1) This document discusses lessons learned from primary care innovations and the future direction of primary care transformation. It highlights the importance of primary care in improving access, quality, and reducing costs. 2) Successful primary care models like the patient-centered medical home aim to enhance access, coordination, and continuity of care through a team-based approach. Early results show reductions in hospitalizations and emergency room visits as well as improved quality and patient experience. 3) Widespread adoption of health information technology, payment reform through programs like meaningful use, and multi-stakeholder demonstrations are helping to advance the medical home model. Further work is needed to engage patients and develop sustainable payment and care delivery systems

1. Innovation in Primary Care:
Lessons Learned and
Future Directions
Asaf Bitton MD, MPH, FACP
Associate Physician, Brigham and Women’s Hospital
Instructor in Medicine and Health Care Policy, Harvard Medical School
Assistant Medical Director, BWH Advanced Primary Care Associates
CIMIT Investigator
A*STAR-Khoo Teck Puat Hospital
Forum on Primary Care Transformation
March 23rd, 2012

2. “Every system is perfectly designed to achieve
exactly the results it gets.”
Don Berwick, MD MPP

3. Singapore

4. Cost-Related Access Problems, 2011
Percent of adults who went without care because of cost in past year *
* Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 4

5. A “Perfect Storm”  Unsustainable cost
growth, inadequate quality, fragmented
care, workforce shortage, aging population
Michael Patmas MD, OHSU, 2006

6. Primary Care as a Focus for
Innovation and Systems Change
•Increased access and/or •Decreased
equitable distribution of care health
•Prevention and early expenditures
management of health problems •Equal or better
•Reduction of unnecessary and health outcomes
harmful specialist interventions •Better patient
•Coordination and integration experiences and
across multiple conditions, increased
treatments, and medications satisfaction

7. Primary Care
Primary care is the provision of integrated,
accessible health care services by clinicians who
are accountable for:
 addressing a large majority of personal health
care needs
 developing a sustained partnership with patients
 practicing in the context of family and community
Source: IOM, Defining Primary Care: An Interim Report. 1994.

8. Essential Attributes of Primary Care
First contact care
characterized by:
Accessibility
Whole Person Comprehen-
Orientation siveness
PRIMARY
CARE
Coordination/
Continuity
Integration

9. Health Expenditures:
Generalists and Specialists Compared
Generalist Density and Specialist Density and
Health Expenditures Health Expenditures
Source: Baicker K & Chandra A. Health Affairs. 2004. Web Exclusive. Dartmouth Atlas projects

10. Better Primary Care Associated
with Lower Costs
Primary Care Scores vs. Per Capita Health Care Costs
4000
US
Per Capita Health Care Expenditures
3500
3000
Germany
2500
Canada
France The Netherlands
2000 Japan
Australia Denmark
Belgium Finland
1500 Sweden United
Spain Kingdom
1000
500
0
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
Average Primary Care Score
Source: Starfield B, Shi L. Health Policy. 2002; 60: 201-218.

11. Access to Primary Care
Able to Get Same Day ER Use for Condition Doctor Could
Appointment with Doctor Have Treated if Available
Percent Percent
75 25
55 53 20
49 16
50 15
42 41 15
11
30 9
10 8
25 22 6
5
5
0 0
GER NZ NETH AUS UK US CAN GER NETH UK NZ AUS US CAN
Source: 2007 Commonwealth Fund International Health Policy Survey 11

12. Patients Value Primary Care
Patient Attitudes Towards Primary Care PCP versus Specialist
Physicians and Specialist Use Preference as First-Contact
Physician for Selected Medical
Don’t Know
Agree Disagree
or Uncertain
Problems
(%) (%) Prefer PCP Prefer Specialist
(%)
90
Value having one primary care 80
94 2 4
physician 70
60
50
Values PCP participation in
89 3 8 40
decision to see specialist
30
20
Can decide whether to see 10
PCP or specialist for a new 46 28 26 0
problem for myself Cough and Arthritis in Blood in Stool
Wheezing Knee
Source: Grumbach K et al., JAMA; 281(3): 261-266.

13. Reinventing Our Delivery System
“Current care systems cannot do the job.
Trying harder will not work. Changing systems
of care will.”
Institute of Medicine. Crossing the Quality Chasm. 2001

14. What is a Patient Centered
Medical Home?

15. “Medical Home? That sounds like a
Nursing Home…”
 Patients not aware
 PCMH: different meanings to different stakeholders

16. Invention vs. Innovation
Kitty Hawk, 1903 DC-3, 1935

17. “Home Team, Centered Around the Patient”
Connected
Personal
Physician through HIT
Whole Enhanced
Person Access
Patient
Quality/ Payment
Safety Reform
PCMH Joint
Physician Care
Led Practice Coordination Principles

18. Common Elements of PCMH
 Personal Physician
 Team-based practice
 Expanded access
 Emphasis on coordination of care
 Proactive population health management
 Care facilitation and data analysis with HIT
 New forms of payment
Fields et al, Health Affairs, May 2010

19. Does HIT = Medical Home?
 Necessary but alone not sufficient
 Enables coordinating connections
 Current Needs:
 Robust decision support
 Registry tools
 Tools enabling team function and pt engagement
 Personal health records
Bates D and Bitton A. “The Future of HIT in the PCMH”. Health Affairs. April 2010.

20. Smaller Practices Lag Behind Large
Practices in HIT
Solo practices
100 Small and medium practices (2–9 physicians)
Large practices (10 or more physicians)
75
75
49 50
50
27
25 21
7
0
Use electronic medical records in practice High electronic information functionality*
* To assess HIT multifunctionality, a 14-count scale was developed. The multifunctional HIT capacity summary variable,
counting the number of functions and categorized systems, includes low (0–3), middle (4–8), and high (9–14).
Source: The Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.

21. HITECH: Advancing the Tipping Point
Technology Adoption
National Grant
Coordination Programs
Enhanced Payment
Trust Incentives
2004 2012 TIME
Source: David Bates MD, MSc

22. Spurring Use of HIT
“To increase the effective use of EHRs:
1. Get doctors, hospitals, and other
health care providers to acquire and
use electronic health records.
2. Get those electronic health records to
"talk to one another" by becoming
interoperable.
3. Get providers to use EHRs to improve
quality and efficiency in the provision of
health care services.”
(The Federal Role in Promoting Health Information Technology,
Source: David Bates MD, MSc Commonwealth Fund, 2009)

23. Meaningful Use “Ascension Path”
Certified EHR Required
2009 2011 2013 2015
HIT-Enabled Health Reform
HITECH
Policies
2011 Meaningful
Use Criteria
(Capture/share
data)
2013 Meaningful
Use Criteria
(Advanced care
processes with 2015 Meaningful
decision support) Use Criteria
(Improved
Outcomes)
Source: David Bates MD, MSc Report of sub-committee of Health IT Policy Committee

24. Meaningful Use Incentives
BUT…Penalty of 1%/yr (max 5%)
reimbursement starting 2015

25. TODAY’S CARE MEDICAL HOME CARE
My patients are those who make Our patients are those who are
appointments to see me registered in our medical home
Care is determined by today’s Care is determined by a proactive plan
problem and time available today to meet patient needs without visits
Patients are responsible for A prepared team of professionals
coordinating their own care coordinates all patients’ care
I know I deliver high quality care We measure our quality and make
because I’m well trained rapid changes to improve it
It’s up to the patient to tell us what We track tests & consultations, and
happened to them follow-up after ED & hospital
Focus of the clinic is the doctor’s A multidisciplinary team works at the
needs top of our licenses with a patient focus
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

26. Patient-Centered Medical Homes
Nationwide

27. National PCMH
Demonstration Activity
RI
Multi-Payer pilot discussions/activity
Identified pilot activity
No identified pilot activity – 6 States Source: PCPCC

28. NCQA Recognized Sites, 2010

29. Results for Current National Demos
Practices 4,659
Physicians 14,389
Patients 4,900,000
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.

30. Models for PCMH Payment
 Enhanced Fee for Service (FFS)
 Higher technical fees
 New codes for phone call and emails
 Higher volume with mid-level providers
 Capitation
 Comprehensive Risk Adjusted Payment Model (NY/MA)
 3 part model
 FFS
 Enhanced pay for performance
 Care management fees (per person per month)

31. Payment for Current National Demos
Per Person Per Month (PPPM) Payments 96%
Range of PPPM Payments $0.50 to $9.00
$720 to $91,146
Range of Additional Revenue per MD/yr
(median $22,834)
Upfront or Start-up Payments 42%
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.

32. PCMH Evaluation:
How do you know if this works?

33. Multi-Dimensional Evaluations
Transformation
Efficiency Quality Experience Education
Patient Staff

34. Early PCMH Results
Project Hosp ER Visits Quality Pt Total $ per
Experience patient/yr
Group Health -6% (all) -29% Improved Improved in -$120
Cooperative (WA) -13% (ACSC) 5 / 7 scales
Geisinger (PA) -18% (all) NA NA NA -7% (+5% to -18%)
-36% (re-ad) (Not Stat Significant)
NDP (national) NA NA Improved Slightly *Practice Rev
worse (NS) +2% to 12%
Community Care of -40% NA Improved NA -$516
North Carolina* asthma, DM
Colorado Medical -18% -16% NA NA -$169 (all)
Homes for Children* -$530 (c. dz)
Intermountain (UT)* -5% (all) 0% (all) NA NA -$640
-19% (c.dz) -7% (c.dz)
North Dakota BCBS* -6% -24% NA NA -$530
Vermont Blueprint* -11% -12% NA NA -$215
*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease
NS = not statistically significant re-ad = readmissions

35. Experienced Coordination Gaps in Past Two Years,
by Medical Home
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information
with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 35

36. Medical, Medication, or Lab Test Errors in Past
Two Years, by Medical Home
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 36

37. Patient Engagement in Care Management
for Chronic Condition, by Medical Home
Percent reporting positive patient engagement in managing chronic condition*
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make
treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 37

38. Rated Quality of Care in Past Year as “Excellent" or
“Very Good,” by Medical Home
Patients with a medical home have a regular practice who is accessible, knows them,
and helps coordinate their care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 38

39. Equity-Enhancing Effects
Percent of Adults 18-64 Reporting Having Received Needed
Medical Care, by Racial and Ethnic Group and Source of Care
Medical home
Regular source of care, not a medical home
100 No regular source of care/ER
74 74 76 74
75
52 53 52 50
50 44
38 34
31
25
0
Total White African American Hispanic
Source: Beal AC et al. The Commonwealth Fund. June 2007. Data from Commonwealth Fund 2006 Health Care Quality
Survey.

40. PCMH in Practice:
Brigham and Women’s Advanced Primary
Care Associates, South Huntington

41. Structure: Core Clinical Team
3 Teams:
•1.5 MD
•1-2 Residents
•2 students (MD), and other students (RN)
• 1 Physician Assistant (8 session)
• 1 Licensed Practical Nurse
• 2 Medical Assistants
• 1 Social Worker

42. Structure: Shared Resources
• 1 Medical Director
• 1 Practice Manager
• 1 Pharmacist
• 1 Population Manager
• 1 Nutritionist
• 6 Secretaries (Check-in, Check-out)
• 1 Community Resource Specialist
• 1 Care Coordination RN

43. Local Opportunity for Innovation
 South Huntington as a “learning laboratory” for
team- based practice innovation and training
 Developing new training models
 System-wide transformation:
 60% of practices transform to PCMH by 2013
 100% by 2015
 Docking Platform for Innovative Technology

44. Innovative Primary Care Technologies

45. Moving Outside the PCMH

46. The Medical Neighborhood
 Extends around PCMH
 “Core” and “Peripheral” neighbors
 Varies by community and provider network arrangement
 Requires formal, reciprocal care agreements
 Enhanced by efficient information transfer (HIT)
 Shared risks and incentives for outcomes
 Compatible with different payment structures
 A stepping stone to ACOs
Source: Pham H, Journal of General Internal Medicine, 2010

47. Accountable Care Organizations:
Integration Through Information and Shared Responsibility
HIT Hospital
Sub-Acute
Care
HIT
Sub-specialty PCMH HIT
Sub-specialty “Medical
Home Neighbor”
HIT
HIT Patient-Centered
Sub-Specialty Medical Home
Procedural Practice
HIT
HIT
Source: David Bates MD, MSc and Asaf Bitton MD

48. Accountable Care Organizations
(ACO)
A group of providers that
has the legal structure to
receive and distribute
incentive payments to
participating providers.
48
Source: Premier Healthcare Alliance

49. Vermont Blueprint for Health: Integrating PCMH/ACOs
with Public Health Through Community Care Teams
Prevention
Programs
Policies and Systems
Local, state, and federal; Hospitals
PCMH
economic/cultural; media
PCMH
Community
Community Care Team
Physical, social and cultural Nurse Coordinator
environment Behavioral
Social Workers PCMH
Health &
Dieticians
Substance
Community Health Workers
Abuse
Organizations Services
Care Coordinators
Schools, worksites, faith- Public Health Prevention Specialist
PCMH
based organizations, etc
Public Health Prevention
Relationships
Family, peers, social
networks, associations
Individual Health IT Framework
Knowledge, attitudes,
beliefs Global Information Framework
Evaluation Framework
Source: Craig Jones MD; Director, Vermont Operations
Blueprint for Health, AcademyHealth 2009

50. Centers for Medicare and
Medicaid Innovations (CMMI)
 Genesis / Funding: Affordable Care Act ($10B)
 Framework for Innovation: Demonstrations
 Dissemination: Spread if Certified
 Key Programs:
 Pioneer ACO
 Comprehensive Primary Care Initiative
 Bundled Payments
 Health Care Innovation Challenge

52. Change is Hard
“Possibility derives less from effort than from
redesign”
 Berwick and Luo, 2010

53. Keys to Innovation
 Clear Strategies
 Aligned Incentives
 Trust Across Institutions
 Clear Communication
 Embrace New Thinking
 Tolerate (and even celebrate) Mavericks
 Don’t Focus Next Quarter’s Results Only
 Leadership

54. Coral Reefs  Innovation

55. Kjell Bjartveit
“It can be done”

56. Concluding Thoughts
 Enhancing primary care capacity and function is
key to building a high-performing health system
 The medical home is about improving care through
teams, HIT, and a renewed focus on the patient
 The medical home model is already widespread and early
results are promising
 Innovation is not only about building new
technologies, but also about where to intelligently
deploy them
 Optimism is a strategic imperative

57. Thank You
 Questions?
 Email: abitton@partners.org