1. The Patient Centered Medical Home in the Information Age
Ted Epperly, M.D.
Program Director and C.E.O.
Family Medicine Residency of Idaho
Clinical Professor of Family and Community Medicine
University of Washington School of Medicine
President-Elect
American Academy of Family Physicians

2. Five Ages of Civilization
Wisdom
Information/
Knowledge Worker
Industrial
Agricultural
Hunter/Gatherer

3. Failure to Embrace Family Medicine
Despite its 39-year history, neither the general public nor healthcare professionals understand all that Family Medicine represents.

4. Identity
Crisis
Moral
Leadership
Financial

5. “Strategic planning does not deal with future decisions
“Strategic planning does not deal with future decisions. It deals with the futurity of present decisions. Decisions exist only in the present. The question that faces the strategic decision-maker is not what his organization should do tomorrow. It is: What do we have to do today to be ready for an uncertain tomorrow?”
-Peter Drucker

6. “Don’t skate to where the puck is, but where the puck will be.”
- Wayne Gretzky

7. The Future of Family Medicine Charge
“Develop a strategy to transform and renew the specialty of family practice to meet the needs of people and society in a changing environment.”

8. Simple Rules for the 21st Century Health Care System
Current Approach
New Rules
Care is based primarily on visits
Care is based on continuous healing relationships
Professional autonomy drives variability
Care is customized according to patient needs and values
Professionals control care
The patient is the source of control
Information is a record
Knowledge is shared and information flows freely
Decision making is based on training and experience
Decision making is evidence-based
Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine Washington, DC, USA: National Academies Press; 2001

9. Simple Rules for the 21st Century Health Care System
Current Approach
New Rules
Do no harm is an individual responsibility
Safety is a system property
Secrecy is necessary
Transparency is necessary
The system reacts to needs
Needs are anticipated
Reduction in cost sought
Waste is continuously decreased
Preference is given to professional roles rather than the system
Cooperation among clinicians is a priority
Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine Washington, DC, USA: National Academies Press; 2001

10. Future of Family Medicine Ten Recommendations
New Model of Family Medicine
Electronic Health Records
Family Medicine Education
Life Long Learning
Enhancing the Science of Family Medicine
Quality of Care
Role of Family Medicine in Academic Health Centers
Promoting a Sufficient Family Medicine Workforce
Communications
Leadership and Advocacy
Source:The Future of Family Medicine - Annals of Family Medicine

11. New Model of Family Medicine
Personal Medical Home
Patient-Centered Care
Team Approach
Elimination of Barriers to Access
Advanced Information Systems
Redesigned Offices
Source:The Future of Family Medicine - Annals of Family Medicine

12. New Model of Family Medicine (cont’d)
Whole-Person Orientation
Care Provided within a Community Context
Emphasis on Quality and Safety
Enhanced Practice Finance
Commitment to Provide Family Medicine’s Basket of Services
Source:The Future of Family Medicine - Annals of Family Medicine

13. Medicine Work Force 300,000,000 Americans 900,000 Physicians 333:1
American/Physician

14. Number of Physicians Per Capita
Total physicians
FP/GP
AMA 2007
Total Number of Physicians – 902,053
Family Medicine Physicians – 80,809
Source: AMA Physicians Characteristics and Distribution 1980, 1990, 2000,
Overpeck MD. Physicians in family practice Public Health Rep 1970; 85(6):

15. Which System is More Stable?
Primary
Care
Specialists OR

16. Why? Salary Lifestyle Increasing Medical School Debt
Perceived Prestige
Rising Overhead
Unfunded Mandates

17. Median Compensation for Selected Medical Specialties
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005

18. $2,300,000,000,000

19. Source: Lebow R. Health Care Meltdown: JRI Press: 2002
America’s Rankings
#1 -
Health Care Dollars Spent Per Capita
Health Care Technology
Research Dollars Spent Per Capita
#20 -
Health Care Outcomes (e.g. life expectancy, infant mortality, and immunizations)
#37 -
Health Care System
#54 -
Fairness (tied with Fiji)
Source: Lebow R. Health Care Meltdown: JRI Press: 2002

20. Starfield B. Is U. S. Health Really the Best in the World
Starfield B. Is U.S. Health Really the Best in the World? JAMA 2000; 284(4):

21. Starfield B. Is U. S. Health Really the Best in the World
Starfield B. Is U.S. Health Really the Best in the World? JAMA 2000; 284(4):

27. Rationale for the Benefits of Primary Care for Health
Greater Access to Needed Services
Better Quality of Care
A Greater Focus on Prevention
Early Management of Health Problems
Cumulative Effect of Primary Care to more Appropriate Care
Reducing Unnecessary and Potentially Harmful Specialist Care
Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) )

28. Rationale of a Primary Health Care Based System
Decreased Morbidity and Mortality
More Equitable Distribution of Health in Populations
Lower Cost of Care
Better Self-Reported Health
Primary Care Physicians achieve Better Outcomes than do Specialists at much Lower Costs
Increasing the Number of Specialists is Associated with Lower Quality, Increased Cost, Increased Morbidity, and Increased Mortality
Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) )

29. “Too many specialists are as dangerous to the quality and quantity of medical care in a community as too few.”
- Stanley R. Truman, M.D.
President Elect AAGP
September 13, 1949

30. Not Just a Change In Name… but a Change In Attitude!
AGGRESSIVE OPTIMISM!

31. Bold
Champion

32. Five Pillars of Healthcare Change
Patient Centered Medical Home
Payment Reform
Student Interest in Family Medicine
Workforce Reform
Healthcare for All

