Patient Centered Primary Care (PCPC) The Time Has Come Paul Grundy MD, MPH, FACPM, FACOEM Director, Global Well-being Services, February 2007 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Our Healthcare Environment: Where We Are Healthcare Drivers Trend Technology Cumulative Changes in Health Insurance Premiums, Overall inflation, and Workers' Earnings 2000-2006 Imaging Specialty Rx & Pharmaco-genomics Personal Medical Devices Overall Inflation Price Waste Supply drives demand Cost insensitivity: expectations Consolidation & litigation Over-utilization Medical Errors Labor Nursing shortage Specialization Administrative costs & IT deficiency
12% 15% 5% 7% 10% 1 4 % 2002 2003 2004 2005 20% 18 % 2006 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Our Healthcare System: How Are We Doing Technology Health Systems Performance Domains Equity Efficiency Access
Quality of Care: Care Outcomes: Outcomes: Long, Healthy & Productive Lives US Health System Performance: National Scorecard 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Patients Are Besieged Our Healthcare Environment: Whats Happening To Insured Patients Technology Challenges -Imaging -Biopharmaceuticals -Devices -Web Data Interpretation & Quality -Personal Health Records Health Plan Complexity -HDHP,-PPO -Tiered networks -HMO, EPO, DMAs -Co-insurance, Co-Pays, OOP Maximums, Deductibles, Plan Maximum, -Centers of Excellences Disease Management & Care Coordination Pharmacy & PBMs -Mail Order Chronic Meds -Specialty Drugs -Tiered Formularies -Adherence & Management Pgms
Health Accounts -Health Reimbursement Account -Health Savings Account -Flexible Spending Account -Medical Savings account -Long term Care Insurance -SHPS, Matria, American Healthways, ActiveHealth, Alere, AirLogix,Focused Health, Life Masters, Q-Med, RMS, Health Plans Privacy Issues Regulatory Agencies (FDA, EMEA, MHLW, WHO, DHHS, CDC) Employer Programs -Integrated Disability -Wellness & Health Promotion -On Site Services, Clinics Advocacy Groups -Unions -Demographic Groups: e.g. AARP -Consumer Groups -Patient Groups 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Patients: More Is On The Way MEDICAL TOURISM DEMOGRAPHIC SHIFT CONSUMERISM
MEDICAL TOURISM BIOTECH ERA 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Physicians Are Under Assault Our Healthcare Environment: Whats Happening To Physicians Network Negotiations Measurement & Reporting -Health Plans -Network Management firms -Hospitals -Claims -HEDIS, NCQA, NQF, Proprietary Quality Ratings Tiered Networks Cost > Quality Prescription Drugs Pay 4 Performance -PBMs: MedCo Health, -Medicare, Medicaid -BTE,Business Coalitions -NQF, NCQA -Health Plans, ETGs Government Agencies & Employers
CMS, States, NBCH, NBGH, PBGH, etc Caremark/APCS, Express Scripts., Aerna, Walgreens, MedImpact, Cigna -Specialty Pharmacies -Pharmacy Consulting firms Disease Management & Care Coordination -SHPS, Matria/Cor Solutions, American Healthways, ActiveHealth, Alere, AirLogix,Focused Health, Life Masters, Q-Med, RMS, Health Plans Interventions -Generic Substitution -Formulary Adherence -Prior Authorization -Dose Optimization & Limits -Medication Adherence -Utilization Management 2006 IBM Corporation Global Well-being Services & Health Benefits What is Primary Care? First Contact & Access to Care initial point of care for all medical needs Accessible days, nights, weekends Timely appointments Comprehensive Accountable for addressing large majority of healthcare needs Recruits other providers to care team as warranted by clinical care needs Considers physical, psychological and emotional needs
Continuity of Care Coordination of Care Develops sustained partnership with patients over long period of time Sustains involvement in care with other providers and institutions Follows through with patient communications Sources and arranges referrals and services with other providers Coordinates decision making with healthcare team to promote best outcomes for patients Coordinates communications with patients to promote patient understanding and participation Person-centered to respect beliefs, preferences, psychological as well as Holistic physical needs Engages family and community resources After:- Malcolm Peterson, ACP, IOM, AIM 1980;84:843-51 - IOM , National Academy Press, 1996; Starfield, B.: Millbank Memorial Fund, 2005 7 2006 IBM Corporation Global Well-being Services & Health Benefits What is Patient-Centered Primary care? Recast role of clinicians to provide more counseling and advising Provide timely access for patients to resources, information and tools Patient Engagement Assistance with self-care and behavior change Use of personal health records and easy patient access to their medical records Enable: evidence-based care, practice-based learning and quality improvement HIT & Clinical Utilization of disease registries, reminders/alerts to physicians and patients Information Clinical decision support on diagnostic and therapeutic options Facilitation condition management, adherence monitoring Systems
