dollar is on treatment and care of chronic diseases, about 8 cents of every health dollars on prevention and wellness. one would suggest that if we can actually attack some of the underlying causes of chronic diseases, get up them at a much earlier stage and help the healthier 50 year olds that we will have a very different, not only cost formula in america, the utter health outcomes. bad like to remind people that in spite of the fact that we spend almost twice as much as in a developed country, we live sicker and die younger than most of our competitors around the globe. and that done a very good formula for not only help the nation, but it's not a very good formula frankly for national prosperity. to me it they national security issue that we really have to look at how we actually have a healthier country.

so the initiative in the affordable care act focus on prevention and wellness has been talked about for decades. but he did finally we have an opportunity and a platform to really get serious about them. and it's everything around rewarding providers for keeping their patients healthy in the first place to looking at strategies and models that we know work. we know that there are very promising indicators that the medical home model works and works very well. but again, it takes a team of providers, often not necessarily has to be a physician intervention at all times, but the coordinated care strategies involving the medical teams with nurses with home health workers, with a variety of caregivers to do a brief name or preventive care to follow up care can be

extraordinarily successful. but built around a primary care provider. and we have just recently added medicare to the system of medical homes that have been in place now with private insurers in parts of the northeast and in the colorado area would want to make sure that medicare is also able to participate in those efforts. the affordable care act as susan said that allows us to move forward unaccountable care organizations. ..

another huge investment was made in the recovery act which i think will then help enhance the primary care system is the investment in health information technology. i would suggest that all too frequently primary-care providers are somewhat handicapped in a system without an electronic medical record where there is a in an ability to route we be able to coordinate care from a primary point of view where the car theologist has one set of records and the hospital may

have another set of records that discussion and the deliberation and appropriate treatment is sometimes very difficult. what i hear from providers across the country who have made the shift to the electronic record system is first they would never practice medicine any other way. they would never go back dwinell system in fact i can't imagine how they used to practice without it also the ease with which patients record can be accessed and viewed simultaneously that appropriate treatment decisions can be made and that again i think a primary-care doctor can often stay in place as all important link with steps along the way which is virtually impossible with a paper system. in addition to just shifting to

the electronic records, the goal isn't just to change everything that's on paper and just dump it into a computer and walk away but really to help drive meaningful use at every point along the way so the investments that are being made really also to capture the protocol of meaningful use and again i think it will enhance the role often of the primary-care provider in fuss dream of medical care. americans access to care is often difficult and, you know, when we think about where we are in the lots of other systems it is really ironic that our health care system is so far behind. think about the difference of ten or 15 years ago and the way

that you needed to go access getting cash. you have to wait until the bank opened. you have to have a checking account and show up, make a withdrawal, show and ied and whatever else. the difference now to go to an atm machine not only anywhere in the country but anywhere in the world and put in a four digit pin and assuming you have some resources standing behind for digit pen money will actually come out seven days a week multiple languages in a country. most industries that used enhanced systems to expedite the way they do business. but we have not employed all sorts of technological advances in the delivery of medical care and ironically we are beginning to read experiment with some

systems in place in developing countries but not in america. for instance in a number of pretty primitive areas, salt and technology is being used to keep pregnant women up to date on medical payments because even in a pretty developed nations there are some funds to the coup -- cell phones owned by the population. we don't yet use that and a program being launched right now, the text for baby that is beginning to experiment with just that strategy and under certain neighborhoods to try and give a salles phone to a newly pregnant woman to try to use a very simple text message back-and-forth to remind people about everything from a plant meant to fight against the steps along the way to try to enhance the prenatal services that are

available. seven-up patient friendly services so people can schedule their doctors' appointments online could ask questions back and forth of medical providers could be in touch with providers without offering to take time off work, schedule an appointment, wheat in the waiting room, go into the office, you're ten minutes and have to go home. again the system is beginning to be in place with everything from minute clinics to the telehealth are beginning to establish a footprint and i would say if the potential revolution within the cincinnati children's hospital a couple of weeks ago the outpatient clinic with a mother and her daughter who had some pretty serious health challenges that has had that since birth

