To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home. A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today? All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are: 1) Cost and demography 2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care) 3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail? But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that. The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military. Also, the health care reform law will likely increase the importance of PCMHs in the USA because under the legislation Accountable Care Organizations (ACOs) will be created in 2012; ACOs are a combination of primary care, hospitals and specialists tied to a defined population and accountable for the quality, outcomes and cost of health care received by that population and the healer relationship based PCMH is the foundation to care that is accountable. One key to the new approach is that many are now willing to pay more for primary care - when primary care takes on more responsibility for improving the patient’s health and coordinating health care. There is a good deal of evidence that this approach results in lower hospitalization rates, lower

1. PCMH Level Care 2011 Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative Paul Grundy MD, MPH IBM International Director Healthcare Transformation Trip to Denmark July 10 2009

3. participant will understand/be able explore the rationale and supporting evidence for PCMH - participant will understand/be able understand the impact on patients, providers and payers Disclosure: – I am a full time Emplyee of IBM I WILL NOT discuss any pharmaceuticals, medical procedures, or devices I have gratefully had my expenses covered to do some of my talks about PCMH by Merck, and Pfizer.

4. Population management !! Accountability !! Who was the Shooter’s Doctor? Away from Episodes of Care - FFS

5. Animated Short: The Amazing Health Care Arms Race http://www.publicradio.org/columns/marketplace/business-news-briefs/2011/09/oh-the-jobs-youll-create.html

6. Why Innovate Affordability $30,000 +166% $25,000 $20,000 $15,000 +118% $10,000 $4,918 $5,000 $0 2001 2009 2019 - Employee Payroll Contributions - Employer Cost - Employee Out of Pocket Expenses a The Elephant in the room $28,530 Costs continue their upward climb… …with employers still picking up much of the tab… $10,743 Slide From Dr Martin Sepulveda

7. If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH) The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians. A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes. The Big Idea: How to Solve the Cost Crisis in Health Care by Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard review

8. Health care is a business issue, not a benefits issue Slide From Dr Martin Sepulveda

9. OUR IBM Patient needs A long-term comprehensive relationship with a Personal Physician empowered with the right tools and linked to their care team.

11. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

12. Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

13. Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

15. ACO and the Principles of the PCMH Whether building a community-wide ACO or a solo primary care practice, adherence to guiding PRINCIPLES provides the foundation. Through the PCMH Joint Principles, we (the buyers and providers) have agreed to change our covenant with one another. The Joint Principles of the PCMH have been agreed on by those who deliver comprehensive care (the primary care providers) and their specialist colleagues. For Accountable Care to achieve its goals, successful organizations will NEED a foundation in these principles. As a buyer, I want to be assured that the foundation - the principles - are in place: a personal relationship with a healer, improved access, care that is coordinated, integrated, and comprehensive.

16. PCMH is the patients view from the bottom up The kind of care they want: relationship, accessible, coordinated From the System view it is ACO Or, like the Euro tunnel you can start on one side building PCMH And the other side ACO, but somewhere you have to meet in the middle, where care is delivered- centered on the needs of the Patient.

17. BCBS MA 6% decrees cost (NEJM) BCBS MI 2670 physician (BIG study)

18. Smarter Healthcare 36.3% Drop in hospital days 32.2% Drop in ER use -9.6% Total cost (Mayo Zero cost increase) 10.5% Inpatient specialty care costs are down 18.9% Ancillary costs down 15.0% Outpatient specialty down Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010

21. HEALTH INDUSTRY -- WSJWellPoint's New Hire.What Is Watson? IBM - Mayo Clinic Establish Medical Imaging Research Center

22. NC 2011 USA 2011 Dubuque, Iowa The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!” - Unaccountable Care Organizations * Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010

23. Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!! Unaccountable care, lack of organization, DO NOT GO THERE ALONE !! Be wise when you pay for care, KNOW WHAT YOU BUY!!

