Edwina Rogers

1
Patient Centered Primary Care CollaborativeJuly
16th Stakeholders Working MeetingPublic and
Private Initiatives Advancing the PCMH
Panel 2 July 16th 2009 PCPCCStakeholders
Working Meeting

• Edwina Rogers
• Executive Director
• Patient Centered Primary Care Collaborative
• 601 Thirteenth St., NW, Suite 400 North
• Washington, D.C. 20005
• Direct 202.724.3331
• Mobile [phone]
• erogers_at_pcpcc.net

2
Boehringer IngelheimCorporate Overview
Family-owned global company Founded 1885 in
Ingelheim, Germany Focus on Human Pharmaceuticals
and Animal Health Corporation 41,300
employees Operating with 138 affiliated companies
in 47 countries Net sales U.S. 17 billion
dollars in 2008 Products marketed in some 152
countries
For U.S. use only
3
Boehringer Ingelheim Our Interest in Healthcare
Reform

• Comprehensive Health Reform Could Increase
  Coverage and Access to Care
• Uninsured Americans face obstacles in obtaining
  health care and suffer adverse health outcomes,
  so we support the goal of extending coverage to
  the uninsured
• The BI Cares Foundation demonstrates our
  commitment to helping the uninsured in 2008
  alone, the Foundation served 53,000 patients and
  provided more than 126,000 prescriptions
• We are committed to improving the quality of life
  for patients through ongoing and innovative
  research

4
Boehringer Ingelheim Our Interest in Healthcare
Reform

• Comprehensive Health Reform Could Increase
  Coverage and Access to Care
• Uninsured Americans face obstacles in obtaining
  health care and suffer adverse health outcomes,
  so we support the goal of extending coverage to
  the uninsured
• The best approach to providing health insurance
  is through private sector competition, which
  offers consumers choices of health benefits and
  controls costs
• For example, Medicare drug benefit program
  successfully delivers access to pharmaceuticals
  at lower than expected costs due to competitive
  market forces
• The program consistently demonstrates
  overwhelming satisfaction from its beneficiaries
  (nearly 90 satisfaction rate)
• We are committed to improving the quality of life
  for patients through ongoing and innovative
  research
• The BI Cares Foundation demonstrates our
  commitment to helping the uninsured in 2008
  alone, the Foundation served 53,000 patients and
  provided more than 126,000 prescriptions

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The Big Picture
Focus on Health Care Reform

• Carolyn M. Clancy, MD
• Director
• Agency for Healthcare Research and Quality
• PCPCC Stakeholders Working Meeting
• Washington, DC July 16, 2009

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Focus on Health Care Reform

• 21st Century Health Care
• Comparative Effectiveness Research
• Revitalization of Primary Care

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Health Care Reform in the Current Economic
Environment
61
37
It is more important than ever to take on health
care reform now
We cannot afford to take on health care reform
right now
2
Kaiser Family Foundation Health Tracking Poll
April 2009
Dont Know/Refused
9
More Say Reform Would Help
Country
Do you think (you and your family/the country as
a whole) would be better off if the president and
Congress passed health care reform, or dont you
think it would make much difference?
Kaiser Family Foundation Health Tracking Poll
(June 2009)
10
21st Century Health Care
Improving Quality, Increasing Access, Containing
Costs
Information-rich, patient-focused enterprises
Information and evidence transform interactions
from reactive to proactive (benefits and harms)
Evidence is continually refined as a by-product
of care delivery
21st Century Health Care
Actionable information available to clinicians
AND patients just in time
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AHRQ Priorities
Patient Safety

• Health IT
• Patient SafetyOrganizations
• New PatientSafety Grants

Effective HealthCare Program
AmbulatoryPatient Safety

• Comparative Effectiveness Reviews
• Comparative Effectiveness Research
• Clear Findings for Multiple Audiences

• Safety Quality Measures,Drug Management
  andPatient-Centered Care
• Patient Safety ImprovementCorps

Medical ExpenditurePanel Surveys
Other Research Dissemination Activities

• Visit-Level Information on Medical Expenditures
• Annual Quality Disparities Reports

• Quality Cost-Effectiveness, e.g.Prevention and
  PharmaceuticalOutcomes
• U.S. Preventive ServicesTask Force
• MRSA/HAIs

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Potential Future Directions Health Care
in 2025

• All institutions and caregivers are members of
  integrated networks which must meet national
  standards for care
• Patient-centered care is considered the redesign
  of health care with patients rather than the
  redesign of care for patients
• There are no barriers for anyone to receiving
  appropriate health care