and the mother was describing the change in the last two years where she can actually go and access provider information in a dialogue with the series of questions. they do a lot of home testing. she can send the results within 30 minutes and get an answer back about whether or not they need the provider visit or whether or not, you know, it is a change in medication or whether or not it is just take a deep breath and this will pass. not only you can't imagine the peace of mind it gives my husband and me but also the extraordinary amount of time it saves for both the providers and for the parents and the patience and i think that technology is on the horizon. enormous investments have been made and i think the recovery act investment gives the tippin point. we are confident that as more

hospitals hoof and provider offices to get a vantage of this and the market will take over but we've got to get to the point where the majority of providers actually are using electronic systems or ordering electronic prescriptions following patient care with coordinated care and again i think it really enhances the opportunity for primary care doctors. so, i don't think there is any question that under way is what has been talked about for decades as a system that needed to be fixed and put back in place. work-force investments are under way and will continue to be made and it's everything from encouraging more medical students to choose primary care fields but also the more appropriate payments when they graduate from medical schools that they are not sitting with a

pile of debt comparing notes with a classmate or colleague who is looking at making three or four times the amount that they might make over a lifetime and have the same amount to get to pay. that is not a very good incentive for people to look at primary care. i think that the focus on the sorts of effort we need to me for prevention and wellness have never been in place in the way that they are right now. the affordable care act actually eliminates the copay for preventive care for screening encouraging everybody for medicare patients to private pay patients to not only establish a medical home of follow the protocols, reducing the financial barriers for really enhancing that. the effort under way on channel to obesity and the prevention and wellness grants, which we've now district across the country

for both obesity related efforts and smoking cessation efforts again can not only change, began to change the health profile of americans which is a very good news but again, put in place and highlight fi importance of prevention and wellness efforts. if we are able to once again decrease the smoking patterns in this country and decrease the proximity of secondhand smoke and really make a serious effort to go after what is an obesity challenge weare two of three american adults and one or three of your children are overweight or obese right now and the underlying health impact of those conditions are extraordinary. they are extraordinarily a expensive but they are also extraordinarily costly in terms of morbidities' and in terms of

life span so having the that effort and initiative underway which again puts a primary-care doctor at the center of a coordinated care health care strategy. the investment and electronic records not only to have the ability to coordinate care throughout the system but have a true medical home model and a true account book your organization with an employee that the underlying technology to really allow the providers to once again be providers. i can't tell you how many doctors i talked to told me first of the haven't hired a new person in their office to deliver medical care in years. anybody in the office is to fill out forms and paperwork. you know, the front office, the building to the cobbling office is run exponentially but often the provider side is more difficult and limited and there are lots of strategies in this

legislation minimizing overhead. the ed ministry of simplification that we will help drive for insurance companies so we get to a much more building form or a one-stop shop for provider form the and for billing operations and then implementing that through an electronic sister to defeat the system can dramatically shift at time elements back to delivering medical care and a way from being a clerk which too many providers spend way too much time doing and i think are eager to have the opportunity to return and then the future with every american having an had system and affordable care strategy that will again allow people and encourage people to access providers at a much more

appropriate time not only through the doors of an emergency room but also seek out health and wellness care and training at an early stage will be able to build incentives around care teams and communities to outreach to the most vulnerable and most difficult populations and often do some exciting experiments with strategies that teach us how better to manage chronic diseases and multiple conditions in a much bigger to become more effective fashion than what's going on right now. so the combination i would suggest is an opportunity to not only clearly we make medical care but use the tools of the enormous public payment system to help transform the delivery system and a lot about that will aim at the primary care

providers. so it is a very exciting time and a very appropriate topic to focus on and there's no question the legislation that has been put in place and the framework that has been put in place since january of 2009 really does tauscher in a new era of medical care but certainly a new era for primary care providers and i just look forward to as we get to the thousands of the secretary shall yield seized the because -- are implemented work in communities and learn what are the best practices and what are the features that we need to fraiman moving forward, and encourage and incentivize providers and systems, health care systems to deliver the best possible care to the american

patient. thank you very much. [applause] >> thank you, psychiatry sebelius for laying out the tremendous foundation and we know that you have to get back to the shells. so we will move on to our first panel this morning which is intended supervise overview of the primary-care prospect excuse me and prospects for reinventions. may i ask the panelists to come up and take a seat here at the bias. we are going to you're framing remarks first from larry and i will introduce him briefly as with all of these participants. he's the chief of the division of of comes and effectiveness research and the livingston fair and as as a professor of public

