Primary Care Update

1. Primary Care Update Dermatology Faculty Meeting Joe Frolkis January 24, 2013

2. The Decisive Moment Behind the Gare St Lazare 1932

3. The “Decisive Moment” in Health Care Unsustainable cost (18% GDP; 2x inflation) Poor Quality Compared to Other, Similar Economies (Rank 37th Internationally) Lack of Access, Persistent Disparities Significant Waste (Estimates of 20-30%=$700b/yr) Fragmented Care Leads to Patient Harm (IOM)

4. Fragmented Care: Nearly Half of U.S. Adults Report Failures to Coordinate Care Your specialist did not receive basic medical information from your primary care doctor Your primary care doctor did not receive a report back from a specialist Test results/medical records were not available at the time of appointment Doctors failed to provide important medical information to other doctors or nurses you think should have it No one contacted you about test results, or you had to call repeatedly to get results Any of the above Percent U.S. adults reported in past two years: Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).

5. Only 65 Percent of US Adults Report Having an Accessible Personal Clinician Percent of adults ages 19–64 with an accessible primary care provider* U.S. Average U.S. Variation 2005 * An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new and ongoing health problems, referrals, and who is easy to get to. Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey. Source: The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008 (New York: The Commonwealth Fund, July 2008).

6. Supply Driving Demand:Overutilization of Resources 20-30% of US Health Care Spending is Estimated to be “Waste”

7. PC’s Impact on the Health of Society(Just a Moment on the Soap Box) When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending. States with higher ratios of PCPs to population have better health outcomes, including decreased mortality from cancer, heart disease, or stroke, and lower costs and hospitalization rates. An increase of 1 primary care physician per 10,000 population in a state was associated with a rise in that state's quality rank by more than 10 places and a reduction in overall spending by $684 per Medicare beneficiary. The more that complex, chronically-ill patients are attached to a PC practice, the lower are overall health system costs (all medical services, hospital services, and drugs). 7

8. The Primary Care Crisis Critical current shortage of Primary Care Physicians (Only 2% of medical students plan PC careers) That will only worsen: Projected shortage of ~ 65,000 PCPs by 2025 when include the 32 mm “covered lives” under PP-ACA Aging of population (# >65 will grow from 35 to 70 mm by 2030) Multiple co-morbidities normative in this group Medical advances mean that care moving inexorably into the ambulatory setting

9. Reasons for the Shortage Not Hard to Find Primary Care Physicians earn 55% of the average specialist salary (leave $3-4mm “on the table” across a career) For a panel of 2500 patients, PCP’s would have to work 23 hours a day to provide all recommended acute, chronic, and preventive care (no current compensation under FFS for the onerous burden of care coordination) Typical PCP works with 229 other physicians to manage his/her panel Burn out a major problem: If you (PCP’s) had to do your career over again : 28% would do again 41% would be a specialist 27% would not be a physician Physician’s Foundation 10/08

10. The Paradigm Shift Current Model Incented by Volume Focus on Physician Focus on Acute Illness, high margin services Focus on individual patient Fill Beds Payor has more risk Evolving Model Incented by Value Focus on Team Focus on prevention, care coordination Focus on population Prevent unnecessary utilization Provider has more risk

11. Source: Health Care Advisory Board interviews and analysis. Navigating the Bridge from Fee-for-Service to Accountable Care Key Strategies for Primary Care Strategy Transformation Assemble a High-Performance Primary Care Network Transition Practice Operations Create a Sustainable Financial Model • Grow and organize the • PCP network of the future • Create the primary care team • Transform in-practice care delivery • Enhance patient primary care access • Anchor a cooperative care network • Craft strategy-aligned PCP compensation • Leverage payment incentives to support practice transformation 100% Total Cost Accountability Primary Care Returns Across the Transition to Accountable Payment Realizing Returns Today Preparing for Tomorrow Revenue Generated • Improved performance on key quality and cost initiatives • Increased practice access, patient visit volume • Stabilized PCP practice retention • Infrastructure base for care coordination, management, patient engagement • Patients treated at lowest-cost site, by lowest-level provider possible • Expanded panel size Fee for Service 0% Time

12. Short term implications 12 Panel sizes will grow (fewer PCPs/more patients) Multidisciplinary PC teams will be necessary to manage care The 1:1 MD-Pt encounter will no longer be the sole clinical care experience in PC PCPs will be needed to both see the most complex cases and to manage the team (skills not currently taught) PCMH emerging as one model that captures these core concepts

13. Patient-Centered Medical Home(Great Medical Care, Delivered by a Team) • Team-based acute, chronic, preventive and coordinated care • Patient-centered care (improved access, e-visits, SMAs, extended hours, pt engagement) • New model of care delivery (evidence-based population management; performance measurement and improvement; interoperable IT) • Need for underlying payment reform (severity adjusted reimbursement for care management, coordination, quality, outcomes) to make model viable, sustainable