Advances in Patient Safety New Directions and
Alternative Approaches, August 2008
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Comparative Effectiveness
and the Recovery Act

• The American Recovery and Reinvestment Act of
  2009 includes 1.1 billion for comparative
  effectiveness research
• AHRQ 300 million
• NIH 400 million (appropriated to AHRQ and
  transferred to NIH)
• Office of the Secretary 400 million (allocated
  at the Secretarys discretion)

www.hhs.gov/recovery
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IOM Priorities for Comparative Effectiveness
Research

• 100 recommendations listed in four groups of 25,
  ranging from highest to lowest priority
• A starting point for a sustained effort to
  conduct comparative effectiveness research, with
  priorities evolving as progress is made
• The highest priority quartile includes a
  recommendation involving medical homes
• Compare the effectiveness of comprehensive care
  coordination programs, such as the medical home,
  and usual care in managing children and adults
  with severe chronic disease, especially in
  populations with known health disparities

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AHRQs Role in Comparative
Effectiveness

• Using Information to Drive Improvement
  Scientific Infrastructure to Support Reform
• Health technology assessment at the request of
  the Centers for Medicare Medicaid Services
• Analyze data/options for Coverage with Evidence
  Development (CED) and post-CED data collection
• Provide translation of comparative effectiveness
  findings
• Promote and fund comparative effectiveness
  methods research
• Fund training grants focused on comparative
  effectiveness

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Revitalizing Primary Care

• Growing popularity of the term medical
  neighborhood
• Primary care unconnected to subspecialty care,
  acute care/hospitals, community and public health
  resources, etc, will not reach potential for
  improving health and increasing value
• Revitalizing primary care will required new
  structures such as the medical home, paired with
  aligned reimbursement and a focus on the primary
  care workforce

Clancy C, Meyers D Primary Care Too Important To
Fail. Annals of Internal Medicine, February 2009
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AHRQ and the Patient- Centered Medical
Home

• There are significant opportunities to address
  the primary care needs of Americans while
  encouraging primary care clinicians to use their
  expertise to help build truly patient-centered
  medical homes
• AHRQ is sponsoring a meeting July 27-28 to
  establish a policy relevant research agenda
  around the medical home
• A request for proposals was issued by AHRQ on
  Tuesday, 7/14, for projects involving health IT
  and the medical home

PCPCCs work has been pivotal in the growth of
the patient-centered medical home
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Comparative Effectiveness Research and Primary
Care

• Comparative effectiveness
  research can be used to study the efficacy of
  delivery systems for primary care and the medical
  home
• It can assist with care coordination challenges
  in primary care and in managing patients with
  chronic diseases, especially in populations with
  known health disparities
• It can enhance patient engagement by promoting
  increased collaboration in decision making among
  patients, clinicians and providers

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Comparative Effectiveness Funding Opportunities

• Opportunities for the field to become involved
  will be made available as soon as possible
• To sign up for updates, visit http//effectiveheal
  thcare.ahrq.gov
• To review AHRQs standing program and training
  award announcements http//www.ahrq.gov/fund/grant
  ix.htm

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Thank you
21

• Patient-Centered Primary Care Collaborative
• Stakeholders Working Meeting
• July 16, 2009
• Steve Wojcik
• Vice President, Public Policy
• National Business Group on Health

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What is Meaningful Health Reform?

• Major Reform Would Require More
• Coordination, Less Fragmentation of Care
• Payment for Outcomes, Not for Volume
• Provider Accountability for Patient Health, Not
  Just for Treatment of Disease
• Coverage Based on Evidence and Effectiveness, Not
  On Other Factors

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Are We Headed Toward Meaningful Health Reform?

• Focus in Washington Almost Exclusively Now on Two
  Issues
• Expanding Coverage, and
• Finding Ways to Pay for It
• Big Issues are Public Plan and Who/What to Tax
• Major Delivery and Payment Reforms Still Missing
• Real Solutions to Controlling Costs, Changing
  Delivery Not Yet in Legislation

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What We Need Real Payment and Delivery Changes

• CBO (June 16,2009)
• Large Reductions in Spending Will Not Actually
  Be Achieved without Fundamental Changes in the
  Financing and Delivery of Care.
• Without Meaningful Reforms, the Substantial
  Costs of Many Current Proposals to Expand Federal
  Subsidies for Health Insurance Would Be Much More
  Likely to Worsen the Long-Range Budget Outlook
  than to Improve It.

