1. Financing Primary Care – The Best of Times The Patient-Centered Medical Home Summit Washington, D.C. October 17, 2008 Roger C. Merrill, M.D., Chief Medical Officer

2. Financing Primary Care – The Best of Times Agenda 1.The Value Proposition: health conveyed per dollar spent 2.The Perdue Experience 3.NBGH Primary Care Work Group product 4.Caution: Do Not Enter the Weird Zone!

3. Financing Primary Care – The Best of Times USA – Cost vs. “Product” Cost/ Intensity of Service Health Status There is a relationship between cost And health status improvement:

4. Financing Primary Care – The Best of Times The solution? Chicken!!

5. Financing Primary Care – The Best of Times The Perdue Experience  On-site primary clinics (called Wellness Centers) which serve as medical home oVisits are on the clock, minimal payroll-deducted co-pay, clinics operate during all production shifts. oGoal is health improvement in a longitudinal model

6. Financing Primary Care – The Best of Times The Perdue Experience  Physician contracting in owned, direct networks. oThis allows us to have efficient networks, yet establish PCP reimbursement at the highest level vs. other payers in each geographic area. oWe want our docs to smile when a Perdue patient comes into the office. oWe ask our PCPs to be Marcus Welby, managing each case whatever the outside service requirements.

7. Financing Primary Care – The Best of Times The Perdue Experience

8. Financing Primary Care – The Best of Times The NBGH Primary Care Work Group Conclusions  Increasing PCP reimbursement is an appropriate goal or tool.  20% payment increase for primary care = 1% total increased Plan spend  Reimbursement changes must be overall cost neutral

9. Financing Primary Care – The Best of Times The NBGH Primary Care Work Group Conclusions  This neutrality will be gained through more efficient use of expensive services, not via price concessions from facilities and specialists.  There must be a quid pro quo for any increase in payment

10. Financing Primary Care – The Best of Times Caution: do not enter the Weird Zone!  In a time of primary care scarcity, setting a performance bar too high will be counterproductive.  What performance or outcome requirements do we set when new procedures, gadgets, or pharmaceuticals are introduced?

11. Financing Primary Care – The Best of Times Caution: do not enter the Weird Zone!  Does a new stent have to demonstrate lower mortality?  Does a new imaging study prove value by reducing overall cost of a condition?  Does an operative intervention have to prove improved, measurable outcome for it to be covered under a medical plan?

12. Financing Primary Care – The Best of Times Caution: do not enter the Weird Zone!  While we ideally should require such data before coverage is permitted, in fact we do not.  Then it is entirely inappropriate to demand a much higher bar for the most ethical, valuable, and patient-centered members of the medical community in their ministrations to our patients.

13. Financing Primary Care – The Best of Times Agenda 1.The Value Proposition: health conveyed per dollar spent 2.The Perdue Experience 3.NBGH Primary Care Work Group product 4.Caution: Do Not Enter the Weird Zone!

14. Financing Primary Care – The Best of Times The Patient-Centered Medical Home Summit Washington, D.C. October 17, 2008 Roger C. Merrill, M.D., Chief Medical Officer