Fred Ralston, Jr. MD, FACP

1
The Rocky Road Toward Universal
HealthInsurance Coverage in the USA

• Fred Ralston, Jr. MD, FACP
• President, American College of Physicians

2

• The past How payment for health care has changed
  over the past 100 years
• The future Understanding the Patient-Centered
  Medical Home What Is It? What Can It Offer
  Patients, Physicians, and Those Paying for Health
  Care?

3
Why 100 years?

• Abraham Flexner, a research scholar at the
  Carnegie Foundation for the Advancement of
  Teaching, undertook an assessment of medical
  education in North America, visiting all 155
  medical schools then in operation in the United
  States and Canada.
• His 1910 report, addressed primarily to the
  public, helped change the face of American
  medical education.
• American Medical Education 100 Years after
  the Flexner Report
  N Engl J Med 20063551339-44

4
Flexner Report

• The power of Flexners report derived from his
  emphasis on the scientific basis of medical
  practice, the comprehensive nature of his survey,
  and the appeal of his message to the American
  public.
• Although reform in medical education was already
  under way, Flexners report fueled change by
  criticizing the mediocre quality and profit
  motive of many schools and teachers, the
  inadequate curricula and facilities at a number
  of schools, and the nonscientific approach to
  preparation for the profession, which contrasted
  with the university-based system of medical
  education in Germany.

5
Early 20th Century

• Nearly half of American Medical Schools closed or
  merged following this report
• Tremendous scientific advances using a more
  European model of education and practice
• With advancing quality come advancing costs
  hence the beginnings of talk regarding health
  insurance to help pay for this higher quality care

6

• After a visit to the Royal College of Physicians
  in London in 1913, Dr. Heinrich Stern tried to
  invoke enthusiasm in his colleagues for a similar
  organization in the United States. But it was two
  years before Dr. Stern could gather enough
  physicians11that he felt necessary to launch
  the new organization, the American College of
  Physicians.
• From the College's first formal meeting in New
  York's Astor Hotel on June 25, 1915, the founding
  members viewed ACP as a way to improve the
  standards and recognition of internal medicine in
  this country.

7
Perspective

• Americans always want to do the right thing
  after they have tried everything else. 
• Winston Churchill

8
Early 20th century Teddy Roosevelt

• In 1906, the American Association of Labor
  Legislation (AALL) initiated a campaign for
  national health insurance.
• 1908 With support of President Roosevelt,
  Congress enacts first Workmans Compensation act
  for civil service employees
• By 1915 Workmans Compensation laws had
  passed in 30 states
• Health insurance coverage was considered to be
  the logical next step

9
Theodore Roosevelt

• Roosevelt believed that no country could be
  strong whose people were sick and poor
• 1912 Roosevelt campaigned on a platform that
  called for mandatory health insurance for workers

10
1910-1920

• 1910s Insurance plans started to offer group
  coverage. Total amount of voluntary HI prior to
  World War I remained very small, however
• Into this vacuum, compulsory HI was discussed as
  part of a broader Social Security movement

11
American Association of Labor Legislation

• 1915 Bill to provide health insurance to the
  working class and all others that earned less
  than 1200 a year, including dependents
• Compulsory coverage for services of physicians,
  nurses, and hospitals
• Also provided for sick pay, maternity benefits,
  and death benefit for funeral expenses
• Costs were to be shared between workers,
  employers, and the state

12
AALL Legislation Defeated

• Supported by the AMA
• Opposed by Labor
• Seen as threat to unions, usurping
• their role in providing social benefits
  Samuel Gompers
• Denounced by AFL leadership as an unnecessary
  paternalistic reform that would create a system
  of state supervision over peoples health
• Opposed by Commercial Insurance Industry
• Threat to private insurance death benefits
• Lacked Popular Support

13
WWI -1929

• Compulsory insurance equated with German
  socialist insurance and Bolshevism
• Increased resistance from physicians
• Viewed as threat to private practice,
  paternalistic, and un-American
• Viewed as a threat to professionalism itself
  mandatory fee schedules, work reviews,
  organizations outside the doctor-patient
  relationship over which doctors have no control
  and limits on patient choice of physician
• 1920 AMA House of Delegates opposes compulsory HI

