Presentation by Sheila Richmeier, MS, RN, FACMPE, President & Founder of Remedy Healthcare Consulting
"Think Clinical: Running a More Efficient Practice through Optimal Clinical Operations"
Presentation given at Lawrence Medical Managers meeting June 8th 2011
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Presentation by Sheila Richmeier
1. 6/8/2011
Patient Centered Medical Home
What Does it Mean?
Lawrence Medical Managers meeting
June 2011
Sheila Richmeier, MS, RN, FACMPE
Declining value of primary care
Primary care is in trouble. . . .
• Overwhelming amount of work
• Poor compensation
• Pipeline is drying up
• Aging and sicker population
• Health care costs skyrocketing
• Quality and coordination lag
• Physician frustration
2010 TransforMED
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2. 6/8/2011
Aging and sicker population
•52% of the American population has a chronic medical
condition
•Number of older people is projected to rise from 31.6 to 65
million from 1990 to 2030
•Lifestyles are having an impact on health like never before
•2/3 of elderly are overweight or obese
•Obesity rates have doubled
• since mid-80s alone
AHRQ Chronic Care
Rising costs
• 52% of US population has a chronic disease
• Individuals with chronic illness account for 80% of health care
spending
▫ 75% of every dollar
▫ 83% of every Medicaid dollar
▫ 99% of every Medicare dollar
• Life style is having an impact on health
▫ 2/3 of elderly are overweight or obese
▫ Obesity rates have doubled since mid-80s
▫ Obesity is responsible for 1/3 of the growth of health care
spending
Hitting the “Bulls-eye” in Health Reform
• Increasing Prevalence of Chronic Conditions and
Increasing Costs
Prevalence of Chronic Conditions Cost of Specific Chronic Conditions
Chronic Condition Prevalence Annual Cost
180 49%
Cardiovascular Disease 80 million $475.3 billion (includes both
170 48% direct and indirect costs)
160 157 Diabetes 23.6 million $116 billion of direct healthcare
47% costs
149
150 $58 billion in indirect costs/ lost
141 46%
productivity
140 133
45%
125 Asthma ~20 million $18.3 billion, including direct
130 healthcare costs (10.1 billion)
118 44% and indirect costs/ lost
120 productivity (8.2 billion)
43%
110 Depression 20.9 million ~$100 billion of direct healthcare
100 42% costs (across all mental
illnesses)
90 41% ~$79 billion in indirect costs/ lost
productivity (across all mental
80 40% illnesses)
1995 2000 2005 2010 2015 2020
2010 TransforMED
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3. 6/8/2011
Frustration
Value of primary care
• Easily accessible first contact with the
health care system
• Comprehensive care for all health related
situations regardless of age or sex
• Coordination and integration of care across
settings
• Personal relationships over time through
partnerships in the context of family and
community
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Easily accessible
• Time • Availability
▫ Office hours ▫ Language barriers
▫ Same day access ▫ Transportation
• Location problems
• Delivery
▫ In person
▫ On phone
▫ Interactive websites
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4. 6/8/2011
Timely access Percent reporting that it is very difficult/difficult:
30
73% of Americans report
having difficulty in
obtaining timely access
41
to their doctor
60
73
0 25 50 75 100
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
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11
After hours care without ER visit
Percent reported very/somewhat difficult getting care on nights,
weekends, or holidays without going to ER*
100
75 65 68
59 63 63
57
50 45 43
38 38
33
25
0
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
* Base: Needed care and answered question.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
2010 TransforMED
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Emergency Room Use in Past Two Years
Percent Any ER use Used ER for condition treatable
by regular doctor, if available
75
50 44
35 37
33
27 29
26 26 25
25 22 22
16 15
10 10 8 12
7 9 7
5 5
0
TH
NZ
N
R
R
H
NZ
N
R
FR
R
S
UK
E
FR
S
IZ
UK
US
E
IZ
US
SW
GE
T
SW
AU
CA
GE
NO
AU
CA
NO
SW
SW
NE
NE
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
2010 TransforMED
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5. 6/8/2011
Growth of Retail Clinics, Year End 2005–2007
Number of retail clinics
900
1000 800 30 states
23 states Dec. 07
800
Dec. 06
600
400
200 60
18 states
Dec. 05
0
2005 2006 2007
Source: Interview with Mary Kate Scott, principal of Scott & Company, July 2008.
%
80 Retail clinic choices
64 62
60 53
48
40 34
20
0
Clinic hours Location Did not have Cost was Did not have
were more was more to make an lower than a usual
convenient convenient appointment another source of care
than another than another for a source of care
source of care source of care retail clinic
Notes: Categories are not mutually exclusive; respondents were able to select multiple categories.
Source: Center for Studying Health System Change 2007 Health Tracking Household Survey, April 2007–January 2008.