25. Dubuque, IA $2,719

26. McAllen TX $2,950

27. Anderson, IN $7,231

28. Punta Gorda, FL $7,168

29. Racine, WI $6,528

30. Providence $6,367

31. Naples, FL $6,312

33. Battle Creek, MI

34. New study -- health care costs are swallowing up almost all income gains that Americans have made over the past decade. Studies like this show us again and again, why it is so necessary that we look for ways to control costs while still providing quality care. “growth in healthcare spending sharply reduced the disposable income of Americans while increasing the federal deficit,". In RI $545 out of employee pockets every month vs . Dr. Arthur Kellerman, Director of RAND Health Sept 2011

36. Coordination -- we do NOT know how to play as a team “ We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now

37. “We do kidney transplants and dialysis more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic complications of renal and heart disease from becoming acute.” George Halvorson (CEO Kaiser) from “Healthcare Reform Now”

38. The Quadruple AimReadiness, Experience of Care, Population Health, Cost Per Capita Cost Population Health The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and financial management System Integrator Patient Experience Productivity

39. If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system. So simple! So much!

40. Defining the Care Centered on Patient Superb Access to Care Team Care Patient Engagement in Care Patient Feedback Clinical Information Systems Publicly Available Information Care Coordination

42. Offer patient self-management support.

43. Provide a visit summary to the patient following each visit.

44. Maintain a summary-of-care record for patient transitions.

45. Email consultations.

46. Telephone consultations.

47. The development of care plans.

49. Provide open scheduling.

50. Provide care management and coordination by specially-trained team members.

51. Use an EHR with decision support.

52. Use CPOE for all orders, test tracking, and follow-up.

53. Medication reconciliation for every visit.

54. Prescription drug decision support.

56. CMS Plus most other buyers 11% CMS Shift in payment away from FFS to other dials. CMS Bundling!! CMS Advanced Primary Care Wellpoint PCMH, BCBS Hawaii no new FFS $$

57. Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

58. PCMH in Action Vermont “Blueprint” model A Coordinated Health System Hospitals Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS PCMH Health IT Framework Specialists Global Information Framework PCMH Evaluation Framework Public Health Prevention Operations

59. Vermont Financial Impact Vermont Financial Impact

60. And Today in NC PCMH practices Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market. $9 PMPM cost savings. Diabetes is better controlled, will improve long-term health and lower medical costs.

61. The NC Plan You Developed a better healthcare system for RI starting with Public Private payers Private payers Joined Strong Primary care is foundational to a high performing healthcare system Additional resources needed to help primary care manage populations Learned timely data is essential to success Learned must build better local healthcare systems (public-private partnership) Physician leadership is critical Improve the quality of the care provided and cost will come down A risk model is not essential to success- shared accountability is!

62. Team-Based HealthcareDelivery Population Health Access to Care Patient is the centerof theMedical Home Advanced IT Systems Patient-Centered Care Decision Support Tools Refocused Medical Training Patient & Physician Feedback Enhancing Health and the Patient Experience Medical Home Model Care that is Accountable Model adapted from theNNMC Medical Home

63. PATIENT CENTERED MEDICAL HOME: VHA Patient Aligned Care Team Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship THE PRIMARY CARE TEAM

64. Reinventing Medicaid findings are Outstanding Oklahoma's patient-centered medical home initiative has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased. The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state. Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively. Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average. The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control. Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

66. Patients love to see meaningful information about themselves and it take IT tools to If you give patients educational materials with their name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you. If you tear off a generic sheet and give it to them, it often goes in the waste basket. If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove to them, “if you the healer make a change, it will make a difference to your patient.”

67. PCMH is non-political – the right POV for delivery transformation “We never abandoned advocating new Models of care. We’ve long pushed folks to realize that Delivery reform is the key.” The patient-centered medical home is core. “We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”

68. 43

69. 44

71. Medical Homes are in demand

72. ACO based thinking is evolving and re-defining partnerships

73. Competitors as well as payers/providers are merging

74. New places and types of care are on the increase

75. Quality is required for both processes and care

76. Consumer health will be the mantra, engagement is key

77. The “End Game” is not clear but the industry is engaged