health and the department of public health at the weill cornell medical college. he came to cornell after nine years at the university of chicago where he was a tenured associate professor. previously he worked 20 years as a family physician and permit practice in california. he also worked extensively with schmidle trade commission and sufficient eckert and hospitals on antitrust issues to the clinical integration physicians and physician hospital organization. we are also here after that from the board certified internal medicine physician working to shape the future of the health care system and recently stepped down as the director of policy for the obama white house office of public engagement and intergovernmental affairs. before that, she served as the defeased debt director for the senate education labor and pension committee under the leadership of the late senator kennedy. before her time in washington she was a clinical instructor at

the university california los angeles and associates scientist at the rand corporation. focussing on research and health care quality. we will hear after that from all this victor von professor of history of medicine at the university of michigan where he is often professor of internal medicine at the school and also history in the college of the dresser didn't covetous designs and art and the fans and policy division of school of public health. he is currently director of the grumet society of medicine and of history and he's going to be providing an overview of the history of primary-care. we will then hear from robert phillips family physician and director of the robert grand center of policy studies and family medicine of primary care. the gramm center has many of you know functions as a division of the american academy of family physicians. savage by a small research team focused on providing evidence to help inform policymaking. dr. phyllis practices in a come

into this residency program in fairfax virginia and has a faculty appointment at its georgetown, george washington university and virginia commonwealth university. finally as i mentioned earlier we will hear from georgia became the seventh president of the mazie foundation in january of 2008. immediately before that he was vice president of the clinical affair is partners healthcare systems in boston and a daughter of the academy and harvard medical school. for nearly four decades he played the leadership roles in many aspects of undergraduate and graduate medical education at harvard. he also serves on the president's wife tells fellow commission and chairs the special medical advisory group. for the department of veterans affairs. let me turn things over now to some comments from larry.

>> i'm going to try to frame one specific issue but i think it is an issue that if it is not addressed i would venture to say that all things the secretary just spoke about will fail. i may be wrong about that but i think this is an issue that needs more attention than it has been given and that is the fundamental transferred transformation of the physicians especially how they spend their time. right now we report that physicians and exploit good physicians and i don't think exploit is too strong a word so if you look at the rich barron's article in the new england journal of medicine this week or last week and keep see the volume of the phone calls and e-mails and other non-visit based care physicians and the practice provide it is stunning. these are good physicians and those things they do for patients are very high volume. there are many physicians in the

country who don't do those things very much that they see a very high volume of patients every day. i can tell you from my inexperience and practice those are the bad physicians. they might see 40 patients in a day and go home at 6:00 and they make a fair amount of money. what i am calling to get physicians see more like 20 patients a day and go home at 9:00 or 10:00 at night and provide high-quality care and lowering health care costs by what they are doing but they are not rewarded. i don't think fans like the patient center and oklahoma are going to do anything to solve the problems of primary care unless there is a transformation of the primary-care workday and that is going to require fundamental change pat systems. uniques and is in neither context here is edward coming downstairs on the back of his head behind christopher robin. it is as far as he knows the only way of coming downstairs but sometimes he feels there is

another way if only he could stop bumping for a moment and think of it. that is how i felt for 20 years in primary care and i think it is the way that most of the physicians deal. the understand things are not right and every day it's like going through war and there's all the chaos of war but really you don't have much time to think about it even if you could and could come up with solutions it wouldn't matter because of the way that you are paid and constraints on what you can do. if you want to do all of the good things that the rich parents group as you do them for free on your own time is basically the way it is in your kids grow up without a that home. so just for a quick background i would say there are two components of the patients entered medical home. one is the old-fashioned primary care, the kind of things that susan mengin first contact comprehensive and so once and for the image always have of the position which is if you don't have one like that it would be good to get one.

