Health Care Reform: Two Challenges to the Primary Care Sector

8/14/2019 Health Care Reform: Two Challenges to the Primary Care Sector

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Excellent Healthcare in Every Neighborhood.

All rights reserved. PCDC 2009

National Health Reform:The Primary Care Imperatives andStrategies for Addressing Them

Presentation to the Center for Family andCommunity Medicine

Columbia University Medical Center

Ronda Kotelchuck, Executive DirectorPrimary Care Development Corporation

Thursday, January 21, 2010


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1. Introduction: The Problems

2. Health Care Reform: The Primary Care Agenda

3. Primary Care Expansion

4. Primary Care Transformation

A. Practice Redesign

B. Health Information Technology

1. Lessons and Reflections

Overview


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1. Introduction: The Problems


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Rising Cost and the Role of Chronic Illness

The rising cost of health care is unsustainable

Cost is driven by the rising rate of chronic illness. It:

Is the single largest cause of morbidity and mortality Is the single largest driver of cost (accounts for 75% of all health

expenses)

Has the heaviest impact on low income communities

Will grow more severe as population ages

Chronic illness is overwhelmingly preventable or primarycare manageable. Prevention and management requirea robust model of primary care.


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Primary Care Today:

Insufficient and Poorly Organized

Primary care capacity is insufficient:

60 million Americans lack access to primary care

Half of primary care doctors plan to reduce or end their practices

Only 20 percent of medical students plan to practice primary care

U.S. is expected to need 46,000 primary care doctors by 2025

Most primary care is poorly organized and still practiced in anoutdated mode. It is:

Reactive and episodic Subject to long waits and delays

Uncoordinated

Inefficient


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Study: US Lags Behind other Countries

in Key Primary Care Indicators

Commonwealth Fund study of 11 countries (November 2009) Australia, Canada, France, Germany, Italy, Netherlands, New

Zealand, Norway, Sweden, UK, US US 10th out of 11 in use of Electronic Medical Records (46% - ahead of Canada) 10th of 11 in use of care teams (ahead of France)

Last in access to after-hours care

Least likely to have financial incentives for clinical outcomes


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2. Health Care ReformThe Primary Care Agenda


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Health Reform Will Drive the Need for Expanded

Primary Care Capacity

Expanded insurance coverage will put millions of newcustomers into the healthcare market

Physician shortages will increase by 25% and workload by29% over the next 15 years.

The Massachusetts experience:

97% coverage

Patients wait months for appointments

40% of family physicians are not accepting new patients

Record use of ER for non-emergencies


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Rising Costs Will Drive the Need to Transform the

Model of Primary Care

Growing evidence shows that primary care is effective in reducing costs,improving health outcomes and eliminating disparities

Employers, insurers and policymakers are looking to primary care as thenew paradigm.

A new model of care is necessary, however, to achieve theseobjectives.

Innovations in practice have been afoot for years (practice redesign,

evidence-based clinical protocols, etc.) Now these are integrated into the concept of the Patient-CenteredMedical Home (PCMH)


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PCDC: Offering Strategies for Primary Care

Expansion and Transformation

Non-profit organization founded in 1993 to address lack ofprimary care access in underserved communities

Premier public-private partnership focused on needs ofsafety net providers - community health centers, hospitals,special needs providers

Three areas of expertise Capital Financing

Performance Improvement

Policy


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3. PCDC:

Strategies for ExpandingPrimary Care Expansion


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PCDC Primary Care Expansion StrategyProblem:

Lack of capital constrains growth of long-standing, dedicated providers ofcare to the underserved; further hampered by credit crisis

Strategy: Use public funds to leverage private investment

Provide favorable-term loans to catalyze construction of new, expandedand renovated sites, modernized facilities

Provide:

Technical assistance for facility development

Provide strong oversight to ensure successful project completion andlong-term sustainability


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Results Total investments of $245 million

for 78 capital projects in New YorkState

Created capacity for 550,000 newpatients/1.7M visits annually

Leverage more than 5:1private:public investment

Cornerstone of local economic

development: 2,200 permanentjobs created; 4,400 withcommunity multipliers

Facilities operating successfully,no defaults

PCDC CapitalProjects (partial list)


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Joseph P. Addabbo Family Health Center Queens, NY

Before After $9.4 million for 22,000 SF new facility;

increased patient visits by 40%


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Callen-Lorde Community Health Center Chelsea

Before

After$9.3 million for relocation & expansionIncreased patient visits from 8,000 to

48,000 annually


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Reflections on Capital Strategy for Expansion

Partnership among stakeholders is key

Creates a permanent community infrastructure

Relative ease of raising capital Builds a baseline of knowledge and relationships that provide great

foundation stones for other initiatives (e.g., transformation; policy)

Technical assistance is critical for organizations that have littleexperience or internal capacity for undertaking a complex, expensive,

risky process Offers a replicable model to address the capacity crisis that will follownational health reform


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4. PCDC:

Strategies for Transforming thePrimary Care Model


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The Need for Transformation Origin: Initial focus on financial strength of borrowers New realization: Poor work processes

Cause much capacity to go unused Become important barrier to access

Result in inefficiency and waste Undermine financial strength Demoralize staff and patients.