eHR, eRx, on demand access to patient data, lab and imaging results Performance data disclosure and access Provider Discount and price disclosure Transparency Patient and peer assessment reporting Systematic Patient Feedback Ongoing, routine practice feedback from patients Targeted improvement planning, measurement and reporting based on practice feedback After:- Davis K., Schoenbaum S.C., Audet A-M., A 2020 Vision of Patient-Centered Primary Care, Commonwealth Fund, 2005 8 2006 IBM Corporation Global Well-being Services & Health Benefits Why Do We Care at IBM About Primary Care Primary Care Attributes Improves major health outcomes supply primary care physicians (PCP) per 10,000 population Reduced adult mortality: total, heart disease, stroke & cancer: an increase of 1 PCP/10,000 reduces overall mortality by 5.3% saving 127,617 lives Reduced infant mortality & low birth weight Reduced hospitalizations for ambulatory care sensitive diagnoses First contact Continuous Comprehensive
Improves delivery preventive services: primary care attributes Coordinates care Patient-focused & long term Family & community orientation Includes: family practice, medicine, pediatrics Impacts significantly associated with being up to date on: Immunization, screening, health habit counseling States with higher ratios PCPs have lower rates smoking, obesity Improves outcomes and access to needed health services for internal poor: reduces the disparity in health outcomes of minorities and the poor - Adverse health effects of income inequality are reduced by access to primary care (e.g. overall mortality, infant mortality, low birth weight) Reduces health care costs: ratio of PCPs per population is associated with 9 Lower hospitalization rates for total US and for Medicare beneficiaries Lower costs of care for common illnesses compared to specialists Lower total cost of health services, lower Medicare spending 2006 IBM Corporation
IBM Global Well-being Services & Health Benefits Primary Care Score vs. Health Care Expenditures, 1997 Primary Care Score 2 UK DK NTH 1.5 FIN SP AUS 1 SWE CAN JAP 0.5 GER BEL 0 1000 1500 US FR
2000 2500 3000 3500 4000 Per Capita Health Care Expenditures Starfield 10/00 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Primary Care and Life Expectancy State Level Analysis 78 Life Expectancy 77 76 75 74 73 72 .ND . N E SD .ME ID .NH .OR . . .
AZ RI . . ID . .MT .NJ NM .IA UT . . . TN FL . .NY WI .KS . .MI.TX . DE .AR . KY .PA .AL WV .NC .VA. IL .MS . .AK .GA . NV SC 71 4.00 . .. .. . CA MN CT WA MA
. HI .MD R=.54 LA P<.05 4.50 5.00 5.50 6.00 6.50 7.00 7.50 Primary Care Physicians/10,000 Population PC physicians/population associated with longer life expectancy. Shi et al. Income, Inequality, Primary Care and Health Indicators. Journal of Family Practice. April 1999 Starfield 03/02 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Rates of Avoidable Adult Hospitalization for 6 Conditions and Family Physicians-Internists per 10,000 Population Source: Parchman & Culler, 2004 2006 IBM Corporation IBM Global Well-being Services & Health Benefits
Physician Access: Went to the ER for Condition that Could Have Been Treated by Regular Doctor if Available Percent % 30 26 25 21 20 15 15 10 6 5 0 AUS CAN GER 9 NZ 12 UK US 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems 2006 IBM Corporation
IBM Global Well-being Services & Health Benefits Complexity of Care & Outcomes: Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Percent 50 45 40 35 30 25 20 15 10 5 0 48 37 40 31 35 28 22 12 15 14 AUS CAN GER 14 NZ 1 MD >/= 4 MDs
12 UK US 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems 2006 IBM Corporation IBM Global Well-being Services & Health Benefits Complexity of Care & Outcomes: Patients Reporting Care Coordination Problem by Number of Doctors Seen in Past Two Years (Percent) 45 43 40 35 30 25 31 27 15 26 22 16 1 MD >/= 4 MDs 11 10 7
5 0 30 23 20 15 30 AUS CAN GER NZ UK US 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems 2006 IBM Corporation Global Well-being Services & Health Benefits the need for primary care is great and its growing Prevalence rate of chronic disease is very high and it is rising 45% of US population (120 million Americans) has a chronic medical condition 50% of Americians with a chronic medical condition (60 million) have more than one chronic medical condition Within 10 years, the number of Americans with at least one chronic medical condition will grow by 25% to 150 million Older age population: growing rapidly and higher rates of chronic disease By 2030, 20% of Americans will be over the age of 65 83% of Medicare beneficiaries have one or more chronic conditions 23% have 5+ chronic conditions Between 2000 and 2010 population over 85+ will increase 50% 92% of adults 80+ have 1 chronic condition; 73% have 2+ conditions