but then there's the kind new notion of much more about i.t. to take protective care and an organized way of the population and practice not just to happen to show up in front of you and paul were in front of you but all of the basis of the time. but it is transformation i am talking about. most physicians see at least 25 patients a day and some see more than that. but i would say that the majority of those visits are a necessary as face-to-face visits. there are high volumes of upper respiratory infections, low back pain, routine checks for high blood pressure or diabetes or other chronic diseases. much of this could be handled over the phone and by e-mail and some of it or why by other methods. some of it doesn't need physicians but as it is the only way to get paid is for doing these visits and so you just bring them out as fast as you can do. some of it is called hamster

care and i would say probably eight to ten patients a day is all a physician needs to see face-to-face. that is basically patience of the first visit or the of complex problems or emotional problems or there is something that needs to be done physically. something needs to be examined, listen to the hard for some reason or therapeutically need to inject the trend. i don't think people don't need to take off work they don't need a babysitter or a nanny and lewis have to dig into the doctor's office. so how would physicians spend the rest of their time? they were suspended in e-mail and phone communications with other health care workers coordinating care and thinking a little bit and then working with the practiced staff to print all of these mice patient medical home concepts into action. this is not a new idea by the way. many people have said this before me but it gets very little attention and i've actually reviewed many articles

about the patient centered medical homes say or the chronic care model also they all -- if you read them and think this has to be the way it is almost never is explicitly said that the private care physicians dtc face-to-face better care of the patients. so why give talks about the medical home to the practicing physicians that come up to me afterwards very sincerely and say this looks great we wish we could do this but we are already working ten, 12 was a day and this would add more to do. how can we do that? so, the thing for the patient centered medical home to change and for primary care to be viable way to function in the future and take care of the newly insured patient that are going to need primary care these responsibilities can't simply be added on to business as usual but most of the demonstration projects going on right now give little or no extra compensation for being a patient centered medical home. only still get paid for the

physics you provide and there are some practices that have people that are enthusiasts and will make a go at this but this will not be a generalized model in the united states unless the payment system is dramatically transformed. how did i do, susan? >> you're on time that you are getting a close. >> i'm trying to set a model for all the laws to keep to the time. >> thank you, larry. [applause] >> thank you to read the was a perfect segue into what we try to do in our paper which is to look at medical homes and try to deduce from the various and attrition projects for of these top-level the metrician projects with the core features were. i want to give some framing comments for what we decide to look is in the white house in particular so leading up to the development the subsequently passed into law for the health

care reform we had been exploring across the country the different levels of the models including medical homes, accountable care organizations and as we don't deeper into these innovating experiments and pilot projects some of which were in place for many years we realized there was a discrepancy and it was not necessarily now intentioned but that there were certainly a number of differing criteria. a lot of different guidance on what a medical home really is and in fact it became a recurring jokes for those of us who work in health care. where is my medical home and what if i am a medical home less? what does that mean for me? we thought then after looking and talking and seeing kind of around the country what was happening on the ground we thought we would take a step back and look at the various criteria. so in the paper you will see a very kind of detailed look at two of the leading sets of criteria. one from the ncqa and the

medical index. those are not the only criteria for the medical home but they tend to be not only with the public sector as well as majority of the private sector look towards when they think about what constitutes a, quote on quote, medical home still looking at this features we decided to then try to take a step back and say if we are thinking about health reform and a very comprehensive context how can we fully appreciate where we are trying to go give in but what we have. so that gives you -- i wanted to show you because a lot of people asked me what were you all thinking in the administration or in the white house when you did what you did and put together a plan that you did and i will say that a lot of the work that was done in pcaca was set into motion by all of the researchers and folks in the current issue of health affairs. and we really wanted to look at how the private insurance market

as it currently existed and the regulations we have in place as well as how we could in his primary care access to come together and also be complemented by the public sector. we put together as the secretary mentioned very significant investments and a cloudy eye toward community-based work force that includes primary care, community health centers and a lot of the things that secretary sebelius mentioned. on top of that we mentioned the need for improved measures and reporting that was clear that in order to do all of this we need to have not only isn't a transparency but a real sense of accountability. and then finally, and not to be temporarily laid in the game, but we realized that needs to be kept off with incentive for this coordination as well as truly panic for value. so when we go through or as you go through the law as it currently exists, this was a bit of the structure for the guidance for which we put into place some of those provisions.