14
The Great Depression and FDR

• Social Security Act of 1935 provided grants for
  states to set up assistance programs for
  indigents

15

Franklin Delano Roosevelt

• FDR spoke in favor of a right to medical care,
  but did not push compulsory HI over fear that it
  would endanger other high priority reforms
• Economic security for workers and aged,
  unemployment, national economic recovery, WWII
• Bill after bill introduced to mandate coverage,
  but none passed the Congress
• Growing conservative opposition to social
  programs after 1938

16
World War II

• 1943 Health insurance and other worker benefits
  exempt from wage and price controls
• 1943-49 Childrens Bureau organized a
  comprehensive program of maternity and infant
  care for military dependents 12 million
  servicemen were eligible for care in hospitals
  and systems organized by the Armed Forces (model
  for the VA)
• By 1944, the War Food Administration was
  responsible for health centers and clinics in 250
  agricultural areas

17
1945-53 Harry Truman

• 1945 Truman proposed a single plan to provide
  coverage for all age groups financed by 4 rise
  in Social Security payroll taxes

18
Truman Plan Fails

• Union leaders advocated for insurance to protect
  workers from rising medical costs
• But fail to enlist rank and file membership
• Opposition from GOP-controlled Congress and
  Southern Democrats
• National attention on Cold War
• Socialized medicine made a symbolic issue in
  crusade against Communist influence
• AMA launched massive public relations and
  lobbying blitz in opposition
• 1946 Hill-Burton Act provides funds for hospital
  construction with obligation to provide free care
  to uninsured

19
1950s Dwight Eisenhower

• Eisenhower proposed to help private HI through
  re-insurance, regulation and initial subsidy, but
  no requirements on private insurance regarding
  how health services were provided
• Tax credits for employer sponsored health
  insurance prompts greater private coverage
• Unions winning health benefits by collective
  bargaining reduces their interest in seeking
  national legislation

20
1950s Eisenhower Administration

• Late 1950s Forand bill proposed hospitalization
  insurance for retirees through Social Security
  bill never went anywhere opposed by Rep. Wilbur
  Mills, chair of the Ways and Means Committee
• 1960 Kerr-Mills Act passed providing grants to
  states to provide need-based assistance for the
  elderly poor, but only 28 states participated
• Federal Employee Health Benefits Program
  established model for future proposals

21
Early 1960s John F. Kennedy

• Kennedy campaigned for a comprehensive program of
  HI coverage for the elderly
• AMA established AMPAC with goal of electing
  conservatives to Congress and opposing Medicare
• AMA won the propaganda war against Medicare bill
  was defeated in the Senate and never got out of
  the House Ways and Means Committee

22
1960s Lyndon B. Johnson

• Assassination of JFK and LBJs ascendancy changed
  everything LBJ believed in Medicare even more
  than JFK and knew how to get legislation through
  Congress
• 1964 elections LBJ trounced Goldwater and the
  Democrats gained a 2-1 majority in Congress

23
Medicare and Medicaid Enacted

• 1965 Medicare and Medicaid passed, providing
  hospital and medical care for the elderly and
  creating a State/Federal partnership to cover the
  very poor

24
Enactment of Medicare was a Triumph of Principled
Pragmatism

• Key pragmatic decisions were made to ensure
  enactment
• Mandated hospital coverage only for the elderly
• Voluntary coverage for physician services
  (Medicare Part B)
• Payments based on usual and customary charges
• Non-interference in practice of medicine promised
  
• Goal was to assure the same level of care for
  elderly, not to attempt to change the status quo
• Medicare had to pay its own way no discounts or
  prospective payments cost-based pay to hospitals

25
1970s Richard Nixon

• 1972 Medicare expanded to cover disabled
• Wage and Price controls beginning of limits on
  Medicare payments to physicians and hospitals
• 1974 National Health Planning Act required
  certificate of need for new construction and
  acquisition of costly technology

26
1970s Nixon and Ford

• 1970 Sen. Ted Kennedy holds
• hearings and proposes single-payer plan
• Sen. Long and Rep. Mills also offer plans
• 1971 Nixon responds with a plan that all large
  employers offer catastrophic HI coverage
• Nixon under threat of impeachment -- bills fail
• Ford supports National HI in 1974 but later
  withdraws support as inflation rises
• Scandal forces Rep. Mills to leave coalitions
  for reform weakened, efforts again fail

27
Jimmy Carter

• 1976 Carter campaigns for catastrophic plan
• After election priority shifts to controlling
  health care costs but he proposes a plan
• Sen. Kennedy offers new legislation for
  mandatory employer HI, government subsidies for
  poor, competition among private plans, and
  negotiated fees
• Bills fail due to economic recession, rising
  health costs, Congressional committee
  restructuring, and failure of advocates for
  comprehensive coverage to compromise

28
1980s Reagan/Bush

• Reagan favored repeal or overhaul of many of the
  regulatory laws passed in the previous decade
  (e.g., National Health Planning Act and PSRO
  program)
• Market-based pro-competition approach and tax
  credits favored for expanding HI
• Medicare catastrophic and prescription drug
  coverage enacted, but repealed as seniors
  objected to paying for it
• Growth in federal budget deficits led to new
  methods of paying doctors and hospitals

29
1990s Bill Clinton

• Rising health care costs and
• 46 million uninsured increased
• popular support for HI reform
• Clinton administration became the first since
  Truman to pursue a comprehensive plan to provide
  universal coverage
• Health Security Act called for mandated employer
  and individual coverage, managed competition,
  purchasing alliances, and global budgets
• Plan fails to pass congressional committees

30
Clinton Plan Fails

31
Late 1990s Clinton Administration

• Following defeat of Clinton plan, more modest
  goals were set for expanding coverage (e.g. 1997
  Childrens Health Insurance Program for
  low-income children)
• GOP take-over of Congress led to enactment of
  Balanced Budget Act of 1997, which mandated cuts
  in payments to hospitals, physicians, other
  providers and new MedicareChoice programfirst
  step toward goal of privatizing Medicare
• In 1998, Congress replaced the VPS with the
  Sustainable Growth Rate (SGR).

32
2001-2009 George W. Bush

• Prevailing conservative political view was to use
  market competition and the purchasing power
  of the federal government to reduce costs and
  improve quality
• Key elements included transparency in pricing
  of services, measurement of performance, public
  reporting of quality and cost data to empower
  consumers, basing compensation on performance
  (P4P), and providing incentives for individuals
  to save for their own care (HSAs) with protection
  against catastrophic costs

33
2001-2009 George W. Bush

• Ironically, Republican Congress passed and
  President George W. Bush sign into law the
  largest expansion of federal entitlements since
  1965 Medicare Prescription Drug Program (Part D)
• Decision to run the program through private
  insurers and PBMs put a conservative stamp on
  expansion of entitlements

34
2001-2009 George W. Bush

• Democrats re-gained control of both the House and
  Senate in 2006 mid-term elections, representing a
  shift away from prevailing conservative trend
• But the country, and the U.S. Senate, remained
  closely divided
• Reauthorization fight over CHIP (2007-2008)
  marked by extreme partisanship

35
2009 Obama Administration

• Obama campaigned for universal health care
  coverage
• 2008 elections returned the Democrats to the
  White House and solidified control over Congress

36
2010 Affordable Health Care Act Passed

• Pragmatic Approach Builds on private insurance
  and existing government programs
• Effort made to gain support of public and
  interest groups
• President worked with Congress
• Support from labor, medicine, business
• Minimized opposition of insurers, hospitals,
• and drug companies
• Provisions implemented gradually 2010-20
• Obama and Congressional leaders persevered

37

• The present an unsustainable health care
  delivery system that overvalues procedures and
  undervalues prevention and primary care
• Is there a way to align incentives in a way where
  patients, physicians and insurers want the
  right treatment at the right time for everyone?
• The Patient-Centered Medical Home What Is It?
  What Can It Offer Patients, Physicians, and Those
  Paying for Health Care?

