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Edwina Rogers


Panel 2 July 16th 2009 PCPCC Stakeholder s Working Meeting Patient Centered Primary Care Collaborative July 16th Stakeholder s Working Meeting – PowerPoint PPT presentation

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Title: Edwina Rogers

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 202.674-7800
  • erogers_at_pcpcc.net

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
For U.S. use only
Boehringer Ingelheim Our Interest in Healthcare
  • 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

Boehringer Ingelheim Our Interest in Healthcare
  • 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
  • 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

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

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
It is more important than ever to take on health
care reform now
We cannot afford to take on health care reform
right now
Kaiser Family Foundation Health Tracking Poll
April 2009
Dont Know/Refused
More Say Reform Would Help
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)
21st Century Health Care
Improving Quality, Increasing Access, Containing
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
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
  • U.S. Preventive ServicesTask Force

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
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)

IOM Priorities for Comparative Effectiveness
  • 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

AHRQs Role in Comparative
  • 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
  • Promote and fund comparative effectiveness
    methods research
  • Fund training grants focused on comparative

Revitalizing Primary Care
  • Growing popularity of the term medical
  • 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
AHRQ and the Patient- Centered Medical
  • 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
Comparative Effectiveness Research and Primary
  • Comparative effectiveness
    research can be used to study the efficacy of
    delivery systems for primary care and the medical
  • 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

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
  • To review AHRQs standing program and training
    award announcements http//www.ahrq.gov/fund/grant

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

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

Are We Headed Toward Meaningful Health Reform?
  • Focus in Washington Almost Exclusively Now on Two
  • 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

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.

Why Primary Care Is Central to Meaningful Reform
  • Patients with Ongoing Primary Care Provider
    Relationship Have Better Health Outcomes, Lower
  • 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
  • 5 Increase in Primary Care Physicians Reduces
    Hospital Admission, Emergency Room Visits, and

How Do We Get There?
  • Workforce Policy
  • Reorganizing Health Care Delivery
  • Payment Policy

Health Reform Bills and Primary Care
  • Economic Stimulus Law Gives Preference to Primary
    Care Providers for Federal HIT Technical
  • House and Senate Finance Bills
  • Increase Medicare Payments for Primary Care
  • 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

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

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

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

Employer Primary Care Initiatives
  • Support Medical Home Pilots
  • Work with Health Plans and Communities on Primary
  • 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

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

Average Physician Income, 1969
Profile of Medical Practice 1978, AMA
Early Drivers of Specialized Medical Practice
  • Higher specialist physician income
  • health insurance coverage for hospital based
  • Increased specialist MD productivity not offset
    by fee reductions
  • WWII codifies higher incomes for military MD
  • Hospital incentives to increase residency
  • Residents provide after-hours coverage, increased
    hospital productivity and assistance to private
  • 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
Early Drivers of Specialized Medical Practice
  • Factors that favor development of a medicine
  • 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
Medicare Physician Payment and Specialist
  • 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

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
Financial Barriers to Generalist Care
  • US Fee-for-service payments provided no reward
    for primary care functions
  • Continuity
  • Comprehensiveness
  • Coordination
  • Accessibility
  • Accountability

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

GDP for Health Care
Source CBO Long-Term Outlook for Health Care
Spending, Dec 2007
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

MD Graduates Choosing Generalist Careers (FM,
Source AAMC Graduation Questionnaire
MD Graduates Choosing Generalist Careers (FM,
Source AAMC Graduation Questionnaire
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

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

GDP for Health Care
18 In 2009?
Source CBO Long-Term Outlook for Health Care
Spending, Dec 2007
Ave Offered Physician Income, (Pre-Bonus) 2008
Merritt and Hawkins MDSalaries.Blogspot.com
Worsening comprehensive care failures
  • Primary care physicians already felt rushed
  • More to do during a single visit now than in
  • MOST Medicare beneficiaries have multiple chronic
  • More drug combinations recommended for each
  • More preventive services/early interventions
  • More extensive documentation regulations
  • DTCA

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
  • 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.

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

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

SGIM/STFM/APA Medical Home Policy research agenda
  • 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

SGIM/STFM/APA Medical Home Policy research agenda
  • 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
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