so, having said that, thinking through how we can compare some of the different models of the medical home we tried as i mentioned and we looked at the ncqa as well as the community medical home in the embassies to see where we overlapping didst if looking at the criteria against each other were looking specifically at which one meant excrete urea and which one mant y we wanted to look holistically at what for the alliance of the medical home and try to see how that could give a little bit of guidance on dustin policymaker but we realize as we take medical homes to scale as larry pointed out a lot of this would be a failure if we didn't also think about incentives for payment. and about all i will say was the striking kind of absence that we noticed in front current set of criteria and that is not the fault for those of a developed the criteria. i think it is a very difficult to add in incentives for

payments or how we talk about payments to those criteria. but it is the essential that if we don't couple guidance to the providers to the health systems as well as insurance plans on how to design these models in taking into consideration payments that we will not have the success but we also have. so you can scan across the chart to see there's a lot more detail in the paper obviously that this gives you a sense of how we look at some very kind of large domains to do they mapping of ncqa and map to the medical home index as well as a number of other organizations which have developed criteria to give guidance to the professionals. and you can see that there are some real kind of teams to the merger and we identified the common features as you can see the the kidcare coordinators, the expanded access to care givers, data driven a analytical tools and incentives for providers.

and after looking at not just the demonstrations and projects lived on the slide even broader than that when we did the literature everything came back to these kind of core functions and in the remainder of the talk today you will hear a lot of these themes emerging and i think the incentives for providers as i mentioned earlier is the key and as larry mentioned that you don't talk about that and you add on top of what the doctor back or provider already has to do you are giving them more of an emotional burden and speaking of emotionally burdened providers i can tell you it is not a good outcome so i want to just touch a little bit on a couple of the programs because i do think that one of the criticisms also is people always do this in an integrated setting so we commonly hear it's easy to do if you are in a closed capitated immigrated setting. we think some of these models were remarkable and innovative and i think that it really shows

promise for the future to scale because they took very high at risk populations, took medicaid populations, in particular north carolina, which there's a say separate paper about that i think taking a close look at how places and states like north carolina in conjunction with not only medicaid and state children's program also adding on the private payers have been able to do remarkable things. and as you can see, there is certainly more than just closed integrated systems although one could argue that as we become a more integrated country it would be easier to do things like a medical home or accountable care organization. quickly i just want to give you some highlights an overview of the outcomes and i know that eric larsen as when to speak potentially a lot more of a group health and he has updated data but as you can see there was a very dramatic reduction crossed these programs and i sometimes don't like to call

them pilots because we sometimes think of a pilot as something that's not quite ready for prime time, and i would argue that a lot of these are not only have they been in place for years but they are more than ready and beyond prime time. but i do think we took the vantage point of saying how do you take these early adopters and pilot programs. you can see across the board we have hospitalization reductions as a me now come. some of the programs didn't have reported reductions but now or at stages where they are looking at that and then obviously the patient total savings for patience and this is an llosa this is per your not per month some of the papers in memphis journal feature per month savings and take into account. some of the savings vary across the settings that show and that you do save money. all of that goes back to the dividing point that we had in the white house and the administration. and if you don't take the criteria and the guidance for

the providers and systems with consideration to the financial piece of this then you are really going to be unable to generalize this and that was something that we thought as authors with an important point to make. i will skip over this to briefly tell you what we thought were some of the challenges for the future and certainly it's easy. there's so much to celebrate and to be proud of and what we've accomplished but as somebody who's very kind of concerned about the implementation and what this means all i will say that it's terrifying to think how much work there is to do for the future and we do think that looking heavily as we did at the features across the board it really is important to think carefully about what features are essentials as we scale and which ones can vary. what levels of obra levity for information technology for example are appropriate? no system is going to be alike so how can we find features the should be common, dedicated your

coordinators as a physical person that's always with the team or care coordinator that is a virtual for example? hawken features like that very in a way that still gives you that same spirit of what we were trying to find in these examples? the other part is the mastermind of the complexity of scaling and i do think that there is quite a bit of need for technical assistance and some of the rapid the planet of assistance for people trying to do this in real time and data. one of the remarkable things we found was the inconsistencies in the data across the programs and again and this is hard enough to ask people to do this again how to measure this and report is and how we can actually aggregate the data in a way that can be forward thinking and help us learn from our mistakes. then finally where do the systemic reforms fit into all that we've passed into the wall and how can we then look forward to what we might need to do to