Traditional Model New Model
• Unnecessary barriers to access • Same or next day access by
by patient patients
• Monday through Friday • After hours and weekend care
9–5 • Alternate means of
• In person visit only communication
• Primary care physician could ▫ Interactive website
not see you ▫ Phone triage and follow-up
• Same physician or team sees you
every time
• Alternate visit types
▫ Group visits
▫ e-visits
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6. 6/8/2011
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Comprehensive
• Whole person care • Quality versus
• Population quantity
management
▫ Preventive
▫ Chronic disease
management
• Non-differentiated
care
• Often birth to death
• Evidence based
Traditional Model New Model
• Event – based medicine • Continuous healthcare
• Experience based
• Quality improvement
▫ Docs with the most
experience are the best ▫ Patient experience survey
docs ▫ Provider satisfaction survey
▫ Employee satisfaction survey
▫ Clinical outcome
measurement
▫ Financial outcome
measurement
▫ Study and planning of results
• Evidence based
▫ Evidence based guidelines
▫ Clinical outcomes reported
Traditional Model New Model
• Reactive management of • Pro-active population
patients’ preventive and management for chronic and
chronic care preventive care
▫ Patient makes appointment ▫ Anticipate needs of patients
when needed prior to visit
▫ Acute chronic is managed in ▫ Pre-visit planning
hospital setting ▫ Management of high acuity
▫ High acuity patients are patients more intensely
known as “frequent flyers” ▫ Overall better management
of chronics
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7. 6/8/2011
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Coordination of care
• Emphasis on • Tracking & follow-up
communication ▫ Referral tracking
▫ With patient /family ▫ Test tracking
▫ Across settings • Medical neighborhood
• Facilitate transitions
▫ Information
▫ Accountability
• Community resources
▫ Home health
▫ Nursing homes
▫ Health departments
2010 TransforMED
Medicare re-hospitalization rates
JAMA
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8. 6/8/2011
Traditional Model New Model
• Proactive transitions of care
• Reactive coordination of care
between hospitals and primary
• Referral specialists taking care
over care
▫ Patients are pro-actively
• Patient goes to specialists as called after hospitalization
needed
• Agreement on roles &
responsibilities between
specialists and primary care
• Referral and test tracking
• PCP coordinates all care
outside office
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Relationship
• Personal physician • Continuity
▫ Increased efficiency
• Team assigned to care
▫ Better quality
• Long term
• Communication
▫ For patient
engagement
▫ For patient education
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9. 6/8/2011
Traditional Model New Model
• Physician is the main • Multidisciplinary team is
source for care the source of care
▫ Each member
participates in the care
▫ Each member has a
role
▫ All members
understand each
others’ roles
Traditional Model New Model
• Patient engagement
• Communication as
▫ Giving test result
needed with patients – numbers
sharing only need to ▫ Giving patients
know information information resources
• Directive communication ▫ Knowledge by patient
about internal and
external team members
• Collaboration
▫ Patients receive care
plan at each visit
▫ Patient is part of care
team helping to make
decisions about care
Goals in running a medical home --
• Good quality outcomes
• Good financial outcomes
• Good satisfaction outcomes
2010 TransforMED
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10. 6/8/2011
Satisfaction outcomes
• Happy docs
• Happy staff
• Happy patients
Medical home concepts - Access, patient centered care,
team based care
2010 TransforMED
Financial outcomes
Internal Health care system
• Salaries • Hospitalization
• Revenues • Re-hospitalizations
• Profit margin • Use of generic drugs
• Bonuses • Complications in
• Cost of unit of service surgery
• ER utilization
Medical home concepts - Care coordination, access,
sound practice management, health information
technology
Quality outcomes
Chronic disease Population
management management
• Disease specific • Preventive medicine
▫ Diabetes ▫ Cancer screening
▫ Hypertension ▫ Immunizations
▫ Coronary heart • High risk behaviors
disease ▫ Obesity
• High users of the system ▫ Smoking
▫ Child safety
Medical home concepts - Care management,
health information technology, care coordination
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What comes first?
Where is medical home?
• PCMH demonstrations rollout in every state except
Alaska.
• Medicare Advanced Primary Care demonstration.
• Federal departments and agencies establish PCMH as
the foundation for national transformations:
▫ Department of Defense
▫ Department of Veterans’ Affairs
▫ HRSA
2010 TransforMED
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12. 6/8/2011
2010 TransforMED
Get started. . . .
"In order to succeed, your desire for success
should be greater than your fear of failure.“ --
Bill Cosby
"The problem in my life and other people's lives is
not the absence of knowing what to do, but the
absence of doing it.” -- Peter Drucker
2010 TransforMED
Questions
Sheila Richmeier, MS, RN, FACMPE
sheila@remedyhc.com
Remedy Healthcare Consulting
www.RemedyHealthcareConsulting.com
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