1. 1
Creating scalable primary
care innovation
Craig P. Tanio MD MBA
Chief Medical Officer, ChenMed
Chairman, Maryland Health Care Commission
Assistant Professor of Medicine, Johns Hopkins School of Medicine
@drtanio
September 2014

2. 2
Snapshot of Chen Med
Who we are: Privately held, primary care-led physician group
Our focus: Low to moderate income adults > 55 with multiple chronic
conditions in urban areas. Typical patient searches for a PCP every 18
months, often considered “frequent flyers” by other health systems.
Care model: 400-450 patients per PCP; on-site Rx, focus on culture,
patient relationships, decision making, customized information technology,
intensive care coordination
Scale: Designed to scale quickly; Growth from 5 centers in Miami market in
2010E to 36 centers in 8 markets at 2013E . 40+k risk lives in 2014.
Payment: Global risk adjusted capitation from Medicare Advantage plans
ranging $7k - $30k per patient per year

3. 3
Miami Outcomes in CY 2011 prior to scaling
Chen NMC National Difference
Consumer Net
Promoter Score
92 40-50 >100%
Medication Possession
Ratio
82 42 73%
Hospital Days per 1000 1058 1712 (38%)
Percent of Ambulatory
Encounters on Site
86% N/A
Patient Visits at Center
Per Year
13.3 N/A
PCP Visits with Same
Physician
92% 40-60% > 50%

4. 4
Our strategy to scale
Innovation
Platform
Selective integration
within geographic
markets
Value based workflows supported
by proprietary information
technology
Accountable clinical culture to create an
optimal enduring healing relationships
Specializing primary care: focus on patient segment,
reimbursement, payor collaboration

5. 5
Key dimensions of focus
▪ Transportation, case management, interdisciplinary team
▪ Control generalist decision making (e.g., primary care, hospitalist,
SNFist) across transitions
▪ Common care plan
▪ Focus on minimizing preventable hospitalizations, poor outcomes
▪ Disparate data integrated into a system for physician to review
▪ Discussion in physician conferences 3 x a week
Real time
attentiveness
▪ Ambulatory ICU layout
▪ Primary care, diagnostics, acupuncture, targeted specialty services
▪ No private offices for physicians
Overcoming
barriers to care
One stop shop
1
Patient
population
▪ Over age 55
▪ 5 or more chronic conditions
▪ Drives > 70% of Medicare costs
▪ Underserved low to moderate income, urban segment

6. 6
Physician culture is critical to get care right
“from the inside out”
2

7. 7
Getting the right physician behavior and mindset
requires a comprehensive approach
Role-modeling
Behavior and
mindset shifts
Developing talent
and skills
Reinforcing with formal
mechanisms
Fostering understanding
and convictions• Physician call
behavior
• Weekend worrier
program
• Medical Director as
master clinician
• Physician meetings 3x
wk
• Interdisciplinary team
meetings
• 4 M leadership
• Physician education
– ChenMed U
• Clinical leadership
programs
• Panel management
tools
• Behavioral interviewing
tools
• Compensation
• 2 day review process
with professional dev
2
Overview discussed in The Health Care
Blog
May 18, 2014
http://bit.ly/1j3BMLj

8. 8
Need to get workflows right at a deep level
Cheaper to build than to modify vendor technology
The technology “last mile” is getting the right share of mind with physician
Create exam room tools with Agile based methodology and front line physician input
• Patient Life Cards
with scanning
functions
• Greeting and eligibility
displays
• Air Traffic Controller
• Patient education
• Electronic Medical
Records
• Diagnostic accuracy
algorithms
• Physician and MA
decision support
• Payor integration to
tap into analytics
• On-site pharmacy
• Referrals and
diagnostic tracking
• Patient education
and portal
• Integration to
hospital, SNF, case
management
systems
• iPhone call system
• Physician toolkit to
review panel
outcomes with
coaching
• Case management
and IDT toolkit for
highest risk patients
• Risk stratification
with qualitative and
quantitative tools
• Data integration from
multiple sources
Patient flow
Decision
support
Care Continuum
and Transitions
Panel
management
Value based workflows are fundamentally different than
volume based ones
3

9. 9
Providing a suite of tools to optimize decision making
in the exam room
Real-time internal
HEDIS Metrics
• My Work
• MAQReal-time patient flow
metrics (i.e. wait times)
• ATC
Inpatient care and
coordination
• HITs Application
• Dash2Go
Medical Costs
• Care Timeline
High Risk home and
social support
limitations
Pharmacy & Medication
Adherence
• CMEDs
Coordinate
comprehensive specialty
clinical data
• My Facesheet
Patient Experience &
Growth
• Apt maker
ChenMed PCP
Standard PCP (Additional responsibilities)
vs.Coordinate
comprehensive
specialty
clinical data
3

10. 10
Manage across
transitions
▪ Build in continuity where possible; hospitalist follows patients to first
follow-up visit
▪ PCP and NP joint SNF decision-making
▪ Initial home assessment
▪ Interdisciplinary weekly team meetings by center
Design around
access
▪ One stop shop – most patients within 7 miles ; transportation
▪ On-site physician drug dispensing
▪ Wellness focused activities on-site
▪ Not looking to be a complete multi-specialty group
Build up care
team
▪ Nurse case manager, social worker, transitions team
▪ Developing medical assistants as coaches
▪ Creating expertise in risk assessment and reduction
▪ Develop relationships with trusted specialists over time
Selective integration with the healthcare geographic
market
4

11. 11
Staged rollout
Pipeline of innovation for the annual plan
We believe that ongoing innovation can eliminate 30-
50% of unnecessary waste in the US
Establish foundation for
secondary prevention
• Physician culture ,
performance assessment,
feedback compensation
• Medicare Advantage and
care coordination skills
• Center design, patient flow
and service
• On-site Rx
• Begin physician capabilities
on risk
• “Boots on the ground” for
transitions of care (hospital,
SNF, home)
Drive complex condition
management
• Physician panel management
capabilities
• Behavioral medicine integration into
model
• Interdisciplinary teams for high risk
patients
• Align payor and provider care
management capabilities
• Hospice and advance care planning
• Point of care decision support
• Complement qualitative and
quantitative risk assessment
• Increase engagement with
preferred specialists
Tackle primary prevention
• “Food as medicine”, sleep,
exercise, health literacy
• Engage entire center around
behavior change – group
visits, employee health,
coaches, patient connectivity
• Remote monitoring
• Use of behavioral economics
• Integration with community
and social services around
health opportunities
• Substitution of office visits as
appropriate
Where we
are today
5

12. 12
Focused and concentrated change can have substantial impact
quickly
Creating the right physician culture, accountability and ownership
for population health results matters
Developing enduring, high quality patient-doctor relationships has a
cumulative effect
Takeaways
Segmenting primary care can unlock significant productivity
improvements for care of patients with multiple chronic conditions

13. 13
How can we create a aspirational culture that elevates professional
excellence and engagement?
2 questions for the NHS
How can we create more effective, high quality relationships
between the patient with multiple chronic conditions and the GP?