Paper by Paul Grundy, Senator Kay R. Hagan, AARP President Jennie Chin Hansen and UCSF Dept of Family Med chair Kevin Grumbach on the moment to transform Primary care using the joint principles of the PCMH

1. Urgency Of Problem
By Paul Grundy, Kay R. Hagan, Jennie Chin Hansen, and Kevin Grumbach
doi: 10.1377/hlthaff.2010.0084
The Multi-Stakeholder Movement
HEALTH AFFAIRS 29,
NO. 5 (2010): –
©2010 Project HOPE—
The People-to-People Health
For Primary Care Renewal Foundation, Inc.
And Reform
Paul Grundy (pgrundy@us.ibm
.com) is global director of
ABSTRACT A multi-stakeholder movement for primary care renewal and healthcare transformation at
reform has emerged in the United States, out of recognition that the IBM in Somers, New York.
achievement of an efficient, effective, and sustainable health system
Kay R. Hagan is a Democratic
requires a vibrant primary care sector. We describe the case for reform U.S. senator representing
North Carolina.
from the perspective of private purchasers, government, consumers, and
clinicians; the principles around which these stakeholders have coalesced; Jennie Chin Hansen is the
outgoing president of AARP
the groundswell of primary care reform initiatives taking place across the
and the incoming chief
country; and the prospects for this coalition to reshape the character of executive officer of the
American Geriatrics Society,
U.S. health care on a stronger foundation of primary care. both in Washington, D.C.
Kevin Grumbach is professor
and chair of the Department
of Family and Community
Medicine, University of
T
he nation’s approach to delivering According to Jennifer Baron and Alexander
California, San Francisco.
health care is inefficient, ineffec- Muggah of the Institute for Strategy and Com-
tive, and unsustainable. For indi- petitiveness at Harvard Business School, “Em-
vidual patients seeking care as ployees and their families who lack effective
well as for large companies trying primary care, prevention, and chronic disease
to stay competitive and create jobs in the United management often cannot be productive mem-
States, health care costs too much and offers too bers of the workforce.”4 Avoidable hospital ad-
little value in return. Government and private- missions for asthma and diabetes complications
sector purchasers of health care are demanding are more than two times more prevalent in the
systems of payment and practice reorganiza- United States than the average among the thirty
tion that promote the comprehensive, patient- countries in the Organization for Economic Co-
focused primary care that beneficiaries and em- operation and Development (OECD). These
ployees require. They are launching primary care higher rates of admission are not explained by
initiatives across the nation to achieve this goal, a higher underlying prevalence of asthma and
often with consumers as active partners. They diabetes in the United States. What’s more, a
are finding primary care clinicians receptive to person with diabetes is twice as likely to undergo
the challenge of creating high-performance a lower-extremity amputation in the United
models of primary care. States as is a diabetic in other developed nations.
The OECD concludes, “The United States does
not do well in preventing costly hospital admis-
The Case For Primary Care Renewal sions for chronic conditions, such as asthma or
And Reform complications from diabetes, which should nor-
Private Purchaser Perspective Large employ- mally be managed through proper primary
ers seek to buy comprehensive, coordinated, care.”5
integrated, accessible health care for their em- Large employers are becoming vocal in artic-
ployees. Instead, what they tend to find is epi- ulating their desire for a more primary care–ori-
sodic, uncoordinated, fragmented, specialty- ented model of care. J. Randall MacDonald,
focused care that seeks to reap rewards from senior vice president for human resources of
costly, specialized medical procedures.1–3 the IBM Corporation, was invited to testify at
M AY 2 01 0 2 9 :5 HEA LT H AF FA IR S 1

2. Urgency Of Problem
the 29 April 2009 House Committee on Ways and care. Sen. Orrin Hatch (R-UT), at a Senate Fi-
Means hearing, “Health Reform in the 21st Cen- nance Committee hearing in April 2009, stated,
tury.” IBM covers more than 450,000 employ- “The U.S. is first in providing rescue care, but
ees, dependents, and retirees in the United this care has little or no impact on the general
States, at a cost of $1.3 billion in 2008. population. We must put more focus on primary
The committee asked MacDonald what he con- care and preventive medicine. How do we trans-
sidered the single most important repair to the form the system to do this?”8 President Barack
health care system. He replied, “Strengthen pri- Obama shared similar concerns at a White House
mary care—transform it and pay differently us- forum, declaring, “We’re not producing enough
ing a model like the patient-centered medical primary care physicians.”9 Building an effective
home.” When MacDonald was asked to identify primary care workforce subsequently became
the next most important issue, he answered, “If one of the key recommendations for health
you don’t fix the first issue and do not have reform from former Senate Majority Leaders
a foundation of powerful primary care, then Howard Baker, Bob Dole, and Tom Daschle.10
you can do nothing else. …Primary care is foun- In drafting health reform bills in 2009, legis-
dational, but we need it to be smarter, with lators in the House and Senate included a variety
the tools and payment reform to allow it to be of measures to strengthen primary care, such as
better integrated, continuous, coordinated, and increases in Medicare and Medicaid fees for pri-
comprehensive.”6 mary care, medical home demonstration pro-
IBM has been a leader among U.S. corpora- grams, increased funding for National Health
tions in demonstrating its willingness to invest Service Corps primary care scholarships and
in revitalization of primary care. It has piloted loan repayment, incentives for recruiting stu-
new approaches to supporting and paying for dents into rural medicine, and a primary care
primary care with its contracting health plans; extension program to support practice improve-
made primary care visits and preventive services ment.With the enactment of health reform legis-
free of any cost sharing under its self-insured lation in March 2010, those steps now have the
plans; and spearheaded a national coalition of force of law behind them.
purchasers, provider organizations, and con- ▸▸ STATE GOVERNMENTS : State governments
sumer groups in the form of the Patient-Centered also have been spearheading innovations in pri-
Primary Care Collaborative. mary care. A leading state-level model is Com-
Government Perspective Public purchasers, munity Care of North Carolina. This program
contending with the same issues confronting links Medicaid and Children’s Health Insurance
private purchasers, are also leading initiatives Program (CHIP) enrollees to community-based
to invest in and redesign primary care. The na- primary care medical homes; provides technical
tion’s lagging clinical outcomes and high rates of assistance to improve chronic care; and employs
avoidable hospitalizations for patients with nurses, mental health workers, pharmacists, and
chronic conditions are particularly salient to other health professionals to collaborate in case
public purchasers. This is the case because pro- management for high-risk patients. In addition
grams such as Medicare and Medicaid cover a to operating on fee-for-service reimbursement,
disproportionate share of the population with the program pays primary care practices a per
chronic illnesses.7 member per month care coordination fee for
▸▸ MEDICARE : Medicare policies have effects each patient registered with the practice, in
that extend well beyond beneficiaries. Because the amount of $2.50 per month for children
Medicare is the largest single buyer of care, many and $5.00 for aged and disabled patients. Started
companies, such as IBM, buy health care the as a pilot program in 1998, Community Care of
same way Medicare does. Private payers often North Carolina now involves more than 1,300
base their physician fee schedules on the Medi- community-based practices, 4,500 primary care
care resource-based relative value scale, thereby clinicians, and 970,558 enrollees throughout
extending the widening gap in Medicare com- North Carolina. Evaluations have documented
pensation for primary care and specialty serv- that this model has improved quality and saved
ices. Medicare is also the dominant source of the state $400 million in 2008.11,12
funds for residency training, providing nearly Consumer Perspective Consumers experi-
$9 billion annually to hospitals for graduate ence frustration and adverse health outcomes
medical education with few requirements about as a result of fragmentation of care and difficulty
the distribution of funded residency positions gaining access to primary care. “Where Have All
between primary care and specialty fields. the Doctors Gone?” queried a headline in the
▸▸ FEDERAL GOVERNMENT : One of the few 2 September 2008 issue of AARP Today, relating
areas of bipartisan agreement in health reform the plight of seniors unable to find a primary care
has been to place more emphasis on primary physician.13 A Harris poll from that same month
2 H E ALT H AF FAI RS M AY 2 0 1 0 2 9 :5

3. found that 67 percent of U.S. adults rated as The Commonwealth Fund survey also impli-
extremely or very important “the ability to have cates U.S. primary care clinicians for not having
a relationship with a doctor who takes a whole- taken more ownership of improving aspects of
person approach to patient care (social, mental care more directly under their control. Only
and physical care) and who provides care for all 29 percent of U.S. primary care physicians re-
levels of health.”14 More than half, or 56 percent, ported that they had after-hours arrangements
reported “difficulty navigating the healthcare for their patients “to see a doctor or nurse with-
system for themselves and/or their family out going to the [emergency room].”17 The
members.” United States ranked the lowest among the
Testifying at a May 2009 Senate Finance Com- eleven nations surveyed on this metric.
