DISCLAIMER . The views expressed in this presentation are the views - - PowerPoint PPT Presentation

Module 4A: Primary Care and Specialist Services Richard J. Baron, MD, MACP Group Director, Seamless Care Models Innovations Center, CMS Clinician Learning Module Organizing and Delivering Care

ACO Accelerated Development Learning Sessions

Minneapolis, MN June 20-22, 2011

June 21, 2011 3:30−4:45 p.m.

• DISCLAIMER. The views expressed in this presentation are the views of the speaker and do not necessarily reflect the views or policies of the

Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

After attending this session, the participant should be able to-

• Describe supply and demand curves for primary care

physician capacity

• Discuss the relationship between medical costs and
• ther economic indices
• Describe the relationships between per capita

distribution of physicians and cost/quality

• Review the characteristics of the uninsured
• Describe the key elements of the Patient Centered

Medical Home

• Explain examples of higher investments in primary

care yielding lower cost, higher quality

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

2

Greenhouse Internists, PC, Philadelphia, PA

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

3

Status of “General” IM

• Dramatic decrease in those picking it
• 2007 data (Hauer and CDIM colleagues, JAMA

2008):

– 23.2% of 4th year students plan IM – 24/1177 (that’s 2% folks) plan “GIM” – 4.2% plan Family Practice – Total complement of US MD graduates: 6.7%

• 10 years after initial cert (Lipner et al., ACP-ABIM

data)

– 98% with SS cert still in practice – 79% IM only are still in practice

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

4

Happening at a Time When Needs Are Going Up

• Population demographics
• Cost pressures
• Access problems
• Increased uninsured
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

5

GIM Predictions

• If we assume 90K GIM in 2006 and today’s rate of

GIM choice along with projected retirements and 21% leaving after 10 years, we have

– 60,000 by 2018 – And 50,000 by 2024

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

6

When the Population Is Aging

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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Which results in increased patient load per remaining generalist

422 497 629 926 1242

200 400 600 800 1000 1200 1400

2006 2009 2013 2018 2024

# People > 65/GIM physician

YEAR

Number of people >65/GIM physician 2006-2024

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

8

Percent Annual Increase in National Health Expenditures (NHE) per Capita vs. Increase in Consumer Price Index (CPI), 1980-2007

Percentage

5.6 5.1 5.8 5.9 7.3 8.0 7.5 5.9 5.3 4.7 4.2 4.1 4.5 4.3 6.2 7.3 8.2 10.5 10.2 10.8 7.9 6.3 8.3 9.2 9.2 11.5 14.7 14.1 2.8 3.2 3.4 2.3 2.7 1.6 2.8 3.4 2.2 1.6 2.3 3.0 2.8 3.0 2.6 3.0 4.2 5.4 4.8 4.1 3.6 1.9 3.6 4.3 3.2 6.2 10.3 13.5 0% 2% 4% 6% 8% 10% 12% 14% 16%

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Annual I ncrease in NHE per Capita Annual I ncrease in CPI Year

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2007; file nhegdp07.zip), and CPI data from Bureau of Labor Statistics at ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt (All Urban Consumers, All Items, 1982- 1984=100, Not Seasonally Adjusted, U.S. city average).

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

9

Increases in Health Insurance Premiums Compared to Other Indicators, 1988-2007

Percentage

18.0% 14.0% 8.5% 0.8% 11.2%* 12.9%* 13.9% 10.9%* 8.2%* 5.3%* 9.2%* 12.0% 7.7%* 6.1%*

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Health Insurance Premiums Workers' Earnings Overall Inflation

3.7% 2.6%

Year

*Estimate is statistically different from estimate for the previous year shown (p<.05). No statistical tests are conducted for years prior to 1999. Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. The average premium increase is weighted by covered workers. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2007; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988, 1989, 1990; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1988-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April).

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

10

Increases in Health Insurance Premiums Compared to Other Indicators, 1988-2007

18.0% 14.0% 8.5% 0.8% 11.2%* 12.9%* 13.9% 10.9%* 8.2%* 5.3%* 9.2%* 12.0% 7.7%* 6.1%*

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Health Insurance Premiums Workers' Earnings Overall Inflation

3.7% 2.6%

*Estimate is statistically different from estimate for the previous year shown (p<.05). No statistical tests are conducted for years prior to 1999. Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. The average premium increase is weighted by covered workers. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2007; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988, 1989, 1990; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1988-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April). (“Shark” courtesy of Arnie Milstein)

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, 2001-2007

Percentage

78% 19%

0% 20% 40% 60% 80% 100% 2001 2002 2003 2004 2005 2006 2007

Health I nsurance Premiums Workers' Earnings

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program. Year

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Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April).

