The Future of Primary Care

Ed Wagner, MD, MPH, MACP

MacColl Center for Health Care InnovationGroup Health Research Institute

Why worry about the future?“I look to the future because that’s where I’m going to

spend the rest of my life”. George Burns

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Only 8 years ago

Primary care providers are dispirited, burning out, and diminishing in number.

Primary Care — Will It Survive?

Bodenheimer T. N Engl J Med. 2006

Percentage of medical students choosing primary care specialties

0

5

10

15

20

FamilyMedicine

General InternalMedicine

Pediatrics

19992009

5

Percent

Physician Satisfaction with Practicing Medicine

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

What’s Threatening Primary Care?

Changing demography and practice content increasing demand

Greater care complexity

Working harder and harder just to keep up

Professional isolation

Declining real income

But then hope!• Federal healthcare reform is counting on

a robust primary care sector to improve quality and reduce costs.

• “The Patient Protection and Affordable Care Act (PPACA) of 2010 … has the potential to reestablish primary care as the foundation of US health care delivery.”*

*Goodson J. Ann Int Med. 2010; 152:742

The ACA is betting that more effective primary care reduce health care costs?

Effective primary care will lower total costs by reducing hospital admissions and ER visits.

How? By taking better care of individuals with multiple chronic illnesses—aka complex patients.

The future of primary care may well depend on its ability to manage complex patients well.

It was abundantly clear that traditional, doctor-driven, reactive practice is not up to the task; we needed a new model.

For primary care to re-establish itself as the foundation of American healthcare, it will have to manage complex patients well, the very group that may be contributing to its existential crisis.

The Questions

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• Can primary care effectively and manage complexchronically ill patients?

• Can primary care reconnect with hospitals and specialiststo improve care sharing and coordination?

• Can primary care once again be an attractive career option?

• Will primary care get the resources it needs to truly become the “foundation of US health care delivery”.

• Will hospital driven ACOs consider primary care as its foundation or a cost center?

Primary Care Teams:Learning from Effective Ambulatory Practices

“The future is here. It’s just not widely distributed yet”.William Gibson

Dr. Margaret Flinter – co-Director

Collect data on innovations and change processes, best practices

Develop a toolkit for broad dissemination

Create a learning community among exemplar sites

Identify up to 30 exemplar sites

30 LEAP Sites

What are we learning?LEAP practices view performance as a system property,

not a function of how smart everyone is.LEAP practices measure performance by provider and

regularly review it.LEAP practices are constantly changing, trying to

improve.LEAP practices innovate “because it is the right thing to

do”, regardless of reimbursement.

LEAP sites really understand the functions that lead to higher quality and lower costs

Team CarePopulation management Planned, proactive careSelf-management supportMedication ManagementCare management/Follow-up/Care CoordinationCost-effective specialty inputTO “really understand” a function means hard wiring it into

your care system—staff training, IT, work flows.

It begins with Skilled and Well-organized Care Teams

Involvement of non-physician care team members in care has been associated with a 0.75% reduction in HbA1c and a 13 mmHg reduction in BP.

Without effective teams, practices find they can’t do many of the other functions.

What have LEAP sites done to create effective teams?

Hire bright, energetic folks with good interpersonal skills.

Define key roles and tasks and distribute them among the team members (everybody at top of their license).

Train staff to perform tasks.Use protocols and standing

orders so that staff can operate independently.

Give teams time to meet.

Population Management Many of the deficiencies in care quality relate to the

reactive nature of medical care.

Defining panels and developing and using IT tools to assess the panel to identify care gaps was a key step .

LEAP sites link assessment with outreach. May account for the biggest leaps in clinical performance.

LEAP site deliver planned care

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How do LEAP sites implement self-management support

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Medication Management

Protocol-based prescribing and monitoring of adherence and outcomes is associated with better outcomes.

LEAP sites view medication reconciliation as a critical intervention for both patient and practice.

Pharmacists and RNs can play important roles in complex med. rec., titrating medications, and addressing non-adherence and other drug problems.

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Planned follow-up and Care Management(outside of visits)

Follow-up can range in intensity from periodic status checks by telephone or e-mail to active care management.

LEAP care teams regularly monitor patients (evidence-based!).

Higher risk patients (poor disease control, frailty, etc.) benefit from regular follow-up (monitoring) AND active care management.

Care management

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Is practice in a LEAP site more satisfying?

All staff Physicians

Most people in the practice enjoy their

work79% agree 84% agree

This practice is a place of joy and hope 64% agree 69% agree

People in our practice actively seek new ways to improve

92% agree 94% agree

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The Questions

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• Can primary care effectively and manage complexchronically ill patients?

• Can primary care reconnect with hospitals and specialiststo improve care sharing and coordination?

• Can primary care once again be an attractive career option?

• Will hospital driven ACOs consider primary care as its foundation or a cost center?

• Will primary care get the resources it needs to truly become the “foundation of US health care delivery”.

A. Goroll, NEJM December 2008 27

“The solution is not an intramural “food fight” over payment. The way to get money redirected to primary care is to improve care management and coordination by the primary care physician.”

www.improvingchroniccare.org

Watch for:www.improvingprimarycare.org

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