14. High-functioning Teams Require New Roles(And is much less MD-Centric) • Other care providers • Advanced Practice Clinicians (NPs, PAs) • Pharmacists • Social Workers • Nutritionists • Population manager • reviews registry, calls patients • Care manager • provides more intensive management/follow-up for high risk patients • the 20% who are 80% of the cost • Medicare patient with 4 or more chronic problems • Self-management Coach • The 80% who are 20% of the cost, but will be the 20% who are 80% of the cost in 20 years • Care Coordinator • tracks referrals/testing, and transitions in care

15. The Implications of Being Truly Patient-Centered “Virtually all physicians and hospitals throughout the world say ‘Patients come first’—but relatively few are ready to act on the implications of this slogan, which include ‘Physicians come second.’” Source: Lee T and Mongan J. Chaos and Organization in Health Care. Cambridge: The MIT Press, 2009; Health Care Advisory Board interviews and analysis.

17. Primary Care at BWF and“Phase 1” Strategic Work

18. The “Value Proposition” for Team-Based Primary Care Key entry point for patients into the system and trusted “home base” for their subsequent experiences of care Provides care that is: - first contact - continuous (across the life cycle) - comprehensive (disease prevention, health promotion/education, patient and family empowerment, acute care, care of chronic illness, palliative care) - coordinated across spectrum of illness (subspecialty care, acute hospitalization, rehab, home health, nursing home) Provides a platform for: - population management - high risk patient management - chronic disease management - effective resource utilization, decreased cost - improved access - improved patient satisfaction - improved quality and clinical outcomes - building a high-functioning medical neighborhood

19. BWH Primary Care: “The Mission” Create a sustainable practice model (team-based care) that recognizes the diversity of individual practices Reduce variability, demonstrate excellence across all practices re: quality, access, patient satisfaction, cost Use these achievements to: - Build a BWH-PC reputation that matches that of the in- patient side of the institution - Restore professional pride and quality of life - Increase job satisfaction, professional growth, and retention - Attract the “best and brightest” back to BWH-PC Make sure the new model readies PC and BWH for the implications of “Accountable” care: reducing unnecessary ED utilization, 30-day readmissions, bundled payments, etc

20. BWH Primary Care Multi-Year Strategy • Expand Clinical Work Force - MD’s: Ongoing Recruitment (31 New Hires since 10/2009) - APC’s: Employ as direct care providers • Invest in Creating A Team-Based Care Model (PCMH) - Stage I (2011-12): Improve Staffing Ratios of core clinical (LPN, MA, RN) and non-clinical (front desk, admin) support staff to improve access, productivity - Stage II (2013-15): Add SW, Nutrition, Pharmacists, Population Mgr to create “fully-functional” teams • Expand Capacity - Add new practices: SH, Norwood (6/12/12), BFP (HVMA; 1/13) - Augment, consolidate current practices (FXB FY13, FH ?FY14) • Enlarge Geographic Foot Print - PHS Business Planning suggests “southern strategy”: FXB-FH • Support use of FH for appropriate secondary, tertiary services

21. Current BWH Practices(Centered in Southern Urban Core) 21 21

23. Creating Team-Based Care, Phase 1Work to Date: FY 10 – 12(Goals-Metrics-Skills-Implementation) • Strategic Planning Process • PC Dashboard • Leadership Development • Implementation (Gap to Goal work) • Grow Enterprise (Recruitment, New Practices)

24. Tenets of the BWH PC Practice of the Future(“Goals”) Patient-Centered Care Team-Based Care Value-Based Payment Practice Standards and Expectations HIT-Facilitated Population Care Multi-Disciplinary Primary Care Workforce

25. PC Dashboard(“Metrics”) • Develop common set of performance goals and metrics by which to evaluate them • Link goals, metrics to Strategic Plan • Share practice –level data transparently at Leadership meetings (leverage our competitiveness) • Work with individual practices to prioritize PI efforts • Work with CCE toward physician-level data

26. BWH Primary Care DashboardCategories of Measures • Practice Snapshot • MD FTE, Total MD’s/APC’s • Annualized Visits/MD FTE • Panel Size/MD FTE • Total New Patients • Billing Performance • Charge Lag • Co-Pay Collection Rate • Days in Accounts Receivable • Quality Metrics • BWPO P4P • Diabetes (A1c, LDL, BP) • Cardiovascular Disease (LDL, BP) • Hypertension (BP) • Patient Experience • Press Ganey: Survey Mean • Press Ganey: Overall Assessment • Access • Press Ganey: Access to Care • New Visit Appointment Lag • Patient Gateway Utilization • Transitions of Care • (“ACO Metrics”) • 30-day Readmission Rate • ED Utilization • F/U Appointment Post Hospital D/C

