Jim Jenkins, MD President, Fairfax Family Practice Centers

 Largely solo practices, mostly primary care until the second half of 20 th century  Sudden growth of specialist practices driven by availability of training programs and large salary discrepancy

 Move from solo practice to group practice is accelerating ◦ 1990: 87.6% in solo practice ◦ 2011: of 230,187 medical practices in the US  52.8% Solo practice  47.2% Group Practice o 37.1% 2 to 5 physicians o 6.3% 6 to 9 physicians o 3.7% 10+ physicians

 First proposed by Harry Truman in 1945 ◦ 56% of people over 65 yo had no health insurance  Signed into law by Lyndon Johnson in 1965 ◦ Medicare: >65 yo and disabled, Federal ◦ Medicaid: Low income, State and Federal  Gradually expanded over the years  Cost growth exceeding population growth

A model of health care delivery  provided by provider-led teams  with the patient at the center  designed to strengthen the doctor‐patient relationship by replacing episodic care based on illnesses with coordinated care and a long‐term healing relationship.

High quality health care that is ◦ Accessible ◦ Personal ◦ Seamless ◦ Continuous Comprehensive patient- centered care that is ◦ Coordinated ◦ Compassionate ◦ Culturally welcoming ◦ Constantly improving

The principles of a medical home include:  Having a personal physician/provider  That provider leads of team of clinical caregivers who collectively take responsibility for ongoing care  An orientation toward the whole patient rather than episodes of need or a single body part  The care provided is coordinated across all elements

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care. Errors include medical mistake, wrong medication/dose, or lab/diagnostic errors. Source: 2007 Commonwealth Fund International Health Policy Survey. Data collection: Harris Interactive, Inc.

Geisinger Health Plan PCMH pilot (1000 enrollees) 18% reduction in hospital admissions relative to controls: 257 admissions per 1,000 members per year in PCMH patients vs. 313 admissions per 1,000 members per year in controls (p<.01). 7% reduction in total PMPM costs relative to controls (p=.21). North Carolina Medicaid PCMH demonstration project (>950,000 as of January 2009) Improved process measures for diabetes, asthma A $10.2M investment saved $244M in overall health care costs in 1 year (FY04). First-year net costs reduced by 7%

Group Health Cooperative of Puget Sound $10 PMPM reduction in total costs; total PMPM cost $488 for PCMH patients vs. $498 for control patients (p=.076). 16% reduction in hospital admissions (p<.001); 5.1 admissions per 1,000 patients per month in PCMH patients vs. 5.4 in controls. Intermountain Healthcare Medical Group Care Management Plus PCMH Model Reduced hospitalizations in PCMH group; by year 2 of follow-up, 31.8% of PCMH patients had been hospitalized at least once vs 34.7% of control patients (p=.23). Among patients with diabetes, 30.5% of the PCMH group were hospitalized vs 39.2% of controls (p=.01). Net reduction in total costs was $640 per patient per year ($1,650 savings per year among highest risk patients).

Barbara Starfield of Johns Hopkins University Within the United States, adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die. In both England and the United States, each additional primary care physician per 10,000 persons is associated with a decrease in mortality rate of 3 to 10 percent. In the United States, an increase of just one primary care physician is associated with 1.44 fewer deaths per 10,000 persons. Commonwealth Fund has reported: A medical home can reduce or even eliminate racial and ethnic disparities in access and quality for insured persons. Denmark has organized its entire health care system around patient- centered medical homes, achieving the highest patient satisfaction ratings in the world. Denmark has among the lowest per capita health expenditures and highest primary care rankings.

ACOs are defined as a group of providers that are accountable for the quality and cost of care for a population of patients and has the legal structure to receive and distribute incentive payments to participating providers.

 Fairfax Family Practice Centers ◦ 12 Sites including a Family Medicine Residency ◦ 100+ providers including 30+ midlevel providers ◦ Certified NCQA Level 3 PCMH in 2010 ◦ PCMH Contracts with CareFirst BCBS, Anthem BCBS, Cigna, Aetna

 Aardvark Report  My Preventive Care

 Printed before morning and afternoon patient care  Lists problems, labs, medications, immunizations  “Action Items” based on evidence based guidelines  Used by clinical staff when rooming patients  Contributes to Clinical Summary given to patient after appointment

 Caring for a defined population of patients, may be defined by geography, location, age or disease  Key to decreasing cost and increasing quality of care  “Big Picture” view of clinical care

FFPC Quality Dashboard

 More integrated with better exchange of clinical data  Better integration of primary care, specialty care, hospital care  Larger role of government  Cultural change to emphasize healthy lifestyle

 Larger role for nurse practitioners  More team based care  More evidence based guidelines  More integration into the community  More emphasis on education