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Why Primary Care Is Central to Meaningful Reform

• Patients with Ongoing Primary Care Provider
  Relationship Have Better Health Outcomes, Lower
  Costs
• When Managed Effectively by Primary Care
  Providers, Patients with Chronic Diseases Have
  Fewer Complications, Hospitalizations
• States with Higher Number of Generalist
  Physicians Per Capita Have Better Quality, Lower
  Costs
• 5 Increase in Primary Care Physicians Reduces
  Hospital Admission, Emergency Room Visits, and
  Surgeries

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How Do We Get There?

• Workforce Policy
• Reorganizing Health Care Delivery
• Payment Policy

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Health Reform Bills and Primary Care

• Economic Stimulus Law Gives Preference to Primary
  Care Providers for Federal HIT Technical
  Assistance
• House and Senate Finance Bills
• Increase Medicare Payments for Primary Care
  Providers
• Enhance and Expand Medical Home Pilots
• Boost Funding/Loan Assistance for Training of
  Primary Care Providers
• Senate HELP Bill
• Provide Grants and Other Support for
  Community-Based Medical Home Models
• Grants for School-Based Primary Care Clinics
• Create Office in HHS to Foster Primary Care
• Loan Assistance for Primary Care Education

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Transformation of Payment Key Elements

• Eliminate Volume Incentives
• Recognize Value of Cognitive Services
• Reward Care Coordination
• Provide Incentives for Quality
• Reward Efficient Use of Technology
• Encourage Accountable Care Organizations/Medical
  Homes

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NBGH Primary Care Work Group

• Increase Awareness Among Employers of Crisis in
  Primary Care
• Advocate for Primary Care Reforms
• Use Market Leverage to Create Change
• Explore Models for Payment Reform
• Coordinate with Primary Care in the Community

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Employer Payment Policy Recommendations

• As Initial Step to Comprehensive Payment Reform,
  Increase FFS Payments for Primary Care
• Blended Reimbursement
• Bundled Episode Payments

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Employer Primary Care Initiatives

• Support Medical Home Pilots
• Work with Health Plans and Communities on Primary
  Care
• Explore Coordination of Services and Exchange of
  Information between Worksite Clinics and Primary
  Care Practices
• Participate in NBGH Primary Care Work Group and
  the PCPCC

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Payment Policy and Primary Care Workforce
Implications for the Medical Home

• Eugene Rich MD
• Scholar in Residence
• Association of American Medical
  CollegesProfessor of MedicineCreighton
  University RWJ Health Policy Fellow 2006-07

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Average Physician Income, 1969
Profile of Medical Practice 1978, AMA
34
Early Drivers of Specialized Medical Practice

• Higher specialist physician income
• health insurance coverage for hospital based
  services
• Increased specialist MD productivity not offset
  by fee reductions
• WWII codifies higher incomes for military MD
  specialists
• Hospital incentives to increase residency
  positions
• Residents provide after-hours coverage, increased
  hospital productivity and assistance to private
  physicians
• GI Bill education benefits provide for payments
  to hospitals for GME
• Residency positions increase from 5000 in 1940 to
  25,000 in 1955
• Medical Education Reform-Flexner Report, 1910
• The ideal medical school would control a teaching
  hospital and would have a full-time faculty
  involved in basic and clinical research

Starr, Social Transformation of American
Medicine, 1982 Ludmerer, Earning to Heal, 1985
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Early Drivers of Specialized Medical Practice

• Factors that favor development of a medicine
  sub-specialty
• Prevalent chronic diseases
• Complex diagnostic technology
• Various treatment options
• Lack of simple curative therapy
• Large volume of scientific literature
• Third-party reimbursement

Beeson, Ann Int Med, 1980
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Medicare Physician Payment and Specialist
Practice

• Carried forward fee payments developed to insure
  against expensive hospital-based illnesses
• Carried forward fee payments developed before
  better technology made procedures less
  time-consuming (and less costly to provide)
• Provided financial access to well compensated
  procedures for the likeliest candidates
• Provided financial access to specialty care at
  the time when specialized practice options were
  rapidly expanding

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Physician Specialty as a Percentage of Total
Active Physicians
Donaldson MS, Yordy KD, Lohr KN, Vanselow NA,
eds. Primary Care Americas Health in a New
Era. Institute of Medicine. Page 155.
National Academy Press, Washington, D.C., 1996.
and COGME Third Report, 1992 Starfield, et al,
Ann Fam Med 2007
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Financial Barriers to Generalist Care

• US Fee-for-service payments provided no reward
  for primary care functions
• Continuity
• Comprehensiveness
• Coordination
• Accessibility
• Accountability