build on to those reforms? i would simply argue didn't do everything in this bill but we set a foundation as the secretary mentioned to build on top of that. and i have to add this in because we spend a lot of time this morning and susan kind of kicked off the topic that the primary care pipeline is centrally how we measure the pipes correctly, do we want copper pipes, have we decided how long the pipes need to be? there is still a lot of debate about how exactly we should staff the medical homes and i know that the other presenters are going to touch on this but i will just say for the anecdotal purposes when we went around not only within the white house but in the administration and looked at all these different models even despite the success car was an overlying concern and kind of fear about if we add millions to the programs that is what everybody wants, that was all good and well intentioned but

how exactly are we going to take care of these people? so i will say even if we feel like as policy makers we can combat that question we still have a lot of communication and education to do. thank you. [applause] >> well, larry and kavita have given a glimpse into the future and larry, i hope you can implement those changes in my home institutions. i have to see some patients on thursday morning and would be nice if you could make the changes buy then. [laughter] what i would like to do is look back at the past and put on my historian hat. you might wonder why are we listening to history? what use is history? history let me make clear is not about predicting what is going to happen as has been said before. a prediction is difficult especially about the future.

rather history is good for examining how and why change happens. historical analysis can demonstrate the fundamental assumptions to underlie the present health care system are assumptions like science is good, technology is useful, specialties are logical, that these assumptions are the result of choices that were made in the past by specific people and at specific times and specific places. and the choices could have been different. in other words, the world we live in today is not inevitable but could have looked very different than it does today. so the forces that lead to change in the contingent nature of the choices are not always obvious. though at that time the choices are taking place. and it is the role of the historian to clarify the traces and contingencies. let's start with health care a century ago. if you became sick, you could choose to get care from people

who had a wide variety of different health care of ideologies. and these were only one logical choice to do what you got sick and wanted to be taken care of. hospitals and technology were simply not very relevant. most medical care was delivered in the home by a practitioner using only what she or he could carry around with them. foss, almost all medical care was at that point primary care. although people didn't call the primary care they just call the medical care. so what happened? we can date the invention of modern medicine from the per goal of the 1890's to the 1930's. we note hospitals that became central for medical care and education. we note increasing technology, the invention of truly spectacular new tools like the x-ray machine and electric cardiogram machine. we can no dramatic changes in medical practice, the discovery of insulin, the availability to reach hanly, safely, painlessly

perform surgery usually in the new hospitals. we note the triumph of the medicine we now call md medicine, the kind of medicine on a malpractice times think most the of the people here. and the reform of medical education. in other words, health care by the 1930's was quite different from health care in the 19th century. and one could argue with a set of core assumptions that are at a fundamental level is essentially the same as today's health care in the 21st century. and yet despite all of these revolutionary changes, primary care remains a central in the form of the general practitioner. so the first historical point i want to make is the changes in medical and scientific knowledge have not and probably will not lead directly to changes in the health care delivery system. so what did? to answer that question we turn to the world war ii and

afterwards from the 1940's to the 1960's. world war two was the big war. the army medical department of 1943 was three times the size of the entire army in 1939. army leaders faced with dramatic increase in the size of the medical department could have chosen a lot of different ways to organize. they just organize on the basis of medical specialties. physicians to enter the mother teresa general practitioners went home looking for special training. there they felt opportunities and new programs and new va hospitals all of which led to growth and opportunities for specialty training and specialty care. there was also dramatic increase in funding for the national institutes of health which ought to stabilize encourage and facilitate the balkanization of medical departments and to some specialties. the structure to if procedures and all of this led to the demise of the general practitioner who was essentially

extinct by 1960. but actions generate reactions. the national committees took note of the demise of the general practitioner. family medicine became the 28 medical specialty but there was new and politically weak. general internal medicine acquired the stronger voice and sometime in the 1960's and 1970's came the invention of a new concept called primary care. and the point i want to make here is primary care was invented as a response to this debt of the increasing dominance of specialty medicine. and we will be talking about primary care for the rest of this meeting. so what happens now? it doesn't take a whole lot to realize the health care system is likely to be heavily influenced by the new technology as we heard earlier this morning from the secretary. but anyone who thinks they could accurately predict what the new technology is and what is plan