16 2006 IBM Corporation Global Well-being Services & Health Benefits but Int. Medicine primary care physician supply is shrinking 17 Demand for internists will increase by 38% between 2000 and 2020 from 106,000 to nearly 147,000) In 2003: First year IM residents only 19% planned primary care careers Third year IM residents only 27% planned to practice general IM down from 54% in 1998 Aging internal medicine workforce: 35% of physicians nationwide are over the age of 55 2004 ACP study: after 10 years practice 21% IM primary care physicians leave practice versus 5% for specialists High debt for medical education and declining compensation for primary care: > 80% of graduating medical students carry debt
Median for private medical schools: $160k Median for public medical schools: $120k 5% have debt > $200k 2006 IBM Corporation Global Well-being Services & Health Benefits and the Family Medicine pipeline is shrinking Residency Positions and Number Filled by U.S. Medical School Graduates. Courtesy of: American Academy of Family Physicians, based on data from the National Resident Matching Program 18 2006 IBM Corporation Global Well-being Services & Health Benefits Physician Income Declines Most Severe for Primary Care 1995-2003 % Change in Average Physician Income 1995-2003 Adjusted for Inflation Professional & 8 6 4 2 0 -2 -4 -6 -8 -10 -12 Technical Workers % Change Hrs. Direct Patient Care Medical Specialists
$175K All Physicians $168K Primary Care $121K Surgical Specialists $225K Center for Studying Health systems Change, Community Tracking Study, Tu & Ginsberg, no. 15, June 2006 19 2006 IBM Corporation Global Well-being Services & Health Benefits Why IBM Came Directly To Primary Care Physicians: Transformation Through Partnership Global Well-being Services and Health Benefits (GWBS & HB) Corporate TransforMed Policy: Expectation patient-centered care by ofAdvance Excellence transforming in Employee practice around: Well-being Outcomes & patient safety Open Access Scheduling Electronic health records Team approach to care Advanced Medical Home
Primary care home for patients Certification for office practices: evidence based guidelines & information technology to deliver patient centered care Value and quality of care measured Reimbursement reform 3 20 2006 IBM Corporation Global Well-being Services & Health Benefits Trusting physician-patient relationships with technology enabled practice-based learning, clinical decision support and full patient engagement Smart Cards..new payment models EHR Hospital events ....admission benefits eligibility, billing Physicians patient files HTS EHR Patient Information at Point of Care Evidence-Based Medicine Guidelines EHR Surgery, recovery, discharge records Measure impacts of targeted interventions Disease management support Telemedicine Devices
Member relationship management 21 Personal genomics Integrating the Patient Centric Record EHR EHR Expression Arrays On Demand Patient Information Analysis of Contact data lab results Medical history Secure, authorized access 2006 IBM Corporation Global Well-being Services & Health Benefits Patient-Centered Primary Care Pilot Superb access to care. Patients can easily make appointments and select 22 the day and time. Waiting times are short. E-mail and telephone consultations are offered. Off-hours service is available. Patient engagement in care. Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with selfcare, and counseling. Clinical information systems that support high-quality care, practice-based
learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. Care coordination. Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided . Integrated and comprehensive team care. There is a free flow of communication among physicians, nurses, and other health professionals. Duplication of tests and procedures is avoided. Routine patient feedback to doctors. Practices take advantage of low-cost, Internet-based patient surveys to learn from patients and inform treatment plans. Publicly available information. Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. 2006 IBM Corporation Employer-Physician Summit: Primary Care 2006 IBM Corporation Patient Centered Primary Care (PCPC) The Time Has Come Paul Grundy MD, MPH, FACPM, FACOEM Director, Global Well-being Services, February 2007 2006 IBM Corporation
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