The Growth Rate of Per Capita Health Care Costs

• “The long term fiscal condition of the United States

has been largely misdiagnosed. Despite all the attention paid to demographic challenges . . . Our country’s financial health will in fact be determined primarily by the growth rate of per capita health care costs.”

Orszag PR, Ellis P. The challenge of rising health care costs- A view from the CBO. NEJM 2007; 357: 1793-95

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

13

Average Annual Premiums for Single and Family Coverage, 1999-2008

Year

$5,791 $2,196 $6,438* $7,061* $8,003* $9,068* $9,950* $10,880* $11,480* $12,106* $12,680* $4,704* $4,479* $4,242* $4,024* $3,695* $3,383* $3,083* $2,689* $2,471* $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 Single Coverage Family Coverage

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program. Dollar amount

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* Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2008.

Shifting Who Pays for Care

• So we shift who pays for care . . .
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

15

Average Annual Worker Premium Contributions Paid by Covered Workers for Single and Family Coverage, 1999-2009

Dollar amount $318 $334 $355 $508 $558 $610 $627 $721 $779 $1,543 $1,619 $2,713 $3,354 $3,515 $466* $694* $3,281* $2,973* $2,661* $2,412* $2,137* $1,787* $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Single Coverage Family Coverage

*Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2009.

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program. Year

16

Average Family Premium Contribution by Firm Size as Percent of Income at 200% FPL, 2001-2007

Percentage

5.1% 5.9% 6.6% 7.1% 7.0% 7.4% 7.9% 6.4% 7.3% 8.1% 9.0% 8.2% 8.9% 10.3% 4.4% 5.2% 5.8% 6.2% 6.4% 6.6% 6.9%

0% 2% 4% 6% 8% 10% 12% 2001 2002 2003 2004 2005 2006 2007

Workers in All Firms Workers in Small Firms (3-199 Workers) Workers in Large Firms (200 or More Workers)

Year Note: 200% FPL was $35,300 for a family of four in 2001. It is $41,300 for a family of four in 2007. Source: Kaiser calculations based on worker contributions to employer-sponsored health insurance premiums from Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007 and Federal Poverty Guidelines from http://aspe.hhs.gov/poverty/figures-fed-reg.shtml

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

17

Characteristics of the Uninsured, 2006

Family Work Status Family Income Age

Part-Time Workers 11% 1 or More Full-Time Workers 71% No Workers 18%

400% FPL+ 11% 200-399% FPL 24% 100-199% FPL 29% < 100% FPL 36%

0-18 20% 55-64 9% 35-54 32% 19-34 39%

Total = 46.5 million uninsured

The federal poverty level was $20,614 for a family of four in 2006. SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

18

What Are the Cost Drivers?

• Technology (e.g., X-ray to CT to MR)
• Pharmaceuticals
• Longevity
• Personal/national wealth
• Increased use of services
• Duplication/uncoordinated care

And how many of these issues do you think primary care could have an impact on?

• Primary care vs. specialty distribution
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

19

More Specialists Mean Higher Spending

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

20

While GPs Are Associated with Less Spending

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

21

As It Turns Out, Cost Is Inversely Related to Quality

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

22

And More Specialists Predict Lower Quality Ranking

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

23

US Health System

• Commonwealth Fund Data confirm comparatively

poor performance of US Health System

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

24

Scores: Dimensions of a High Performance Health System

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

25

But What Is It about Primary Care that Leads to Higher Quality/Lower Cost?

• Is it the 8 minute visit?
• The failure to refer?
• The willingness to tolerate uncertainty and not to

refer?