38
Two kinds of talks

• Emotional from the heart but without the data
  to back it up
• Data filled slides that put everyone to sleep and
  while evidence-based are met with skepticism by
  those who feel they may not be relevant to those
  practicing in the real world whether
  community or academia
• I hope to show you why as a practicing internist
  I am so excited about the medical home and also
  that we have the data to back this up

39
From the heart

• Internal medicine both general and subspecialty
  is a highly rewarding professional career I
  would argue among the highest callings possible
• General internal medicine and many
  subspecialties face tremendous threats to
  survival without improved payment
• Those subspecialists who like the current payment
  system need to know that it is unsustainable and
  will melt down if the cost curve is not bent

40
From a self-professed health policy wonk

• I am convinced that there is no way possible
  under the current payment model to rebalance
  primary care through modifications to the RBRVS
  alone
• There is no traction to pleas asking for higher
  payments for primary care using the current
  delivery model
• There will be continued unfunded or semi-funded
  mandates or expectations involving but not
  limited to quality improvement and reporting

41
From a self-professed health policy wonk in
private practice

• I am sympathetic to internists who say that the
  patient-centered medical home is what they have
  been doing for twenty years
• Many practices are close but require
  documentation and others have further to go
• With current trends in workforce and practice
  overhead, if there is no fundamental change in
  payment private practice of general internal
  medicine will only exist in subsidized
  environments

42
Subsidized environments?

• Hospital ownership of practices
• Integrated groups pulling in revenue from
  ancillaries and other specialties
• Those offering an insurance product or gain
  sharing with insurers
• Concierge medicine

43
Unintended Consequences

• Smaller practices with seasoned veterans may
  close before they can attract new physicians to
  provide care
• It would be wise to bring a new generation to
  learn the art of medicine from those who have
  decades of experience
• Time is short
• We need to increase the pipeline for primary care
  before these potential mentors leave practice

44
Alignment of incentives

• Hospitals, unless the process changes from
  previous efforts, are not well suited to be
  nimble in running medical practices
• Some of the first savings to be gained from
  improved medical practice is savings from
  hospital admissions that runs counter to
  financial pressures on hospitals
• If general internal medicine (and other primary
  care) is reimbursed according to its true worth
  rather than as a loss leader it allows us to test
  various models of practice organization

45
From someone in private practice GIM since 1983

• Revenue is flat
• Less free time and more hassles
• Expenses rise relentlessly
• Over the years experts have regularly presented a
  new idea which didnt work to save or enhance
  primary care

46
Initial response to medical home

• I dont have the time to set one up
• I dont have the money and resources to set up a
  medical home
• Its just another idea that will end up not
  working
• Notice the I (or even we referring to my
  physician partners)

47
Why have I changed my mind and started to set one
up?

• I have been hearing great things from practices
  large and small who have started this process
• Someone else is paying much of the start-up costs
• There is a full time employee (not paid out of
  our limited revenue) to help us transform our
  practice
• The patient-centered medical home will provide a
  platform to deal with some ongoing issues related
  to continuous quality improvement

48
Preliminary Results Indicate These Trends

• Happier patients
• Happier staff
• Happier doctors
• Lower cost
• Higher quality
• Helps practices do many of the things we are
  expected to do now but become easier in a team
  based approach with the proper resources

49
Why isnt this just another passing fad?

• Aligns incentives toward improved care
• While the payment levels are not yet finalized
  initial levels for general internal medicine are
  much higher than current practice revenues allow
• Best hope to provide attractive practice
  opportunity for new doctors
• Provides proper resources to free up physicians
  for direct patient care and builds in CQI
• Team based approach provides opportunity to use
  scarce health professionals in evidence-based
  ways to provide cost-effective care

50
Why is Primary Care Important?

• States with higher ratios of primary care
  physicians to population have better health
  outcomes
• Supply of primary care physicians associated with
  an increase in life span reduced low
  birth-weight rates
• In both England and the US, each additional
  primary care physician per 10,000 population (a
  12-20 increase) is associated with a decrease in
  mortality of 3-10, depending on the cause of
  death