33. How Do We Change Our Health Care System?

34. Health Care for Everyone
Medical Home
No Financial Barriers for
Primary Care
Prenatal Care
Well Child Care
Immunizations
Evidence Based Preventive Services
Hospice Care

35. Health Care for Everyone (cont’d)
The Individual will Share Financial Responsibility for:
Medications
Hospitalizations
Durable Medical Equipment
ED visits
Consultations and Referrals
Dx Tests and Procedures not done in Medical Home
Long-Term Care

36. Health Care for Everyone (cont’d)
How is this paid for?
Enhanced Fee for Service
P4R
P4P
CMF
Care Management Fee
$15 PMPM
Lewin Group
$8 Billion Cost to CMS but Saves $15 Billion/Year
$48 Billion Cost to Rest of U.S. but Save $83 Billion/Year
Saves $15.63 /Person Per Month

37. Health Care for Everyone (cont’d)
The Type of Payment System Does Not Matter
What Does Matter:
Primary Care Based System
Medical Home
Primary Care Physicians – Integration/Coordination/Relationships
Higher Quality, Better Outcomes, More Preventive Services, Improved Patient Satisfaction, Significantly Lower Costs

38. Joint Principles of the Medical Home (AAFP, ACP, AAP, AOA)
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Care is Coordinated and Integrated
Quality and Safety are Hallmarks
Access is Enhanced
Payment Reform

39. Patient Families Communities
Family Physician

40. Patient Centered Primary Care Collaborative (PCPCC)
Employers - 50 Million Plus
Consumer Groups - 47 Million Plus
Physician Groups - 330,000 Plus
Insurers – All of the Big Six

41. AARP Aetna. American Academy of Family Physicians
AARP Aetna* American Academy of Family Physicians* American Academy of Pediatrics* American Board of Medical Specialties American College of Osteopathic Family Physicians American Board of Medical Specialties American College of Cardiology American College of Osteopathic Internists American College of Physicians* American Geriatrics Society American Health Quality Association American Heart Association American Osteopathic Association* Aurum Dx Automotive Industry Action Group BlueCross BlueShield Association* Bridges To Excellence The Capital District Physicians’ Health Plan, Inc. Carena, Inc. Caterpillar The Center for Excellence in Primary Care The Center for Health Value Innovation Colorado Center for Chronic Care Innovations CIGNA* CVS Caremark* § CVS/pharmacy § Caremark Pharmacy Services § MinuteClinic Delmarva Foundation The Department for Family and Community Medicine, University of California, San Francisco Delphi Corporation Deseret Mutual DMAA: The Care Continuum Alliance eHealth Initiative The ERISA Industry Committee* Exelon Corp FedEx Corporation Foundation for Informed Medical Decision Making General Mills, Inc. General Motors
Geisinger Health Systems GlaxoSmithKline Health Dialog HR Policy Association Humana, Inc.* IBM* Incenter Strategies McKesson Corporation MDdatacore Medco* Medical Network One Merck* MVP Health Care National Association of Community Health Centers National Business Group on Health National Business Coalition on Health National Coalition on Health Care National Committee for Quality Assurance National Consumers League National Partnership for Women & Families National Retail Federation New England Quality Care Alliance New York City Department of Health and Mental Hygiene Novo Nordisk The Pacific Business Group on Health Partners In Care Pfizer* Practice Transformation Institute Pudget Sound Health Alliance The Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health Service Employees International Union Society of General Internal Medicine Society of Teachers of Family Medicine The Stoeckle Center at Massachusetts General Hospital UnitedHealthcare* United States Steel University of Pittsburgh Medical Center Walgreens Health Initiatives* WellPoint, Inc.* Wyeth Xerox
Updated 12/18/07

43. Must Pass Elements at 50% Performance Level
PPC-PCMH Scoring
Level of Qualifying
Points
Must Pass Elements at 50% Performance Level
Level 3
10 of 10
Level 2
50 – 74
Level 1
25 – 49
5 of 10
Not Recognized
0 – 24
< 5
Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points but passes only 7 “Must Pass” Elements, the practice will achieve at Level 1.
Practices with a numeric score of 0 to 24 points or less than 5 “Must Pass” Elements do not Qualify.

44. NCQA Medical Home – 5 Musts
Has written standards for patient access and patient communication;
Uses data to show it meets its standards for patient access and communications;
Uses paper or electronic charting tools to organize clinical information;
Uses data to identify important diagnoses and conditions in practice;
Implements evidence-based guidelines for al least three conditions;
Actively supports patient self-management;
Tracks tests and identified abnormal results systematically;
Tracks referrals using a paper-based or electronic system;
Measures clinical or service performance by physician or across the practice;
Reports performance by physician or across the practice.

45. The Health Care Paradigm
Buyers
Payors
Providers
Business
Insurance
Companies
Physicians

46. Care Management Fee for PC-MH RVC Proposal to CMS
Level 1 - $30
Level 2 - $40
Level 3 - $50

47. What Next? Advocacy Education Communication Payment Reform
Politics / PAC
Tipping Point?

48. Trim-Tab Leaders

49. “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
- Margaret Mead

50. “The only limit to our realization of tomorrow will be our doubts of today, so let us move forward with strong and active faith.”
- Franklin D. Roosevelt

51. Summary Medical Home in the Information Age
Strategy to Transform and Renew
Future of Family Medicine – New Model
Basket of Services – Integrate and Coordinate
Primary Care Foundational to Health Care System
Medical Home and Designation
Payment Reform – Blended Rate
Workforce Reform
Patient Centered Primary Care Collaborative (PCPCC)
Health Care for Everyone

52. Patient Centered Medical Home in the Informational Age
Questions?