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Engines of Success for Turbulent Times for Primary Care and U.S. Health Care November 3, 2011 | Eric B. Larson, MD, MPH Vice President for Research, Group.

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Presentation on theme: "Engines of Success for Turbulent Times for Primary Care and U.S. Health Care November 3, 2011 | Eric B. Larson, MD, MPH Vice President for Research, Group."— Presentation transcript:

1 Engines of Success for Turbulent Times for Primary Care and U.S. Health Care November 3, 2011 | Eric B. Larson, MD, MPH Vice President for Research, Group Health Executive Director, Group Health Research Institute Medical Homes and “Learning Health Care Systems”: 4 th Annual Primary Care Summit Rocky Hill, Connecticut

2 Lecture Outline Where have we been, where are we going? IOM defined our challenges with To Err is Human (2000) and Crossing the Quality Chasm (2001) as problems in quality, safety, cost & value. By 2004, we hoped the “chaos” could “spur innovation” 2010: U.S. health reform law is passed and implementation begins 2011: Facing daunting challenges for primary care and health care in general The promise of “learning health care systems” Patient-centered medical home and lessons learned to-date Opportunities for primary care to lead based on patient-centered medical home Other examples Innovation is not enough!

3 The industry was both shaken and inspired by two powerful Institute of Medicine reports describing crises in quality, access, value, affordability, and safety. U.S. Health Care: 2000-2001

4 To Err is Human: Building a Safer Health System IOM reported: As many as 98,000 people die in hospitals each year due to preventable errors. Errors result in total annual cost of $17 billion to $29 billion. Recommended strategies: Establish national focus to enhance safety knowledge base Develop national reporting system Raise standards and expectations Implement safety system to ensure safe practices

5 Crossing the Quality Chasm: A New Health System for the 21 st Century Concluded that U.S. health care: Is poorly organized, overly complex Is inefficient and wasteful Operates in silos Is especially problematic for those with chronic illness Requires fundamental sweeping redesign of the entire system Recommended ways to improve safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

6 Crossing the Quality Chasm: A New Health System for the 21 st Century 10 rules to redesign care: 1.Continuous healing relationships 2.Customization based on patient needs and values 3.Patient as a source of control 4.Shared knowledge and free flow of information 5.Evidence-based decision making 6.Safety as a systems property 7.Transparency 8.Anticipation of needs 9.Continuous decrease in waste 10.Cooperation among clinicians

7 Medicine is locked in a craft model rooted in 18th century 20th Century brought wonderful technical capacity and innovation Now, great complexity, fragmentation, and ability to harm Can we shift to "patient-centered care"? Ideally based on ongoing doctor-patient relationships --Merry MD, Quality Progress 2003; 31-5 Change was Certainly Overdue

8 “Every day, patients, their doctors, and other caregivers team up to achieve unprecedented health improvements…. Prospects for medical science, informatics, and service delivery have never seemed brighter. Yet inefficiency, unsafe systems, medical errors and a quality chasm between the best possible care and routine everyday care plague the delivery non-system of U.S. health care.” -- “System Chaos Should Spur Innovation” a report from the Task Force on the Domain of General Internal Medicine (Annals of Internal Medicine, April 19, 2004) 2004: GIM Task Force Examines “Chaos” in American Health Care

9 Cost of care is rising rapidly with no evidence that this will lead to better outcomes. Emergency departments and hospitals are overcrowded, often because medical care is underdeveloped and inaccessible. People with sufficient wealth see “boutique” practitioners offering guaranteed access to care that most insured persons once considered routine. Meanwhile: More than 40 million Americans are uninsured. Declining reimbursements discourage physicians from accepting new Medicare patients.” 2004: GIM Task Force Examines “Chaos” in American Health Care

10 A fellow and new faculty member: “My 85-year-old grandmother just fell and broke her hip. I need to fly to Boston to make sure something doesn't go wrong." EBL: "That's really good of you, a wonderful thing to do. … (long pause) But, think of what you just said." What does this exchange say about: Our trust in our own profession? The reliability of our nation’s health care system? Personal Anecdote from 2004

11 . The industry was both shaken and inspired by two powerful Institute of Medicine reports describing crises in quality, access, value, affordability, and safety. U.S. Health Care: 2000-2001

12 Now we know that simply believing that “system chaos should spur innovation” was insufficient – particularly in light of: market forces that drive people out of primary care persistent uninsurance and inadequate access to services Fast Forward to 2011

13 In Fact, the Chasm has Grown Wider The Commonwealth Fund recently reported: U.S. ranks last out of 19 countries on measures of “mortality amenable to health care.” This is down from 15th in past five years as other nations raised the bar on performance. Up to 101,000 deaths could be prevented each year if U.S. raised standards of care to benchmark levels abroad. U.S. spends two times what other nations spend on health, but there’s overwhelming evidence of inappropriate care, missed opportunities, and waste.

