Extracting Value

Patient Centered Medical Home

Hillcrest 2015 Winter CME Update

Paul Grundy MD, MPH - IBM Director, Healthcare Transformation

@Paul_PCPCChttps://twitter.com/Paul_PCPCC

“Godfather” of the Patient Centered Medical HomeIBM Global Director Healthcare Transformation President of PCPCC Ambassador for Denmark Healthcare Member Institute of MedicineMember Board ACGME Professor Univ. of Utah Department Family Medicine Winner NCQA national Quality Award A Leader of MOH level taskforce primary care transformation 8 nations: USA, Canada, New Zealand, Australia, Holland, Denmark, UK, Belgium, Univ. of California MD, John Hopkins Trained

Paul Grundy MD MPH Bio

The System Integrator

Creates a partnership across the medical neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial management

Away from Episode of Care to Management of PopulationWITH DATA

Community Health

PopulationHealth

System Integrator

PatientExperience

Per Capita Cost

Public Health

@Paul_PCPCChttps://twitter.com/Paul_PCPCC

Hillcrest HealthCare System: Changing lives for the better, together

“First Follower: Leadership Lessons from Dancing Guy”

– BUT -where the delivery system works – a Patient in a trusting relation with a healer who is a comprehensivist where the patients data is in charge”

In much of the world, no one is in charge. And the result is the most wasteful and Unsustainable

36.3% Drop in hospital days

32.2% Drop in ER use

12.8% Increase Chronic Medication use

-15.6% Total cost

10.5% Drop Inpatient specialty care costs

18.9% Ancillary costs down

15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012

Smarter Healthcare

•9.9 percent lower rate of adult ER visits

•27.5 percent lower rate of adult ambulatory care sensitive

inpatient stays

•11.8 percent lower rate of adult primary care sensitive ER

visits

•8.7 percent lower rate of adult high-tech radiology usage

•14.9 percent lower rate of pediatric ER visits

•21.3 percent lower rate of pediatric primary-care sensitive ER

visits

24 July 2014 Michigan Blues’ patient-centered medical home program

shows statewide transformation of care YEAR 6

4,022 primary care doctors at 1,422 practices around the state

in its sixth year of operation. These practices care for more

than 1.2 million BCBSM members.

17 found improvements incost 24 improvements in quality 10 found improvements in access 8 found improvements in satisfaction 24 found improvements in utilization

Beyond Flexner --- Driven by Actionable - Personalized Data

USA 2012

Ogden UT

Watson is ushering in a new

era of computing

TabulatingSystems Era

ProgrammableSystems Era

CognitiveSystems Era

1900

1950

2011

MobileFirst Patient Consumer

PreventiveMedicine

MedicationRefills Acute Care

Nursing

Test Results

Master Builder

DOCTOR

Source: Southcentral Foundation, Anchorage AK

Behavioral

Health

Case

ManagerMedical

Assistants

Chronic Disease

Monitoring

Practice transformation away from episode of care

Source: Southcentral Foundation, Anchorage AK

PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain

Medication

Refills

Chronic

Disease

Monitoring

Test

Results

Acute

Care

Preventive

Medicine

Point of

Care Testing

Acute

Mental

Health

Complaint

Chronic

Disease

Compliance

Barriers

Healthcare

Support

Team Behavioral

Health

Medical

Assistants

Case

Manager Clinician

Healthcare Will Transform --- Family Medicine for America’s Health

Data Driven

Every person has a plan

Team based

Managing a population down to the person

.

Today’s Care PCMH Care

My patients are those who make appointments to see

me

Our patients are the population community

Care is determined by today’s problem and time

available today

Care is determined by a proactive plan to

meet patient 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

Patients are responsible for coordinating their own

care

A prepared team of professionals coordinates all

patients’ care

I know I deliver high quality care because I’m well

trained

We measure our quality and make rapid changes to

improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after

ED & hospital

Clinic operations center on meeting the doctor’s

needs

A multidisciplinary team works at the top of our

licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

Superb Access to Care

Patient Engagement in Care

Clinical Information Systems, Registry

Care Coordination

Team Care

Communication Patient Feedback

Mobile easy to use and Available Information

Defining the Care Centered on Patient

HIT Infrastructure: EHRs and Connectivity

Primary Care Capacity: Patient Centered Medical Home

Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $

Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures

Value-Based Purchasing: Reimbursement Tied to Performance on Value (quality, appropriate utilization and patient satisfaction)

Achieve Supportive Base for ACOs and Bundled Payments with Outcome Measurement and Health Plan Involvement

Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

Source: Hudson Valley Initiative

Payment reform requires more than one method, you have dials, adjust them!!!

“fee for health”

“fee for value”

“fee for outcome”

“fee for process”

“fee for belonging

“fee for service”

“fee for satisfaction”

Nearly 1/3 traditional Medicare tied to alternative reimbursement models—such as Patient Centered Medical home (PCMH)/ accountable care organizations (ACOs) or bundled payments—by the end of 2016 50% by end 2018

And end of 2018 90% of traditional Medicare payments to quality or value through programs such as the Partnership for Patients Hospital, Value Based Purchasing and the Hospital Readmissions

Businesses are no longer accepting cost-shifting.

40% of commercial in-network payments are value-based up from 11% -- 2012

Government and private insurers increasingly are paying for value and outcomes, not volume; they are also employing new payment models for hospitals and clinicians.

Half of these payments are “at risk” and

half are upside only.

Transformation is Here • HHS to spend $840 million on readying practices for value-based pay. -- Part of the 10 Billion • The Transforming Clinical Practice Initiative will invest $840 million over four years to support

150,000 clinicians.• It will provide a combination of incentives, tools and information to encourage doctors to team

with peers and others to transition to value-based services.• Momentum building toward value-based payment methods, this initiative hopes to leverage the

success of leading practices, health systems and professional orgs to coach others in how to best move to value-based reimbursement. It fits well into the broader federal strategy.

• Transforming Clinical Practice• Group practices health systems and Medical Societies • Impact 150,000 clinicians

• AND You ARE READY!!!!!!!

Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments

% Total

Healthcare

Spend

% of Members

Those who

are well or

think they

are well

Those with

chronic

illness

Those with

severe, acute

illness or

injuries

Public Health Prevention

Specialists

PCMH 2.0 in Action

Community Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health PreventionHEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

Thank you

Apply new insights from interactions and outcomes

to enable continuous transformation

LEARNING

Identify and influence individuals and populations, and recognize

intervention opportunities

INTERVENTION

COORDINATIONDeliver care and monitor progress across

clinical and social requirements

COLLABORATIONAssess and engage individuals and stakeholders to drive individualized care plans

Drive evidence-based andstandardized care planning

KNOWLEDGE

WELLNESS

A comprehensive approach helps reduce costs while improving care

need to move from traditional care provider to health partner

if your do not choose innovation (play a better game) you will

be forced into disruption ( game Changed for you). Honest you

can see it coming and some places is already there

Millennials are already finding the convenience, economics and

technology in powerful virtual engagement compelling so you

can chose innovation or disruption.

Virtual access become a required defensive strategy Primary

Care team engaged in virtual augmented relationship – or your

history loss the relationship.

How many patients can you see?

How many patients’ problems can you solve?

How can we encourage and convince patients to get required prevention?

How can we create systems that significantly increase that patients get required prevention?

How often should a physician see a patient to optimally monitor a condition?

What is the best way to optimally monitor a condition?

Asking New Questions

From

To

From

To

From

To

*Source: 2014 Kaiser Permanente Jack Cochran