mittee hearing, AARP president Jennie Chin Primary care physician organizations have en-
Hansen stated, “Effective practice models that dorsed getting their own medical house in order.
emphasize, encourage, and improve primary The American Academy of Family Physicians’
care should be expanded and incentives should Future of Family Medicine project called for
be created to encourage individuals to practice in new models of practice.18 The academy invested
primary care. …Strengthening the primary care resources to develop the TransforMED center to
workforce is an essential part of ensuring the facilitate and provide technical assistance for a
provision of quality affordable health care for national demonstration project of practice trans-
all.”15 formation. Other primary care physician organ-
There is an urgent need for solutions as access izations have mounted their own primary care
issues become more visible. More than thirty improvement programs.
consumer organizations, including AARP, the
AFL-CIO, Consumers Union, Families USA, the
NAACP, and the National Partnership for Building A Coalition For Renewal
Women and Families, have endorsed a statement And Reform
of principles, titled “The Medical Home from the Purchasers, consumers, and clinicians are form-
Consumer’s Perspective.”16 ing a coalition to renew and reform primary care.
Primary Care Clinician Perspective Pri- They are motivated by the shared beliefs that
mary care clinicians often feel undervalued primary care is vital to a well-functioning health
and overwhelmed. They experience a paradox: system and that the traditional focus of primary
Primary care is more important than ever in the care—care that is accessible, comprehensive,
twenty-first century, but the approach to deliv- and integrated and that fosters a healing rela-
ering it is stuck in the early twentieth century. A tionship over time in the context of family and
growing array of evidence-based interventions community—remains just as relevant today for
can be applied in primary care settings to prevent achieving high-value health care as when first
disease, manage chronic illness, and alleviate articulated decades ago.19,20
suffering. At the same time, the coordinating Need For Practice Redesign The call for re-
role of primary care has taken on added value form, and not simply renewal, derives from the
in proportion to the increasing complexity of belief that the form for delivering the traditional,
modern health care. And health information core primary care functions of first-contact
technology (IT) makes possible new ways to accessibility, comprehensiveness, coordination,
communicate with patients over space and time, and continuity must be retooled in the context of
integrate care, and measure and manage the care twenty-first-century health care. Dysfunctional
of a defined population of patients. practice models must be redesigned to better
Despite these advances, investment in primary meet the needs of patients and primary care cli-
care has lagged in the United States. This inat- nicians alike.
tention is seen not only in the widening gap in For example, primary care practices must
earnings between primary care physicians and adopt new methods to promote access, such as
specialists, but also in the undercapitalization of same-day “open access” appointment systems, as
primary care practices. A 2009 Commonwealth well as Web portals for secure e-mailing and com-
Fund survey found that fewer than half of pri- munication of laboratory results. The achieve-
mary care physicians in the United States had an ment of comprehensive, coordinated care for
electronic health record in their offices, com- patients with chronic illnesses requires team-
pared with more than 90 percent of primary care based models of primary care that can pro-
physicians in most European nations surveyed. actively intervene to avert deterioration of con-
U.S. primary care physicians were also much less ditions such as heart failure and asthma, activate
likely than their European counterparts to have patients in the self-management of their diabetes
practice teams that included nonphysicians to and other chronic illnesses, and use electronic
collaborate on chronic care management.17 registries to track key clinical metrics.21
M AY 20 1 0 2 9 :5 HEA LT H AFFA IR S 3

4. Urgency Of Problem
New Levels Of Agreement Renewal and re- The Future Of Primary Care Is Now
form of primary care in the United States Across the nation, examples can be found where
requires a new compact among purchasers, con- the future is already here for primary care.
sumers, and clinicians. Purchasers and consum- Whole Child Pediatrics Xavier Savilla oper-
ers must value primary care, invest resources to ates Whole Child Pediatrics near Tampa Bay,
revitalize the primary care infrastructure, sup- Florida, a solo practice providing services in En-
port innovative models of care, and provide glish and Spanish to patients insured by a variety
greater incentives for careers in primary care. of health plans, including Medicaid. Savilla re-
In return, primary care clinicians must accept gards his patients and their families as equal
greater accountability for performance stan- partners in his practice.