27. Cheerfulness of practice • Cleanliness of practice • Overall rating of care received during visit • Likelihood of recommending practice to others

28. BWH Primary Care ED Utilization(Category: Transitions of Care)Between April and December 2010, out of the 11,354 ED visits by BWH Primary Care patients, 3139 (27.6%) of these visits were classified as “Low-Acuity” by the ED clinician performing the triage (ESI rating of 4 or 5). Of the 3139 Low Acuity ED visits by a BWH Primary Care patient, 1312 of these visits occurred while the patients’ Primary Care Physician’s office was open. This represented 11.6% of all BWH Primary Care ED visits to the BWH ED, FH ED, and NWH ED.The chart below shows the percentages of Low Acuity ED visits and Low Acuity ED visits that occurred while each site was open, relative to each site’s total ED visits.

29. Leadership Training(“Skills”) • CAP • Adaptive Leadership • Lean

30. Sample – Gap to Goal Assessment (“Implementation”) Categories: Practice skills: - Access - Continuity - Team - Prevention - Pt engagement Leadership assessment: - Understand the vision - Understand the need - Practice can make the changes MD Ratings Staff Ratings Works Well Real Problem Strongly Agree Somewhat Disagree Not a Problem Totally Broken Somewhat Agree Strongly Disagree Small Problem N/A Source: focus group

31. Organizing for Phase 2 • Continue to move toward fully-functional teams and the infrastructure to support them • PCMH Recognition Process – Primed Status • Building the Medical Neighborhood • Building the Infrastructure for Population Management (CPM) • Transitioning metrics to an evolving, multi-stakeholder environment • Remain mindful of the challenges (cultural resistance, residual variance, change fatigue, balancing transformational and daily work)

32. PCMH Recognition: Primed Status to NCQA A Partners Strategic Imperative • Access • Evening/weekend hours, agreement with facility for after-hours care • Coordination of care • Information to/from specialists/facilities (ie post acute)/patient, update care plan • Team-based care • Defined roles and responsibilities, training, communication • Role of medical home • Discuss roles/expectations for medical home and for patients • Care management • Pre-visit planning, care planning during visit, patient self-care, point of care reminders • Medication management • Include mental health/substance abuse/behaviors affecting health • Self-care management with community resources/referrals • Identify/address population needs/risks • Quality improvement • Performance measurement • Patient experience 32 32

33. Why a Neighborhood? • Care coordination central to delivering on the promise of the PCMH (access, quality, cost) • Chronically ill, often elderly, multiply co-morbid patients a key focus for care coordination • By definition, requires efficient, effective, patient-centered, bi-directional work flows between PCP’s, specialists • High interest by specialists to develop pilots

34. What Do We Mean by ‘Medical Neighborhood?’ Adapted from ACP White Paper, 2010 American College of Physicians. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. Philadelphia: American College of Physicians; 2010: Policy Paper. 34 • Set of agreements between PCP and specialty practices that defines effective communication, coordination, and integration • Structure and processes in place to ensure patient-centered approach to collaboration: • Appropriate and timely consultations, referrals, and testing • Efficient and effective flow of information • Determines responsibility in co-management situations

35. Everybody Wins in the Medical Neighborhood Patients • Prompt access when needed • Patient concerns are addressed quickly, they do not have to navigate between fragmented silos Physicians • PCPs and specialists practice at the top of their license • Specialists see more patients that require their expertise and action • Clearer expectations and better communication makes patient care easier and more enjoyable BWHC • Patients stay within BWHC family and are not referred out • Reduced trend through fewer unnecessary referrals • Reduced trend through fewer unnecessary diagnostic tests related to referrals and co-management 35

36. BWH Pilots Planned • Discussions around dedicated Primary Care Practice Cardiology team, available for education, referral triage, and referrals Cardiology • Enhanced access for PCP • New referral email/phone line being introduced • Clinicam (tool for pre-referral triage) is being discussed in Dermatology Dermatology • Discussions around standardized triage process, using consult team (attending and PA) to triage curbsides and referrals Gastroenterology • Discussions around standardized triage process, using physicians assistant to field curbsides and determine appropriate next step Orthopedics • Discussions around standardized triage process, using consult team (attending and fellow) to triage curbsides and referrals Rheumatology • Ongoing PCP-Surgeon workgroup, discussing referral triage using on-call paging system Surgery 4 PCP Sites • Plan to develop and pilot interventions with the sites above Need input Ready to pilot Status of Proposal: