The Latest in Our Ongoing United States Healthcare Saga Idaho Academy of Family Physicians | May 20, 2017 Ted Epperly, MD President and Chief Executive Officer | Family Medicine Residency of Idaho, Boise, Idaho Clinical Professor of Family Medicine | University of Washington School of Medicine Past President and Past Chairman of the Board | American Academy of Family Physicians Co-Chair, Center on Care Delivery and Integration | Patient Centered Primary Care Collaborative Board Member | Accreditation Council for Graduate Medical Education Chairman | Idaho Healthcare Coalition Member | Council of Graduate Medical Education

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness.” Charles Dickens

Major U.S. Health Care Problems 28.5 Million Uninsured* (Down from 18% to 9%) Wrong Focus Disease Instead of Health Wrong Delivery Model Not Enough PCP’s Poor Access Staggering Costs Quality Problems Health Care Insurance Problems SOURCE: Kaiser Family Foundation Key Facts about the Uninsured Population, September 2016. http://files.kff.org/attachment/Fact-Sheet-Key-Facts-about-the-Uninsured-Population

In An Average Month: White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025.

$3,000,000,000,000

National Health Spending in Billions Note: Selected rather than continuous years of data are shown prior to 2000. Years 2015 forward are CMS projections. Source: Office of the Actuary in the Centers for Medicare & Medicaid Services. 7/14/2016. cms.gov

Health Spending Everything Else

Pinball

The goal of policies and environmental change work, whether it is to improve PANT, or to provide access to clean water, uncontaminated foods, safe sex practices, immunizations or disaster ready communities- we collectively tackle 70% of factors that contribute to health by making health the default (or the healthy choice the easy choice). Policy and environmental change are about access.

Actual Causes of Death in the U.S. McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12. Mokdad AH, Marks JS, Stroup DF, Gereberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Preventable Causes of Death 3-4-50 Three Behaviors: Physical Inactivity Poor Nutrition Tobacco Use Four Chronic Diseases: Cancer Heart Disease and Stroke Pulmonary Disease Diabetes Fifty Percent of Deaths Three behaviors: physical activity nutrition tobacco Four chronic diseases: cancer, heart disease and stroke, pulmonary disease and diabetes Fifty percent of deaths worldwide Top two leading causes of preventable death- physical activity and nutrition (obesity) and tobacco

“Insanity: Doing the same thing over and over again and expecting different results.” Albert Einstein

“Nobody knew health care could be so complicated.” Donald Trump February 28, 2017

What Improves Health Care Outcomes the Most! Some type of insurance coverage. A usual source of care. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance, Lisa A. Cooper and Neil R. Powe, The Commonwealth Fund, July 2004

Triple Aim Better Health Better Health Care Lower Cost

The Quadruple Aim Better Health Better Health Care Lower Cost Joy of Practice

Patient Centered Medical Home Place Process

The Essential Nature of Primary Care Greater Access to Needed Services Better Quality of Care A Greater Focus on Prevention Early Management of Health Problems Cumulative Effect of Primary Care to more Appropriate Care Reducing Unnecessary and Potentially Harmful Specialist Care Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

The Essential Nature of Primary Care (cont’d.) Decreased Morbidity and Mortality More Equitable Distribution of Health in Populations Lower Cost of Care Better Self-Reported Health Primary Care Physicians achieve Better Outcomes than do Specialists at much Lower Costs Increasing the Number of Specialists is Associated with Lower Quality, Increased Cost, Increased Morbidity, and Increased Mortality Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

Primary Care = Quality

Primary Care = Lower Cost

Increased Specialty Care = Worse Quality

Increased Specialty Care = Higher Cost

Increased Generalist Care = Higher Quality

Increased Generalist Care = Lower Costs

The Medical Home Neighborhood Systems Level

Innovation in Delivery Systems Level ACO Accountable Care Organizations

Symphony of Care

“If you want to go fast, you go alone “If you want to go fast, you go alone. If you want to go far, you go together” African Proverb

Patient Centered Medical Home Place Process

Shared Principles of Primary Care Person and Family Centered Continuous Comprehensive and Equitable Team-Based and Collaborative Coordinated and Integrated Accessible High Value Source: Patient Centered Primary Care Collaborative. 2017

Primary Care is a Team Sport

Why will many of the Provisions of the ACA and future Republican efforts move forward? Republicans and Democrats Agree >80% Lower Cost Improved Quality Greater Access Better Prevention and Wellness Importance of Primary Care Patient Centered Medical Home Can’t Afford Not To

What May Trumpcare/Ryancare Look Like? Repeal and Replace Health Savings Accounts (HSA’s) High Risk Pools Medicaid Block Grants Medicare Privatization? Medication Cost Control – Medicaid and Medicare Primary Care / PCMH – Still Important More Austere 24 Million More Uninsured Others

www.fracturedhealthcare.com www.amazon.com

Summary The Essential Role of Primary Care in a Rapidly Changing Health Care Environment Much Turmoil in Trying to Figure out Healthcare Expense of Healthcare Killing the Country Primary Care is Fundamental to America’s Health Care Success Triple Aim – Nation’s Strategy Integration not Fragmentation Teams Passing the Ball Leveraging Technology Person-Centered Care Complicated and Complex Work Right Direction; Right Thing to Do Trump/Administration – Wildcard How much horsepower will continued Republican efforts to repeal and replace have?

“America will always do the right thing, after it tries every other option!” Winston Churchill

“Never, never, never, give up.” Winston Churchill

Questions and Discussion