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

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

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

Identity Crisis Moral Leadership Financial

“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

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

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.”

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

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

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 - 2004

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 - 2004

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 - 2004

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

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 1931-67. Public Health Rep 1970; 85(6):485-494.

Which System is More Stable? Primary Care Specialists OR

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

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

$2,300,000,000,000

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

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):483-485.

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):483-485.

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) 457-501)

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) 457-501)

“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

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

Bold Champion

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

How Do We Change Our Health Care System?

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

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

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

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

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

Patient Families Communities Family Physician

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

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

Must Pass Elements at 50% Performance Level PPC-PCMH Scoring Level of Qualifying Points Must Pass Elements at 50% Performance Level Level 3 75 -100 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.

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.

The Health Care Paradigm Buyers Payors Providers Business Insurance Companies Physicians

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

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

Trim-Tab Leaders

“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

“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

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

Patient Centered Medical Home in the Informational Age Questions?