1. Primary Care In Healthcare Reform The Innovator’s Opportunity United Health Care October 5, 2010 Sue Houck Houck & Associates, Inc Boulder, CO

2. Request Reconsider sacred cows

3. Less Waste, More Shared Savings “In return for a share of whatever savings they achieve, physicians and hospitals will have to reduce waste… The ACO model is set up to gradually transfer more financial risk to providers, forcing doctors to become more efficient. ” New Payment Models: What They Could Mean to Doctors Part 1: Accountable Care Organizations. Medscape Business of Medicine

4. What Innovative Providers Do 1. Resources generate value 2. Simplify 3. Culture shift

5. 12345678 Make appointment Register Vitals & history Physical exam Discuss Dx & Rx Health education Document Diagnostic & Lab 1. Resources Generate Value Patients are most satisfied with medical visits in which they talk about their specific treatment, are examined, and receive health education. There was a negative relationship with time spent on history taking. The Influence of Physician Practice Behaviors On Patient Satisfaction. Fam Med. 1993 Jan;25(1):17-20.Robbins, JA, Bertakis, KD, Helms, LJ, Azri, R, Callahan, EJ, Creten, DA

6. 12345678 Make appointment Register Vitals & History Physical exam Discuss Dx & Rx Health education Document Diagnostic & Lab Automate, delegate, streamline M A X I M I Z E Automate, delegate, streamline 1. Resources Generate Value

7. GreenField Health in Portland, OR combines e-mail care with e-visits and an interactive website. The innovative practice now does 40% of patient interactions through web messaging, 40% via telephone and only 20% via traditional office visits. Total costs of care are 20% less than national average. 1. Resources Generate Value Could focus on 1:1 physician office visits actually limit primary care supply and innovation? Blood pressure check Physical Sore throat Poorly controlled diabetes Conjunctivitis

8. Non-physician work delegated MD:FTE clinical staff: 3.5 vs. 1.56 Same day access to own provider Near top of 200+ physician group for NCQA's Heart Stroke Recognition Program Patients likely to return >95% 2. Simplify Peter Anderson, MD

9. “I got my professional life back and now do only the work that only I can do as a physician. The nurses are happier because they have a lot more responsibility” “My patients love that I’m available when they want to be seen and am not distracted with administrative tasks or entering data into a computer.” 2. Simplify Peter Anderson, MD

10. 3. Culture Shift Beyond our social contract to avoid risk A new kind of leadership Patients as core resource

11. Inventive Leadership Director of Epidemiology, Rika Murthy at Cedars-Sinai was frustrated that after efforts to “catch and award” physician hand washing with $10 Starbucks cards, compliance rose from 65 to about 80 percent-better, but not great. During a Chief of Staff meeting, Murthy gave each attendee a petri dish and cultured their palms. The resulting images, “were disgusting and striking, with gobs of bacteria.” One photograph was made into a screen saver and posted on every Cedars-Sinai computer. Reasons for not complying vanished in the face of vivid evidence. Overnight, hand washing compliance rose to just under 100%.

12. Your uncle, ex-rock star Frank Sweet has well controlled Type II Diabetes and a strong independent streak. He currently averages 5 medical office visits per year and is routinely told to RTC in 3 months. His blood pressure is occasionally elevated and blood sugar well controlled. Frank has never been hospitalized. Frank is also computer savvy and has a Facebook page. Frank’s satisfied with his primary care physician, Ben Francisco but hates the “hassle” of office visits. In the last year he has visits for: conjunctivitis, sore throat, blood pressure check, a physical and diabetes.

13. What Innovative Providers Do Blend office visits and alternatives for Frank T y p e o f V i s i t Reason for visit MD Mid- levelNurseE-visitGroup Self- care Conjunctivitisxxxxx BP Checkxxxxx Sore Throatxxxxx Physicalxx Diabetesxxx Estimated Cost $50.51$23.29$10$7.12$32.450

14. Why Innovate? Sample outcomes A two year randomized clinical trial of 400 patients at the University of Colorado found that group visit patient hospitalizations dropped from 39% to 27% and annual per patient ED visit rates dropped from 53% to 35% In a randomized, controlled trial of patients completing a self-management program, intervention group diabetic patients showed significant reductions in glycated hemoglobin levels. There was also a correlation between the patient’s level of confidence and improved outcomes. In seven studies where nurses conducted planned diabetic care visits, glycemic control improved. The report concluded that nurse can deliver many aspects of diabetes care with protocols and training After almost 40 years of experience and research, NP outcomes in hypertension, diabetes mellitus, asthma, and other health problems are equal to physician outcomes

15. Most improvement to date incremental vs. systematic Reimbursement does not match impact on system costs Impact of vested interests on transforming care Focus on process vs. outcomes Elephant in the Room

16. Beyond Incremental: Primary Care Strategy Map Heal, Enable & Delight Patients Cost-Effectively Every Time Ratio of clinical staff:MD Clinical decisions rely on human memory Patients key team members Memorable service experience Care happens at the office Leverage technology Accountable for value Non-physician tasks delegated low high =Prototype practice =Current state Innovative Practice Current State

17. The fact is that in times of great challenge, it is the learners who will inherit the future; the learned find themselves equipped to live in a world that no longer exists. Eric Hoffer