Ted Epperly, M.D.

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Carrying the Banner of Family MedicineThe
Patient Centered Medical Home in the Information
Age

• Ted Epperly, M.D.
• Chairman and Program Director
• Family Medicine Residency of Idaho
• Clinical Professor of Family and Community
  Medicine
• University of Washington School of Medicine
• President-Elect
• AAFP

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Five Ages of Civilization
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Failure to Embrace Family Medicine

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

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• 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

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• Dont skate to where the puck is, but where the
  puck will be.
• - Wayne Gretzky

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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.

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Simple Rules for the 21st Century Health Care
System
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
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Simple Rules for the 21st Century Health Care
System
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
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Future of Family MedicineTen 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

SourceThe Future of Family Medicine - Annals of
Family Medicine - 2004
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New Model of Family Medicine

• Personal Medical Home
• Patient-Centered Care
• Team Approach
• Elimination of Barriers to Access
• Advanced Information Systems
• Redesigned Offices

SourceThe Future of Family Medicine - Annals of
Family Medicine - 2004
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New Model of Family Medicine (contd)

• Whole-Person Orientation
• Care Provided within a Community Context
• Emphasis on Quality and Safety
• Enhanced Practice Finance
• Commitment to Provide Family Medicines Basket of
  Services

SourceThe Future of Family Medicine - Annals of
Family Medicine - 2004
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Basket of Services in New Model

• Healthcare Provided to Children and Adults
• Maternity Care Hospital Care
• Primary Mental Health Care
• Health Assessment (evaluate health and risk
  status)
• Disease Prevention (early detection of
  asymptomatic disease)
• Health Promotion (primary prevention and health
  behavior/lifestyle modification)
• Patient Education and Support for
  Self-Care

SourceThe Future of Family Medicine - Annals of
Family Medicine 2004
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Basket of Services in New Model (contd)

• Diagnosis and Management of Acute Injuries and
  Illnesses
• Diagnosis and Management of Chronic Diseases
• Supportive Care, Including End-of-Life Care
• Consultation and Referral Services as Necessary
• Advocacy for the Patient Within the Health Care
  System
• Quality Improvement and Practice-Based Research
• Integration of Personal Healthcare (coordinate
  and facilitate care)

SourceThe Future of Family Medicine - Annals of
Family Medicine - 2004
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Medicine Work Force
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Number of Physicians Per Capita
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.
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Which System is More Stable?
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Why?

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

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Median Compensation for Selected Medical
Specialties
Data are from the Medical Group Management
Association Physician Compensation and Production
Survey, 1998 and 2005
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2,000,000,000,000
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Americas Rankings
Source Lebow R. Health Care Meltdown JRI Press
2002
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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)
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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)
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• 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

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Not Just a Change In Namebut a Change In
Attitude!
AGGRESSIVE OPTIMISM!
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Bold Champion
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Five Pillars of Healthcare Change

• Patient Centered Medical Home
• Payment Reform
• Student Interest in Family Medicine
• Workforce Reform
• Healthcare for All

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How Do We Change Our Health Care System?
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Health Care for Everyone

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

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Health Care for Everyone (contd)

• 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

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Health Care for Everyone (contd)

• 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

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Health Care for Everyone (contd)

• 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

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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

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FamilyPhysician
PatientFamiliesCommunities
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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

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• AARPAetnaAmerican Academy of Family
  PhysiciansAmerican Academy of
  PediatricsAmerican Board of Medical
  SpecialtiesAmerican College of Osteopathic
  Family PhysiciansAmerican Board of Medical
  SpecialtiesAmerican College of
  CardiologyAmerican College of Osteopathic
  InternistsAmerican College of PhysiciansAmerica
  n Geriatrics SocietyAmerican Health Quality
  AssociationAmerican Heart AssociationAmerican
  Osteopathic AssociationAurum DxAutomotive
  Industry Action GroupBlueCross BlueShield
  AssociationBridges To ExcellenceThe Capital
  District Physicians HealthPlan, Inc.Carena,
  Inc.CaterpillarThe Center for Excellence in
  Primary CareThe Center for Health Value
  InnovationColorado Center for Chronic Care
  InnovationsCIGNACVS Caremark CVS/pharmacy
  Caremark Pharmacy Services
  MinuteClinicDelmarva FoundationThe Department
  for Family and Community Medicine, University of
  California, San FranciscoDelphi
  CorporationDeseret MutualDMAA The Care
  Continuum AllianceeHealth InitiativeThe ERISA
  Industry CommitteeExelon CorpFedEx
  CorporationFoundation for Informed Medical
  Decision MakingGeneral Mills, Inc.General
  Motors

• Geisinger Health SystemsGlaxoSmithKlineHealth
  DialogHR Policy AssociationHumana,
  Inc.IBMIncenter StrategiesMcKesson
  CorporationMDdatacoreMedcoMedical Network
  OneMerckMVP Health CareNational Association
  of Community Health CentersNational Business
  Group on HealthNational Business Coalition on
  HealthNational Coalition on Health CareNational
  Committee for Quality AssuranceNational
  Consumers LeagueNational Partnership for Women
  FamiliesNational Retail FederationNew England
  Quality Care AllianceNew York City Department of
  Health and Mental Hygiene Novo NordiskThe
  Pacific Business Group on Health Partners In
  CarePfizerPractice Transformation
  InstitutePudget Sound Health AllianceThe Roger
  C. Lipitz Center for Integrated Health Care at
  the Johns Hopkins Bloomberg School of Public
  HealthService Employees International
  UnionSociety of General Internal
  MedicineSociety of Teachers of Family
  MedicineThe Stoeckle Center at Massachusetts
  General Hospital UnitedHealthcareUnited States
  SteelUniversity of Pittsburgh Medical Center
  Walgreens Health InitiativesWellPoint, Inc.
  WyethXerox
• Updated 12/18/07

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PPC-PCMH Scoring
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.
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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.

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What Next?

• Advocacy
• Education
• Communication
• Payment Reform
• Politics / PAC
• Tipping Point?

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Trim-Tab Leaders
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• 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

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• 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

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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

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Carrying the Banner of Family Medicine
Patient-Centered Medical Home in the
Informational Age

• Questions?