• Care coordination?
• Care management?
• Proactive, inter-visit care?
• Preventive care?
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

26

Patient Centered Medical Home: ACP, AAP, AAFM, AOA

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access
• Payment
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

27

NCQA PPC PCMH Tool Criteria

• Access and communication
• Patient tracking and registry
• Care management
• Patient self-management support
• Electronic prescribing
• Test tracking
• Referral tracking
• Performance reporting and improvement
• Advanced electronic communication
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

28

Consumer “Principles for Patient- and Family-Centered Care”

• Interdisciplinary team, patient at center
• Coordinates care across settings and time
• Patient has ready access to care
• PCMH “knows” its patients
• Patients and clinicians are partners in making decisions
• Open communication supported
• Patients and caregivers supported in managing the patient’s

health

• Environment of trust and respect
• Safe, timely, effective, efficient, equitable, patient centered, and

family focused

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

29

Milstein: Ambulatory Intensive Caring Unit, a “Super-Model” of Primary Care

• Targeted at most expensive 20% (who utilize 60% of

next year’s resources)

• First floor

– RN, CHW, pharmacist, dietitian under protocol

• Second floor

– IT-enabled and streamlined NP and MD visits

• Third floor

– Integration with first two, care directed to high performers

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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Aggregate Financial Impact

• A-ICU operating costs: $1018 PMPY ($644 more

than, or 2.7 times as much as, the “typical primary care clinic”)

• Overall projected net savings: 36.9%

– Base projection without A-ICU: $6525 PMPY – With A-ICU, net of primary care cost increase: $4118

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

31

PCMH at Group Health*

• Decreased panel size (2327 1800)
• Added staff: PAs, RNs, MAs, pharm
• Promoted e-mail, Web portal
• Pre-visit planning, patient outreach
• Daily huddles
• Added cost: $16 PPPY

*Reid RJ et al. The Group Health medical home: higher patient satisfaction and less burnout for doctors. Health Affairs 2010;29(5): 835-43.

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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Impact

• Improved patient satisfaction/self-management
• Decreased burnout in staff/docs
• Improved quality (acute, chronic/preventive care)
• 29% fewer ER visits
• No change in total hosp, but 11% fewer admits for

ASCs

• Overall, no impact on total costs
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

33

Other Pieces of the Evidence Base

• Care Management, Transitions: several, most not statistically

significant – Steele et al.: 7-9% savings – Boult et al.: Guided Care, 11% savings – GRACE trial.: 23% savings – Multiple others: significant improvements in quality, patient experience; no measurable impact on total cost

• Access

– Actuarial data on difference in costs for common problems (e.g., “acute bronchitis” managed by Pulmonary Specialist costs 532% of PCP cost) – Reductions in ER utilization, hospital admissions—no reliable data on achievement of total cost reduction

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

34

High Leverage Changes

• Identify—and proactively care manage—high-risk

patients

• Continuity/availability to participate in care decisions

that occur “off-site” and “off hours”

• Integration of mental health
• Shared decision making
• All supported by comprehensive HIT adoption

– Registry functionality – Proactive panel management – Enable/support team-based care

• New payment models

– Gorroll: “Comprehensive pay for comprehensive work” – More global, less—but still some—FFS

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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ABIM Work on CCIM: New Skills Are Required, It’s Not Just Funding

• Expert diagnostician and clinician
• Patient advocate
• Effective communicator
• Team leader and an effective teammate
• Systems manager
• Effective user of health information technology and

health data

• Effective change agent
• Practitioner accountable for efficient, accessible care
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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But We Need Reorganized Practices Because the Work of Primary Care Has Changed

Type of service Number per physician per day Office visit 18.1 Telephone call 23.7 Rx refill 12.1 E-mail message 16.8 Laboratory report 19.5 Imaging report 11.1 Consultation report 13.9

Baron RJ. What’s keeping us so busy in primary care? A snapshot from one practice. New Engl Journal of Med, April 29, 2010.

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

37

How Might ACOs Support This?

• Different “internal bookkeeping” for primary care

– If all you do is replicate FFS internally, you will miss

• pportunities
• Explicitly negotiated and supported care models

– Define the capacity you believe is necessary – Likely need to “redirect” resources to assure this capacity

• Create accountability framework for primary care

– Performance metrics that include quality and resources

• Incentive structures send powerful signals
• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

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Richard J. Baron, MD, MACP Group Director, Seamless Care Models Innovations Center, CMS

Richard.Baron@cms.hhs.gov (410) 786-8626

Module 4A: Primary Care and Specialist Services

• DISCLAIMER. The views expressed in this presentation are the views of the

speaker and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services. The materials provided are intended for educational use and the information contained within has no bearing on participation in any CMS program.

39