dards, be receptive to innovation and practice Whole Child Pediatrics has an electronic
redesign, and embrace a more patient-centered health record with a patient portal, and families
approach.22 Terms such as patient-centered medi- review the medical record at the end of each visit.
cal home and advanced primary care models have Parents of children in the practice serve on an
come into use to convey this spirit of renewal and advisory board for Whole Child Pediatrics. Chil-
reform of primary care.23 dren with asthma monitor their peak-flow tests
Shared Vision The goal of renewal and reform at home in tandem with an Internet-based self-
appear to be in sight, thanks to a shared vision management program. In the past two years,
among stakeholders for the future of primary only one of the asthmatics under Savilla’s care
care, and an unprecedented willingness of stake- has required hospitalization. Family ratings of
holders to work together. The catalyst for this the practice are exceptionally high.27
partnership has been the Patient-Centered Pri- Redlands Family Practice In Southern Cal-
mary Care Collaborative, a coalition of more than ifornia, Redlands Family Practice focuses on pa-
600 organizations, including large employers tients at the other end of the age spectrum. This
such as IBM, Boeing, GlaxoSmithKline, Good- private practice of three family physicians, a
year, and Whirlpool; consumer groups; unions; physician assistant, a registered nurse, and five
primary care clinician organizations; and other office staff was recently profiled in Health Affairs
groups, with a mission to “advance the patient- as a “medical home run” for its ability to improve
centered medical home.”1,24 care while lowering costs.28 Concentrating on
One of the collaborative’s first major achieve- enhanced care for elderly patients with chronic
ments was to overcome the historical divisions illnesses, the Redlands Family Practice model
between primary care specialty groups. In 2007 includes round-the-clock phone access, a team-
the American Academy of Family Physicians, oriented approach, proactive nursing outreach,
American Academy of Pediatrics, American Col- and careful selection of specialists for referral.
lege of Physicians, and American Osteopathic Medical Associates Clinic Of Dubuque In
Association, collectively representing about Dubuque, Iowa, a group of general internists
one-third of U.S. physicians, agreed on a set of working in a 100-physician, multispecialty
joint principles of the patient-centered medical group practice has implemented an innovative
home.25 team model that closely pairs physicians with
The collaborative has subsequently worked registered nurses and licensed practical nurses
to make language in the joint principles more to create practice efficiencies, improve the qual-
inclusive of nurse practitioners, physician assist- ity of physician-patient interaction, and promote
ants, and other nonphysician clinicians, agree- more timely access to care.29,30
ing to support nurse practitioner–led patient- Eleventh Street Family Health Services
centered medical home pilots that conform to Eleventh Street Family Health Services, a
legal and clinical standards.26 nurse-managed, full-service, open-access com-
Through a combination of conferences, re- munity health center, serves residents of four
ports and brochures, technical assistance, advo- public housing developments and the surround-
cacy, and coalition building, the collaborative ing community. Through the practice’s combi-
has played a critical role in advancing primary nation of “one-stop shopping” with state-of-the
care reform. The diversity of its member organ- art disease management protocols, a predomi-
izations gives it a distinctive legitimacy and in- nantly poor and minority urban population has
fluence. Its positions cannot be dismissed as achieved improved hypertension and diabetes
simply those of self-interested professional control.31
groups, or as a one-sided attempt by purchasers Group Health Cooperative Integrated deliv-
and health plans to impose an unpopular organi- ery systems are reengineering primary care on a
zational model on physicians and patients—the broader scale. In 2007 Group Health Cooperative
type of criticism leveled at managed care reforms of Puget Sound piloted an advanced primary care
in the 1990s. model at one of its Seattle sites. It entailed hiring
4 H E ALTH A FFAI RS M AY 2 0 1 0 2 9 :5

5. additional primary care physicians to reduce the demonstration programs.36 The Department of
number of patients cared for by each physician; Defense announced a policy in September 2009
lengthening the duration of in-person visits; requiring implementation of the medical home
using more planned telephone and e-mail en- as a “comprehensive primary care model to im-
counters; building more team-based chronic prove patient satisfaction and outcomes”37 for all
and preventive care; and promoting round-the- members of the military’s health care system.