Starfield, B., et al The Milbank Quarterly
2005 83457-502 Gulliford, J Public Health Med
2002 24252-4
51
Primary Care Associated with Decreased Costs

• According to the Center for Evaluative Clinical
  Sciences at Dartmouth, for patients with severe
  chronic diseases, those who live U.S. states that
  relied more on primary care have
• Lower Medicare spending (inpatient reimbursements
  and Part B payments)
• Lower resource inputs (hospital beds, ICU beds,
  total physician labor, primary care labor, and
  medical specialist labor)
• Lower utilization rates (physician visits, days
  in ICUs, days in the hospital, and fewer patients
  seeing 10 or more physicians)
• Better quality of care (fewer ICU deaths and a
  higher composite quality score

Dartmouth Atlas of Health Care, Variation among
States in the Management of Severe Chronic
Illness, 2006
52
How Connected Are You to Your Primary Care
Physician

• Not surprisingly, those patients with the
  strongest relationships to specific primary care
  physicians were more likely to receive
  recommended tests and preventive care. In fact,
  this sense of connection with a single doctor had
  a greater influence on the kind of preventive
  care received than the patients age, sex,
• race or ethnicity.

How Connected Are You to Your Doctor?
PatientPhysician Connectedness and Quality of
Primary Care Steven J. Atlas, MD, MPH Richard
W. Grant, MD, MPH Timothy G. Ferris, MD
Yuchiao Chang, PhD and Michael J. Barry, MD 3
March 2009 Volume 150 Issue 5 Pages 325-335
53
The PCMH concept advocates enhanced access to
comprehensive, coordinated, evidence-based,
interdisciplinary care
Todays Care
Medical Home Care
Our patients are those who are registered in our
medical home
My patients are those who make appointments to
see me
Care is determined by todays problem and time
available today
Care is determined by a proactive plan to meet
health needs, with or without visits
Care varies by scheduled time and memory or skill
of the doctor
Care is standardized according to evidence-based
guidelines
I know I deliver high quality care because Im
well trained
We measure our quality and make rapid changes to
improve it
Patients are responsible for coordinating their
own care
A prepared team of professionals coordinates all
patients care
Its up to the patient to tell us what happened
to them
We track tests and consultations, and follow-up
after ED and hospital
Clinic operations center on meeting the doctors
needs
An interdisciplinary team works at the top of our
licenses to serve patients
Source Adapted with permission by IBM from
Daniel F. Duffy, M.D.
54
The Patient-Centered Primary Care
CollaborativeExamples of broad stakeholder
support and participation
Providers 333,000 primary care
Purchasers Most of the Fortune 500

• IBM

• General Motors

• ACP

• AAP

• General Electric

• FedEx

• AAFP

• AOA

• Merck

• Pfizer

• ABIM

• ACC

• Business Coalitions

• ACOI

• AHI

• Wal-Mart

80 Million lives
The Patient-Centered Medical Home
Payers
Patients

• NCQA

• AFL-CIO

• BCBSA

• Aetna

• National Partnership for Women and Families

• Humana

• United

• HCSC
• MVP

• CIGNA

• Foundation for Informed Decision Making

• WellPoint
• Kaiser

• SEIU

55
Why the Patient-Centered Medical Home?

• The Patient Centered Medical Home creates a
  framework for change
• The Patient Centered Medical Home creates a
  common language for change
• The Patient Centered Medical Home creates an
  opportunity for change
• The Patient Centered Medical Home aligns
• payment with the added valve and therapeutic
• relationship.

56
Pilots BCBS North Dakota, Marillac Clinic
(Chicago)

• 6 decrease in hospital admissions
• 24 decrease emergency room
• 500 per member per year savings

Marillacs Integrated Care Patients (PCMH)
57
Pilot Geisinger Health System
58
Results Clinical Process Metric Improvement
HbA1c Testing
January 2007
November2007
Permission from Horizon Blue Cross Blue Shield
and Partners in Care, Corp.
59
Pilot with best overall data

• Group Healths experience in a prototype
  clinic suggests that primary care enhancements,
  in the form of the medical home, hold promise for
• Controlling costs
• Improving quality
• Better meeting the needs of patients and care
  teams.