Hallmarks of poorly organized processes: Long waits for appointments; lengthy cycle times; low productivity; high no-shows;

staff-focused (rather than patient-focused) processes; poor customer service

Discovery of the gap between what is possible and what is. Whats possible? Care that is safe, effective, patient-centered, timely, efficient

and equitable (six Aims of the IOMs Crossing the Quality Chasm)

The promise of a new primary care model: the medical home


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A Vision of Transformation:

The Patient-Centered Medical Home

The medical home concept: Continuity Well organized (efficient) practice

Easy access: Same day appointments, 24/7 telephone access, alternative access Responsibility for health outcomes Panel management Care coordination across settings Decision support Incorporation of evidence based practice (prevention, treatment, management)

Patient /family engagement

Formalization and the growth of a movement: Principles agreed to by major professional associations NCQA standards, measures, system of recognition

The promise: Better health outcomes, reduced disparities;lower health care cost


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A Vision of Beyond the Medical Home:Integrated Delivery Systems/Accountable CareOrganizations

Vertically integrated, comprehensive services Responsible for total care of a population

Use of value-based payment (bundled or global payments)which:

Rewards quality and outcomes Achieves savings

Examples: Kaiser, Mayo, Geisinger, Intermountain


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Strategies for Transformation:

PCDC Performance Improvement Programs

1. Medical Home Recognition Assist providers to achieve NCQArecognition and transformation (also 2 programs below)

2. Practice Redesign Improve access and efficiency by eliminatingwait times--both for appointments and during the visitincreasingthrough-put (productivity), improving patient and staff satisfaction andincreasing revenues.

3. HIT Implementation and Meaningful Use Adopt and integratetechnology to improve quality, coordinate and manage care, engagepatients and improve patient-provider communication.

4. Other PCDC Performance Improvement Programs:

Attracting and Retaining Patients

Increasing Revenue

Primary Care Emergency Preparedness


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Performance Improvement

PCDC Approach

Focus on:

System Design Implementation Measurable Results Staff Organized as Care

Teams Building Client Capability

Sustainability

Use of:

Change Teams Change Concepts & Tactics Coaching and Training Collaborative Learning Project Management Frameworks for Improvement

Model for Improvement (IHI) Chronic Care Model (Ed

Wagner) Medical Home Model


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A. Practice Redesign

The Issues: Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time). Patients often wait 3-6 weeks for an appointment; instead go to the ER No shows run as high as 50-60%; providers overbook to make up Organizations operate well below capacity (25-35%) Redesign process is complex, resource-intensive, challenging for self-implementation

Program Results: Trained 219 teams No show rates decrease by nearly 70% Appointment backlogs drop from an average of 21 to 0-5 days Providers able to hold 4-8 same-day appointments in daily schedule Cycle time reduced to an average of 51 minutes (50%+ reduction)

Provider productivity increase of 33% Improved patient and staff satisfaction

.


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B. Implementation and Meaningful Use of HIT

The Issues: Difficult, expensive, risky process Organizations with little experience or internal capacity, few resources Excessive, vendor-generated information; little ability to evaluate

The Program:TA for all stages of HIT adoption (38 teams) HIT vendor selection and contracting (23 teams) Planning and readiness (11 teams)

Internal capacity: team building, staff training, project management Design (workflow, decision support) Budgeting

Implementation and go-live (6 teams) Effective use (Assure meaningful use compliance)

Data reporting (Quality, compliance, panel management) (2 teams) Health information exchange (6 teams)

Remediation (1 team)


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The Challenge of the Next Five Years

2 simultaneous, highly-interrelated, time-limited initiatives

Both improve care, provide financial incentives NCQA medical home recognition: NYS Medicaid Incentive Pool

FFS: $5.50/$11.25/$16.75 per visit for Levels 1/2/3 Managed Care: $2/$4/$6 pmpm for Levels 1/2/3

Level I phased out after December 2012

HIT meaningful use compliance

Medicaid: Up to $63,750 over 6 years

Medicare: Up to $48,000; penalties beginning in 2015

Both are complex, expensive, a challenge for self-implementation Current focus on PCDC programdevelopment


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5. Lessons & Reflections


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5. Reflections: The Nature of Organizational Change The under-appreciation of implementation

People know what needs to be changed. They lack knowledge of how tochange

Transforming the model of primary care requires major, thorough-goingorganizational and cultural change.

Myths:

It can been done fast and cheap

Its a project. Once done, we can move on to other things.

It can be delegated from the top The importance of technical assistance, willingness to invest in the change

process

The under-appreciation of everyday operations

Practice redesign, HIT as preconditions for clinical improvements, quality


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Reflections on Safety Net Settings Private practice

Strong on continuity, access and efficiency

Isolation raises concerns about quality, coordination

Setting is simpler, change is easier

Small size, spare resources pose a challenge to implementing HIT, PCMH Community Health Centers

Continuity, access, efficiency not assured

FQHCs offer robust model, many PCMH functions, experience in qualityimprovement

Special Needs Providers

Already offer a care home, instinctually understand medical home

Hospital OPDs

Broad scope of service available (specialties, ancillaries)

Continuity, access, efficiency present challenge in teaching environment

Primary care is not the institutional focus or priority


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Reflections: PCDC as a Model for Expanding and

Transforming Primary Care

Leverages private investment for small investment of public resources;availability of capital (relative to expense)

Produces measurable, sustainable outcomes, able to reach scale;

builds lasting community infrastructure; delivers important communitydevelopment benefits Works across wide range of provider types (community health centers,

hospitals, private practitioners) Is adaptable to localities, states, foundations Offers excellent platform upon which to build additional programs and

services Value of an organization dedicated solely to primary care Builds a strong community of interest in the success of primary care.


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Contact

Ronda Kotelchuck

Executive DirectorPrimary Care Development Corporation

Phone: (212) 437-3917

E-Mail: [email protected]: www.pcdcny.org
mailto:[email protected]:[email protected]

Health Care Reform: Two Challenges to the Primary Care Sector

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