clock access using modalities such as electronic Community Health Centers Federally
health record patient portals. A twelve-month, funded community health centers have also been
controlled evaluation found that quality and pa- making steady progress in practice redesign,
tient experiences improved, emergency depart- supported in part by Health Resources and Serv-
ment visits and hospitalizations for ambulatory ices Administration (HRSA) initiatives such as
care–sensitive conditions decreased, and physi- health center chronic care collaboratives. In
cian and staff ratings of the work environment December 2009, President Obama committed
improved.32 Group Health is currently spreading funds to support the next level of primary care
this model to all twenty-six of its primary care transformation at these health centers.38
clinics, serving 380,000 patients. Department Of Veterans Affairs One of the
Other Factors These examples represent the least-heralded “big wins” in primary care trans-
innovators and early adopters of new models of formation has been the reorganization of the
primary care. For these types of models to be- U.S. Department of Veterans Affairs (VA) sys-
come the norm, systematic action from payers tem. Although there is widespread recognition
and purchasers is needed to provide the financial that the VA has refashioned itself into a quality
incentives, resources, and technical support to leader, much less appreciated is the instrumen-
drive large-scale transformation of primary care. tal role of primary care in this transformation.
Indeed, payers and purchasers appear to be mov- The VA continues to reorient its delivery model
ing in this direction. More than thirty states have around primary care, investing in the primary
followed North Carolina’s lead in implementing care workforce and ambulatory care facilities
advanced primary care models for their Medicaid and supporting integrated care models with a
and CHIP programs.33 well-functioning electronic health record.39
Private and public payers are beginning to col-
laborate on regional, multipayer projects to
reach a critical mass of practices and the majority Challenges And Opportunities
of the patients in these practices.34 For example, The compelling case for primary care, the devel-
in 2009 the Hudson Valley and Adirondack re- opment of a coalition of diverse stakeholders to
gions of New York embarked on major primary advocate for primary care, the promising exam-
care reform initiatives involving most private ples of innovators implementing advanced mod-
health plans in each region and Medicaid and els of primary care, and the evidence that
including more than 700 primary care clinicians. purchasers and payers are beginning to invest
Health plans and the New York State govern- in more-systematic transformation of primary
ment are supporting the implementation of care all bode well for the renewal and reform
health IT in the participating practices and offer- of U.S. primary care. Will this movement be
ing enhanced care coordination payments to transformative, creating a renaissance in pri-
practices meeting National Committee for Qual- mary care, or will it falter at the stage of early
ity Assurance (NCQA) medical home recognition adopters and demonstrations?
standards.35 Need For More Resources One key driver of
National Health Reform With the enact- sustained change will be the dedication of more
ment into law of comprehensive health reform resources to primary care, to increase primary
in March 2010, the federal government’s engage- care compensation and to support and reward
ment in primary care renewal is likely to be enhanced models of primary care. Concerns
intensified. The American Recovery and Rein- about the high costs of health care in the United
vestment Act (ARRA) of 2009 provided as much States are likely to make this a zero-sum game for
as $29 billion in health IT funding by 2016. It also the most part. Many purchasers and payers ex-
targeted a substantial amount of these funds to pect that there will be offsetting savings in other
assist primary care practices in purchasing elec- health sectors for the additional investments
tronic health records and achieving meaningful made in primary care. However, this expectation
use of this technology. will present political and policy challenges. A
In September 2009, Health and Human Serv- recent Medicare fee schedule revision that mod-
ices Secretary Kathleen Sebelius announced that estly increased primary care fees and reduced
states could petition to have Medicare partici- fees for imaging and certain procedural services
pate in state-based, multipayer, primary care in cardiology and other fields was greeted
M AY 20 1 0 2 9 :5 HEA LT H AFFA IR S 5

6. Urgency Of Problem
warmly by primary care specialty societies but to other reforms, such as accountable care or-
was roundly criticized by several specialty soci- ganizations, to reorient incentives and values
eties. The recently enacted health reform legis- across all health care tiers.40
lation will also boost payment for primary care Questions also remain about whether wide-
under both Medicare and Medicaid. But how spread transformation can occur across the
much further policy makers will push to revalue small, independent offices and clinics where
fees from specialty to primary care remains to be most primary care is delivered in the United
determined. States.41,42 Currently, successful scaling-up of
Short-Term Savings In addition, many pub- new models of primary care is largely happening
lic and private purchasers that have agreed to pay in integrated delivery systems. In nations with
more for medical home pilot programs have robust primary care systems, single-payer or co-
done so with the expectation that these pro- ordinated all-payer systems have provided a
grams will yield a short-term return on invest- means of implementing systematic reform of
ment, in the form of reduced expenditures for primary care, such as systemwide rollout of elec-
emergency department visits and hospitaliza- tronic health records and payment reforms. The
tions. Although some of the early programs have more diverse payment and delivery systems in
shown such favorable results,32,34 many primary the United States make implementing such
care advocates believe that the economic benefits broad transformation more difficult.