60
Health Affairs May 2010 Group Health

• Paper examines the effects of the medical
  home prototype at twenty-one to twenty-four
  months after implementation on
• Patients experiences
• Quality
• Burnout of clinicians
• Total costs

61
Health Affairs May 2010 Group Health

• Results show improvements in patients
  experiences, quality, and clinician burnout
  through two years.
• Patients experiences
• Quality
• Burnout of clinicians
• Total costs

62
Health Affairs May 2010 Group Health

• Patients in the medical home experienced
• 29 percent fewer emergency visits
• 6 percent fewer hospitalizations.
• Estimated total savings of 10.30 per patient per
  month twenty-one months into the pilot

63
What is the Patient-Centered Medical Home?

• a vision of health care as it should be
• a framework for organizing systems of care at
  both the micro (practice) and macro (society)
  level
• a model to test, improve, and validate
• part of the health care reform agenda

64
PCMH is a Term

• to describe a pathway to excellent health care
• to re-claim a role as advocates for our patients
  (with our patients their families)
• to encourage team-based care
• to create educational opportunities
• to attract medical students and residents to
  primary care

65
The Joint Principles of the PCMH
Team-based care NP/PA RN/LPN Medical
Assistant Office Staff Care Coordinator Nutritioni
st/Educator Pharmacist Behavioral Health Case
Manager Social Worker Community resources Other
clinical specialists DM companies Others

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access to care
• Payment to support the PCMH

66
Gaps in Care Coordination

• Primary care and specialists
• No information sent to Peds specialist 49 of
  time no feedback to primary care 55 of time
• Dissatisfaction with quality of referrals (28 of
  primary care 43 of specialists rating
  information from the other)
• Emergency Department
• 30 of adults indicated regular physician not
  informed about visit
• Hospital
• 33 of adults with chronic condition did not have
  follow-up plans post hospital discharge
• 3 of primary care physicians discussed discharge
  plans with hospital physicians
• 66 of time primary care follow-up post discharge
  was done without a hospital discharge summary

Bodenheimer, T Coordinating Care A Perilous
Journey through the Health Care System. NEJM
200835810
67
Collaborative Care

• Collaboration includes ongoing interdisciplinary
  communication regarding the care of individuals
  and populations of patients in order to promote
  quality and cost-effective care
• Critical to ensuring that all patients receive
  the highest possible quality of care

68
Important Questions

• How do you recognize a PCMH?
• How is care different?
• Will physicians their teams want to build the
  medical home?
• How do we prepare physicians, students
  residents?

69
NCQA Physician Practice Connections/PCMH

• Access Communication
• Patient Tracking Registry Functions
• Care Management
• Patient Self-Management Support
• Electronic Prescribing

• Test Tracking
• Referral Tracking
• Performance Reporting Improvement
• Advanced Electronic Communication

70
The Process

• Gap analysis take the pre-test.
• Analyze your results.
• Implement changes necessary
• Retake the pre-test.
• If ready submit application to NCQA.
• Cost Readiness assessment 80
• NCQA application fee varies by size of practice
  from 450 for 1 physician to 2,700 for 6

71
ACP Resource to Prepare Your Practice

• ACP Medical Home Builder Kit
• Nominal cost - 85 for my 8 physician practice
  total value of the deal for about 2 years
• Practice biopsy
• Links to tools for areas needing improvement

72
Level 1 25-49 Points

• Demonstrates timely access and communication
  processes
• Organizes charts (paper or electronic) to
  facilitate team-based care and tracking
  age-appropriate and condition-specific
  interventions
• Identifies key clinical conditions among
  population served follows evidence-based
  guidelines

• Encourages and provides support for
  patient/family self-management
• Addresses health literacy issues
• Tracks tests referrals to assure completion
• Collects and reports on quality satisfaction
  data to practice