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Financial Barriers to Generalist Care

• US Fee-for-service payments provided no reward
  for primary care functions
• Continuity?- only if openings
• Comprehensiveness?- Why?
• Coordination?- NO!
• Accessibility?- NO!
• Accountability?- To Whom??
• Widespread visibility and access to specialists

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GDP for Health Care
Percent
Source CBO Long-Term Outlook for Health Care
Spending, Dec 2007
41
The Primary Care Gatekeeper

• The policy vision
• a financial rationale for continuous,
  coordinated, comprehensive, accessible,
  accountable generalist practice
• 1983 - Primary-care gatekeeper and cost control-
  the SAFECO experience, NEJM
• 1985- General Internist as Gatekeeper, J
  Eisenberg, Ann Int Med

42
MD Graduates Choosing Generalist Careers (FM,
GIM, GPEDs)
Source AAMC Graduation Questionnaire
43
MD Graduates Choosing Generalist Careers (FM,
GIM, GPEDs)
Source AAMC Graduation Questionnaire
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1999-2008 The Deconstruction of Primary Care
into profit lines

• Continuity- virtual continuity provided by
  Health plans using their administrative data
• Comprehensiveness- direct access to specialized
  clinical programs with their own imaging
  facilities and surgical suites
• Coordination- national companies selling disease
  management services.
• Accessibility- Discount stores and pharmacy
  chains build sales thru quick access to care in
  minute clinics
• Accountability- the ownership society, and
  consumer-directed health care-patients are
  accountable to chose from a smorgasbord of
  cleverly marketed health care services

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Ongoing Problems with the Medicare Fee Schedule

• Relative Value Update Committee (RUC) and
  overvalued services
• Budget neutrality to fee schedule changes
• Practice Expense calculations
• Physician side-businesses (e.g. infusion centers,
  imaging centers, endoscopy centers, surgery
  centers)

46
GDP for Health Care
18 In 2009?
Percent
Source CBO Long-Term Outlook for Health Care
Spending, Dec 2007
47
Ave Offered Physician Income, (Pre-Bonus) 2008
Merritt and Hawkins MDSalaries.Blogspot.com
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Worsening comprehensive care failures

• Primary care physicians already felt rushed
• More to do during a single visit now than in
  1980s
• MOST Medicare beneficiaries have multiple chronic
  diseases
• More drug combinations recommended for each
  disease
• More preventive services/early interventions
• More extensive documentation regulations
• DTCA

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Worsening acces failures
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Congressional Advisors Unanimous on Need for
Fundamental Change

• Congressional Budget Office Dec 2007
• Growth in US Health Care Spending Unsustainable
• Government Accountability Office Feb 2008
• Ample research concludes that the nations over
  reliance on specialty care services at the
  expense of primary care leads to a health care
  system that is less efficient
• research shows that preventive care, care
  coordination for the chronically ill, and
  continuity of careall hallmarks of primary care
  medicinecan achieve improved outcomes and cost
  savings.
• MedPAC March 2008
• Medicares FFS payment system does not reward
  physicians who providecare coordination
• We are especially concerned about the impact on
  access to primary care services
• medical home programs if designed carefully,
  may be a way to improve the value of physician
  and other health care services.

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Paying for Primary Care Functions
Patient-Centered Medical Home

• Joint Principles adopted March 2007- AAFP, AAP,
  ACP, AOA
• Medical Practice- meeting special qualifications
• Whole Person Orientation
• Care is Coordinated and Integrated
• Extra Quality and Safety infrastructure, HIT
• Enhanced Access

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Changing payment for medical homes

• Improved incentives for traditional primary
  medical care?
• New payment for new medical home services?
• Technology-enhanced practice patient tracking,
  disease registries, reminders, email
  communication, remote monitoring
• Patient engagement, informed decision-making
• The chronic care model and team care

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SGIM/STFM/APA Medical Home Policy research agenda
project

• Convene national researchers, major primary care
  professional organizations, representatives and
  evaluators of PCMH demonstrations, health care
  purchasers, payers, patient advocates, and
  relevant policy makers
• specific objective
• Develop a policy research agenda to inform the
  ongoing development and implementation of the PCMH

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SGIM/STFM/APA Medical Home Policy research agenda
project

• Topics for white papers
• Practice Transformation
• Payment Reform and the PCMH
• Measuring and Operationalizing the PCMH
• Clinical, Satisfaction, and Quality of Care
  Outcomes of the PCMH
• PCMH connections to the Delivery System
• Workforce issues and training requirements