1. 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

2. “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

3. 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.

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

6. $3,000,000,000,000

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

8. Health Spending Everything Else

10. Pinball

11. 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.

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

13. 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

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

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

16. 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

17. Triple Aim
Better Health
Better Health Care
Lower Cost

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

19. Patient Centered Medical Home
Place
Process

20. 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) )

21. 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) )

22. Primary Care = Quality

23. Primary Care = Lower Cost

24. Increased Specialty Care = Worse Quality

25. Increased Specialty Care = Higher Cost

26. Increased Generalist Care = Higher Quality

27. Increased Generalist Care = Lower Costs

28. The Medical Home Neighborhood Systems Level

29. Innovation in Delivery Systems Level
ACO
Accountable Care Organizations

30. Symphony of Care

31. “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

32. Patient Centered Medical Home
Place
Process

33. 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

34. Primary Care is a Team Sport

35. 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

36. 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

37. www.fracturedhealthcare.com www.amazon.com

38. 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?

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

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

41. Questions and Discussion