of primary care accrue over the long term. They Importance Of Primary Care Despite these
say that it is unrealistic to expect primary care challenges, a consensus has emerged that pri-
reforms to yield short-term savings from year to mary care is “too important to fail.”43 The goal
year in the face of the many inflationary pres- of a more affordable, effective, equitable, and
sures affecting the health system. There is worry sustainable health system for the American peo-
that purchasers’ enthusiasm for primary care ple cannot be achieved without renewal and re-
reform will wane if short-term savings fail to form of primary care. Talk about the importance
materialize. of primary care is hardly new in the United
Better Medical ‘Neighborhood’ There is States, yet the nation’s health system has been
also concern that even the best medical home remarkably resistant to past efforts to reshape it
might not achieve its promise of better health on a solid foundation of primary care. The
care value if located in a medical “neighborhood” unprecedented coalescing of diverse stakehold-
of hospitals and other provider organizations ers around a forward-looking vision of revital-
that resist integration of care and responsible ized primary care augurs well for a far different
stewardship of health care resources. In that outcome than in the past. ▪
case, primary care renewal may need to be linked
NOTES
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M AY 2 0 1 0 29:5 H E ALT H AF FAI RS 7

8. Urgency Of Problem
ABOUT THE AUTHOR: PAUL GRUNDY
problem in not demanding systems of for International SOS, the world’s
payment and practice organization largest medical assistance company,
that encourage and enable the and for Adventist Health Systems, the
accessible and coordinated patient- second largest nonprofit medical
focused primary care we desire,” he center in the world. He went to
Paul Grundy has says. medical school at the University of
helped IBM lead the “There is no money paid for the California, San Francisco, and trained
way in transforming necessary investments in teams and at the Johns Hopkins University.
the health care
health information systems,” Grundy The son of Quaker missionaries, he
system.
continues. “Current payment methods grew up “in the poorest country in the
As global director of healthcare reward medical procedures and world—Sierra Leone,” he says. “This
transformation at IBM, Dr. Paul Grundy discourage spending time with upbringing helped instill in me a need
is trying to shift health care delivery patients in such essential activities as to stand up for transformation.”
around the world toward consumer- history-taking, diagnosis, and Individuals and small groups can
focused, primary care–based systems. prevention. This must change.” change history by practicing the laws
Yet his father’s death last year A social entrepreneur and speaker of social change—such as sharing a
brought home to him “why I fight so on global health care transformation, common purpose or intent.”
hard to change what we buy for our Grundy, 58, is president of the To Grundy’s way of thinking, in
employees, our parents, our children. I Patient-Centered Primary Care health care “less is often more.” At
saw how my father’s primary care Collaborative—a coalition he led IBM least the uninsured, he says, are
physician—based on how she was in creating in 2006, one dedicated to protected from unnecessary surgery,
paid—lacked the incentive and the advancing a new primary care model or other forms of overtreatment and
ability to coordinate my father’s care. called the patient-centered medical toxic care that the current health care
So much was done to him and not for home. He is an adjunct professor at system encourages. “The terrible truth
him. We can do better.” the University of Utah’s Department is that you can no longer count on the
IBM has led the way for other of Family and Preventive Medicine. professionalism of the doctor to do
corporations to transform the health Before joining IBM in 2000, Grundy the right thing. If money can be made
care system, after concluding that “we was a senior diplomat in the State off your body, most likely it will be.”
the buyers have been part of the Department and the medical director
8 H E ALT H AF FAI RS M AY 2 0 1 0 2 9 :5