14 Many Big Challenges Ahead An aging population Increases in obesity, diabetes, and other chronic illness Rising cost of drugs, medical equipment, and care A market-driven health care economy encourages more care rather than better care prices not linked to value perverse incentives paying more for care here than abroad

15 Many Big Challenges Ahead The new health reform law extends access and coverage to millions. But we need more specific solutions for controlling costs, improving quality.

16 One Proposal: The Creation and Support of “Learning Health Care Systems” The term comes from IOM’s 2009 Roundtable on Evidence-Based Medicine, where participants identified best practices for generating and applying evidence in health care. Problem: Evidence is not available when needed to guide clinical decision-making Problem: Evidence is not applied for effectiveness and efficiency Opportunity: To build knowledge development and application in to health care delivery so we can: improve today’s care address growing demand for future evidence-based care.

17 IOM Group’s Recommendations on “Learning Health Care Systems” A new clinical research paradigm to draw clinical research closer to clinical practice Development of new study methodologies adapted to the practice environment: Scientists and clinicians working together Studies occurring in everyday practice settings Comprehensive deployment of electronic medical records that can be linked and mined for research. Stronger notion of clinical data as a public good.

18 Attributes of a Learning Health Care System Leverages health information technology (data repositories drawing from electronic medical records) Patient-centered and clinical decision support Patient engagement Use of evidence-based clinical guidelines Research and clinical care integrated through scientifically rigorous cycles of PDCA (Plan, Do, Check, Adjust)

19 IOM Group’s Recommendations on “Learning Health Care Systems” With these changes we can have a learning health care system where researchers: help design and implement innovations in practice draw data from demonstrations and analyze it provide data to clinicians, who use it for further improvement and innovation Knowledge flows bi-directionally Research influences practice; practice influences research

20 Bi-directional, reciprocal learning can address priorities for the nation and its health care systems. The Learning Health Care System


22 Research on the Patient-centered Medical Home in a Learning Health Care System: Group Health 2002 “Access Initiative” came first Group Health has always been primary-care based; aspired to be patient-centered. Reputation and past performance in “managed care” and as a traditional HMO: Access was a problem. Access Initiative elements included: Same-day appointments Open access to specialists A new EMR with secure website for members Ambitious productivity standards Reimbursement change

23 Research on the Patient-centered Medical home in a Learning Health Care System: Group Health UW/GH study of “Access Initiative” showed: Increased patient satisfaction Markedly improved access and productivity But no gains in clinical quality, and A dramatic negative impact on primary care provider work life Next step: Patient-centered medical home pilot Can it improve quality and revitalize primary care? Our design benefitted from “lessons learned” through the “Access Initiative”

24 Patient-centered Medical Home to Revitalize Primary Care Reinvigorated core attributes of primary care System support for chronic illness care Advanced information technologies (EMR, registries, reminders, patient portals) Supportive physician payment methods (promotes medical home goals, not simply volume) Design principles for Group Health’s pilot: Panel size reduced from 2,300 to 1,800 patients Appointment times increased from 20 to 30 minutes. Expanded multi-disciplinary clinical teams Desktop time E-technology and communication (EMR and secure email with patients)

25 Medical Home Change Components ED & urgent care visits Hospital discharges Quality deficiency reports e-health risk assessment Birthday reminder letters Medication management New patients Patient-centered outreach Calls redirected to care teams Secure e-mail Phone encounters Pre-visit chart review Collaborative care plans EHR best practice alerts EHR prevention reminders Defined team roles Point-of-care changes PCMH Model Team huddles Visual display systems PDCA improvement cycles Salary only MD compensation Management & payment

26 Reid RJ et al, Health Affairs 2010;29(5):835-43 Larson EB et al, JAMA 2010; 306(16):1644-45 Reid RJ et al, Am J Manag Care 2009;15(9):e71-87

27 Patient Experience at Group Health’s Medical Home Significantly higher scores for patients at Medical Home pilot clinic Year 1 Year 2 Quality of patient-doctor interactions Shared decision making Coordination of care Access Helpfulness of office staff Patient activation/involvement Goal setting/tailoring Compared to controls: Difference not significant Medical Home higher Medical Home lower

28 ** p<0.01 Staff Burnout at GH Medical Home Marked improvement in burnout levels at prototype clinic at 1 year

29 Utilization and Costs in Group Health’s Medical Home Year 1: 29% fewer ER visits 11% fewer preventable hospitalizations 6% fewer but longer in-person visits No significant difference in total costs between Medical Home and control clinics Year 2: Significant utilization changes persisted Overall patient care costs lower at Medical Home (~$10 PMPM)

30 Lessons Learned from Group Health’s Patient-centered Medical Home Pilot Patient-centered care saves costs by lowering inappropriate use of emergency care and avoiding preventable hospitalizations. Investment in a medical home can achieve relatively rapid returns across a range of key outcomes, even in an already integrated system The Group Health PCMH evaluation provides some of the first empirical evidence of the benefits of the medical home. The evaluation has led Group Health to spread the PCMH to all 26 of its medical centers.