73
Key Points for Level 1 PCMH

• Does not require electronic health record
• Will require registry tracking functions
• Emphasis is on providing better care through
• Access to care
• Organization of office structure processes
• Enhancing patient self-management addressing
  health literacy issues
• Introduction of evidence-based guidelines,
  measurement quality improvement

74
Level 2 ? Level 3

• Advanced access options for patients
• Electronic health record
• More, and more complex care coordination and
  patient support
• Robust population management
• Advanced reporting and quality improvement
  initiatives
• Additional technology solutions

75
Are you blurry eyed yet?

• Remember this is a team effort
• You dont have to do it all and most of the
  process activities should be handled by others
• Need outside help with start-up costs
• Need outside help with practice transformation
• Need support structures facilitating conversation
  and co-operation with those in similar practices
• May lead to shared services or groups without
  walls

76
More Features of a PCMH Practice

• Each team member practices to highest capability
  (and no lower)
• Supports cultural competency training
• Understands health literacy
• Establishes connections to the community
• Provides extensive self-management support
• Engages a Patient/Family Advisory Group

77
More Features of a PCMH Practice

• Provides individualized written care plans and
  monitors adherence to plan with patient/family
• Assesses barriers to adherence and initiates
  plans to overcome them
• Collaborates with other physicians institutions
  to insure timely access to health care and health
  care information
• Manages transitions of care seamlessly

78
Specialty Care Connections
X

• PCMH is NOT a gatekeeper system
• Jointly develop/identify referral guidelines
• Emphasis on transitions in care continuity
• Referral agreements
• Care transitions programs
• Some subspecialists may want to qualify as PCMH
• ACP in discussions with several groups regarding
  the PCMH model and primary care/specialty care
  interface (sharing care medical neighborhood)

79
Practice Implications

• Challenges of transformation
• Initial capital and restructuring costs
• Ongoing support maintenance
• Reporting on quality, cost and satisfaction
• Implementation of HIT coincident with PCMH

80
Strengths

• Patient-centered model
• Encourages evidence-based medicine
• Could improve quality
• Could bend the curve on costs
• Payment models decrease incentive for volume and
  encourage investment in practice changes to
  promote quality

81
Weaknesses

• Requires considerable change in practice
• Data pending on practicality
• Unknown return on investment
• May disenfranchise small practices
• Workforce projections for primary care
• Uncertain impact on access will panel sizes
  decrease?

82
Opportunities

• Demonstration projects including public private
  payers
• Inter-professional collaboration
• Health information technology
• Modeling of different payment models and
  organizational structures

83
Threats

• Perception that this is a zero-um game
• Primary care workforce
• Physicians overwhelmed
• Fear of change
• Consumers may not understand/accept the model (or
  name)
• Unintended consequences

84
Growing Interest in the PCMH

• Patient-Centered Primary Care Collaborative
• 300 organizations represent 50 million people
• www.pcpcc.net
• Articles in NEJM, JAMA, Health Affairs, Annals
  of Internal Medicine
• Trade Lay Press
• Legislation
• Commercial payer demos
• Public payer demos

85
The Need for Education Support

• Team-based care
• Everyone practices to the level of his/her
  license, skill, and ability and no lower
• Patient-centered care
• Communication skills
• Use of technology
• Quality improvement measurement skills

86
A Commitment to Excellence

• Patient-centered communication
• Shared decision making
• Timely access to care
• Electronic health records
• Use of comparative effectiveness research
  evidence-based guidelines
• Measure, improve, measure
• Transparency accountability
• Safety

87
Thinking about becoming a medical home?

• Look at ACP Medical Home Builder Kit nominal
  cost (About 85 for our 8 MDs total)
• Look for initiatives that are in place for
  start-up funds
• Perhaps talk with insurers about becoming more
  involved in PCMH
• Look at practice size large and small can work
  but likely a critical mass needed (Consider
  virtual groups with other like-minded small
  groups)

88
Questions or comments?

• Fred Ralston, Jr. MD FACP
• Private Practice General Internal Medicine
• Fayetteville Medical Associates
• 207 South Elk Avenue
• Fayetteville, Tennessee 37334
• ralston_at_fpunet.com
• President
• American College of Physicians