

Certified EHR Required

Meaningful Use Incentives

BUT…Penalty of 1%/yr (max 5%) reimbursement starting 2015

TODAY’S CARE MEDICAL HOME CARE

My patients are those who make

appointments to see me

Our patients are those who are

registered in our medical home

Care is determined by a proactive plan

to meet patient needs without visits

Care is determined by today’s

problem and time available today

A prepared team of professionals

coordinates all patients’ care

Patients are responsible for

coordinating their own care

We measure our quality and make

rapid changes to improve it

I know I deliver high quality care

because I’m well trained

We track tests & consultations, and

follow-up after ED & hospital

It’s up to the patient to tell us what

happened to them

A multidisciplinary team works at the

top of our licenses with a patient focus

Focus of the clinic is the doctor’s

needs

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

Patient-Centered Medical Homes Nationwide

RI

Multi-Payer pilot discussions/activity

Identified pilot activity

No identified pilot activity – 6 States

National PCMHDemonstration Activity

Source: PCPCC

NCQA Recognized Sites, 2010

Results for Current National Demos

Practices 4,659

Physicians 14,389

Patients 4,900,000

Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.

Models for PCMH Payment

Enhanced Fee for Service (FFS)

Higher technical fees

New codes for phone call and emails

Higher volume with mid-level providers

Capitation

Comprehensive Risk Adjusted Payment Model (NY/MA)

3 part model

FFS

Enhanced pay for performance

Care management fees (per person per month)

Payment for Current National Demos

Per Person Per Month (PPPM) Payments 96%

Range of PPPM Payments $0.50 to $9.00

Range of Additional Revenue per MD/yr$720 to $91,146

(median $22,834)

Upfront or Start-up Payments 42%

Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.

PCMH Evaluation: How do you know if this works?

Multi-Dimensional Evaluations

Transformation

Efficiency Quality Experience

Patient Staff

Education

Early PCMH ResultsProject Hosp ER Visits Quality Pt

ExperienceTotal $ per patient/yr

Group Health Cooperative (WA)

-6% (all)

-13% (ACSC)

-29% Improved Improved in 5 / 7 scales

-$120

Geisinger (PA) -18% (all)

-36% (re-ad)

NA NA NA -7% (+5% to -18%)

(Not Stat Significant)

NDP (national) NA NA Improved Slightly worse (NS)

*Practice Rev +2% to 12%

Community Care of North Carolina*

-40% NA Improved asthma, DM

NA -$516

Colorado Medical Homes for Children*

-18% -16% NA NA -$169 (all)

-$530 (c. dz)

Intermountain (UT)* -5% (all)

-19% (c.dz)

0% (all)

-7% (c.dz)

NA NA -$640

North Dakota BCBS* -6% -24% NA NA -$530

Vermont Blueprint* -11% -12% NA NA -$215

*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease

NS = not statistically significant re-ad = readmissions

35

Experienced Coordination Gaps in Past Two Years, by Medical Home

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information

with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

Patients with a medical home have a regular practice who is accessible, knows them,

and helps coordinate their care.

36Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home

* Reported medical mistake, medication error, and/or lab test error or delay in past two years.



Patient Engagement in Care Management for Chronic Condition, by Medical Home


Percent reporting positive patient engagement in managing chronic condition*

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make

treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.




Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home



7476

7474

50525352

3431

38

44

0

25

50

75

100

Total White African American Hispanic

Medical home

Regular source of care, not a medical home

No regular source of care/ER

Percent of Adults 18-64 Reporting Having Received Needed

Medical Care, by Racial and Ethnic Group and Source of Care

Source: Beal AC et al. The Commonwealth Fund. June 2007. Data from Commonwealth Fund 2006 Health Care Quality

Survey.

Equity-Enhancing Effects

PCMH in Practice: Brigham and Women’s Advanced Primary Care Associates, South Huntington

Structure: Core Clinical Team

3 Teams:

•1.5 MD•1-2 Residents

•2 students (MD), and other students (RN)• 1 Physician Assistant (8 session)• 1 Licensed Practical Nurse• 2 Medical Assistants• 1 Social Worker

Structure: Shared Resources

• 1 Medical Director• 1 Practice Manager• 1 Pharmacist• 1 Population Manager• 1 Nutritionist• 6 Secretaries (Check-in, Check-out)• 1 Community Resource Specialist• 1 Care Coordination RN

Local Opportunity for Innovation

South Huntington as a “learning laboratory” for team- based practice innovation and training

Developing new training models

System-wide transformation:

60% of practices transform to PCMH by 2013

100% by 2015

Docking Platform for Innovative Technology

Innovative Primary Care Technologies

Moving Outside the PCMH

The Medical Neighborhood

Extends around PCMH “Core” and “Peripheral” neighbors

Varies by community and provider network arrangement

Requires formal, reciprocal care agreements

Enhanced by efficient information transfer (HIT)

Shared risks and incentives for outcomes

Compatible with different payment structures

A stepping stone to ACOs

Source: Pham H, Journal of General Internal Medicine, 2010

Accountable Care Organizations: Integration Through Information and Shared Responsibility

Patient-Centered

Medical Home

Sub-specialty PCMH

Sub-specialty “Medical

Home Neighbor”

Sub-Specialty

Procedural Practice

Hospital

Sub-Acute

Care

HIT

HIT

HIT

HIT

HIT

HIT

HIT

Source: David Bates MD, MSc and Asaf Bitton MD

Accountable Care Organizations (ACO)

48Source: Premier Healthcare Alliance

A group of providers thathas the legal structure toreceive and distributeincentive payments toparticipating providers.

Operations

PCMH

PCMH

PCMH

PCMHHospitals

Public Health Prevention

Community Care Team

Nurse Coordinator

Social Workers

Dieticians

Community Health Workers

Care Coordinators

Public Health Prevention Specialist

Behavioral Health & Substance Abuse

Services

Prevention Programs

Policies and SystemsLocal, state, and federal; economic/cultural; media

CommunityPhysical, social and cultural environment

OrganizationsSchools, worksites, faith-based organizations, etc

RelationshipsFamily, peers, social networks, associations

IndividualKnowledge, attitudes, beliefs

Vermont Blueprint for Health: Integrating PCMH/ACOs

with Public Health Through Community Care Teams

Health IT Framework

Global Information Framework

Evaluation Framework

Source: Craig Jones MD; Director, Vermont

Blueprint for Health, AcademyHealth 2009

Centers for Medicare and Medicaid Innovations (CMMI)

Genesis / Funding: Affordable Care Act ($10B)

Framework for Innovation: Demonstrations

Dissemination: Spread if Certified

Key Programs:

Pioneer ACO

Comprehensive Primary Care Initiative

Bundled Payments

Health Care Innovation Challenge

Change is Hard

“Possibility derives less from effort than from redesign”

Berwick and Luo, 2010

Keys to Innovation

Clear Strategies

Aligned Incentives

Trust Across Institutions

Clear Communication

Embrace New Thinking

Tolerate (and even celebrate) Mavericks

Don’t Focus Next Quarter’s Results Only

Leadership

Coral Reefs Innovation

Kjell Bjartveit

“It can be done”

Concluding Thoughts

Enhancing primary care capacity and function is key to building a high-performing health system

The medical home is about improving care through teams, HIT, and a renewed focus on the patient

The medical home model is already widespread and early results are promising

Innovation is not only about building new technologies, but also about where to intelligently deploy them

Optimism is a strategic imperative

Thank You

Questions?

Email: [email protected]

01 asaf bitton - innovation in primary care

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