31 Patient-Centered Medical Home: 2011 and Beyond Medical Home principles are just basic primary care principles. But the Medical Home principles address: Complexity of today's patients (especially chronic disease and geriatrics) Complexity of fragmented, highly specialized system we work in Use of technology in ways that are patient centered Payment is changed. Experts agree: Payment reform is necessary for MH to endure. Medical Home is prominent in the U.S. health reform law: Key will be spread and local execution.

32 More Examples of Innovation in Group Health’s Learning Health Care System A shared-decision making initiative: Informed choices may reduce unwarranted variations in treatment for preference-sensitive medical conditions Current study is examining use of DVDs, booklets, Web-based videos to help patients make informed choices

33 More Examples of Innovation in Group Health’s Learning Health Care System Shared-decision making evaluation focuses on 12 kinds of surgery, including: Knee replacement Hip replacement Cardiac procedures Low back surgery Hysterectomy Prostate surgery Breast cancer (mastectomy vs. lumpectomy) Researchers will learn how the initiative affects: Use of surgery Total health care utilization Total costs

34 More examples of innovation in GH ’ s Health ’ s learning health care system Value-based benefit design Pilot of Group Health’s 9,000 employees Higher co-pays for high-cost, low-value services, such as high-tech radiology Wellness incentives AHRQ-funded study to evaluate impact on employee health, quality of life, productivity, utilization, costs Pediatric oral health  Research on the integration of oral health promotion practices into well- child care showed high satisfaction among patients and physicians.  Resulted in dissemination at all 26 Group Health clinics.

35 Example of Prevention in a Learning Health Care System: Free & Clear 1985: Group Health launches study of Free & Clear, a groundbreaking, phone- based smoking cessation program funded by NCI. 1991: Research shows Free & Clear boost quit rates 50% 1998: Study of 90,000 Group Health members shows providing coverage for smoking cessation increases quit rates. 2002: Study of blue-collar workers demonstrates a 27.5% quit rate and 27% ROI due to reduced utilization for tobacco-related illness. 2002: Boeing offers Free & Clear at no cost for its 150,000 employees; 10% participation; quit rates of up to 35%.

36 Example of Prevention in a Learning Health Care System: Free & Clear 2003: Free & Clear, Inc., becomes an independent business with investment from venture capitalists. 2009: Washington State announces state smoking rate hits a new low for the 6 th consecutive year, thanks in part to Free & Clear. Today, Free & Clear, Inc., is the only commercial smoking cessation program w/proof of effectiveness (>20 clinical trials, 50 program evaluations, >80 peer reviewed publications). Serves >18 state governments and 280 commercial clients (51 in the Fortune 500). More than 2 million people have used Free & Clear

37 Prospects that primary care, revitalized by the Patient-centered Medical Home can help Achieve Goals of Healthcare Reform: Access for All at an Affordable Cost International comparison data support primary care based systems yield highest quality, best value. PCMH creates environment where care can be delivered based on basic primary care principles. Effective primary care: Keep care local when possible and linked to ongoing healing relationships. Spread of PCMH at GH and nationwide demonstrations show - in the US "all healthcare is local" effective leadership and team function is critical diverse role functions are characteristic Primacy of cost containment, a local and worldwide challenge

38 Learning Through Research and then Evaluation must Continue Evaluation of PCMH results will be critical to whether PCMH can truly revitalize primary care in the US and achieve goals of reform. Research on the effects of primary care will remain valuable and ideally ongoing. Interesting Example: Einarsdottir, et al.: Regular Primary Care Plays a Significant Role in Secondary Prevention of Ischemic Heart Disease in a Western Australia Cohort (JGIM 2011;26:1092-7; Editorial – Ogedegbe and Williams: Primary Care Equals Secondary Prevention in Ischemic Heart Disease) In a "trohoc" study of 30,000 (mean age 73) discharged with heart disease and followed to time of death or IHD rehospitalization: Frequency of primary care visits divided into quartiles: there was a dose response from least to most regular visits for both death and IHD rehospitalization. HR for mortality and IHD mortality were: 0.71 and 0.65. Conclusion: Regular primary visitation offers protection against morbidity and mortality in older people with established IHD. Mechanism unknown but probably related to better care associated with continuity.

39 Innovation is not enough. We must focus on what happens afterward.

40 Healthcare reform is not enough. It will provide more universal access, but we need to focus on what happens after that.

41 “This is our moment. This is our time. …Our time to bring new energy and new ideas to the challenges we face.” “We’ll restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost.”

42 "It gradually dawns on you that things work, and there are a lot of people that want to help it work. …Success is cumulative and optimism builds on cumulative success." --William Foege, MD, MPH, Advisor to the Carter Foundation and the Bill & Melinda Gates Foundation; Led the successful campaign to eradicate small pox


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