to be used to think only need will take back five for ten years and see how difficult that sort of prediction would be. historical analysis suggests organizational change is unlikely to be driven by new scientific knowledge though it may be justified by such knowledge. rather any change is likely to be driven by social and political relationships. and that relationships will involve all of the relevant groups. just as it did in the past change will impact the way specialists and generalists can react. relationships between physicians and nurses. any increase in salary for primary care providers is likely to lead to changes for other providers perverse in the political minefield is going to be difficult. any increase in reimbursements or change for primary-care physicians is likely to lead to other physicians claiming to practice primary care. just the other day i saw a young woman, 25-years-old. she has type i diabetes so she

sees her and volcanologists every other month. she had a problem of the pap smears so she has seen her obstetrician gynecologist every two or three months yet when you talk about primary care and who is delivering primary care and asking the questions it's not there. secure is somebody in shirred seeing the doctor essentially every month or two but she isn't getting primary care. my guess is there is an it to get primary care of her and broke enologist and obstetrician will be claimed to be provided in primary care. wealthy? i don't know so i would like to conclude by saying while historians cannot predict the future we can be certain that things will continue to change and the meaning of this thing we call primary-care is likely to continue to be invented and reinvented, that the changes are likely to be social and organizational as they are scientific and any changes in one part of the system are likely to impact changes in the other part of the system. thank you. [applause]

[inaudible] >> [inaudible] [laughter] thank you. i really appreciate the opportunity to speak today. the foundation asked us in preparation for the conference as suzanne mentioned to develop a bit about the definition of primary care because clearly people in this country think they understand what primary care is but clearly they don't. as dole was just pointing to. so the doctor and i prepared this for them. i want to start here with the

definition and this is the institute of medicine the commission to read only one of many but probably still the best one in this country. the primary care is the provision of integrated and accessible health care service by clinicians who are accountable for addressing a large majority of personal health care needs developing a sustained partnership with patience and practicing in the context of family and community. so, in that definition is not just about the personal care provided to someone. it's about turning it into a relationship and putting it into the context of the family and community. and it's the definition that is the logical foundation that affected the health care system. so almost 15 years later we sit having that implemented and to our own peril. because as the world health organization pointed out a decade ago and commonwealth fund since, despite spending twice as much as our nearest competitor in the health care spending rates we are ranked 37th in

overall in the world and if you had in the adjustments for disability and lifeysç expectany we fall 72nd in the world and that is fundamentally because of our problem of understanding with primary care is and not implementing it. and one of the biggest problems we put on the paper is the weakness of financing and you will hear that routinely. you heard from three speakers already. but that financing is driving stood in decisions. students and trainees in medical schools and residency programs are as said white follows grain. so the choices are strongly influenced by the average income of specialties. but guess what? personal incentives are important. they certainly are. but it's also affecting the marketplace. it's affecting with academic health centers are doing with the training pipeline. as we have seen an erosion of almost 1200 primary-care training spots in the last decade.

and that same line is there for what's happened with the build out of other training programs in the country over the last decade. this isn't about the personal reasons, this is about market-based incentives so if academic health centers are building out those pieces of the business model that makes them money and staffing it with of the lowest cheapest labor they can in terms of residence this is what happens. you see any erosion of the low and where pediatrics and family medicine have lost income in th last decade when you adjust for inflation and dermatology has increased income by 40%, radiology 25% of the time. this isn't bad peter this is market driven behavior. so, what is influencing students decisions is influencing academic health center decions, a it'taken us from producing one-third of our physicians in this country and primary care down to about 22%. the financing is important. so most and have of the geography of the country is in shortage. most of that is a distributional issue and what is -- with this

agreement and today about expanding the health centers and group will help this but we are facing is a shortage the next ten to 15 years because the shrinkage in the pipeline. the shrinkage of the production of primary care in the country. and with 30 to 40 million ensure we can't have that shortage or we will see quote atingua down further and see costs go up and we at this time of transition for the health care system we can't afford that. so realizing the full definition of primary care and moving the market to support that is going to be essential if we are going to meet the needs of the country and if we are going to try to lower cost and if we are going to try to bring the country of in the rankings we can afford. thank you. [applause] thank you. it's a pleasure to be here and

see this audience so interested in this crucial and central issue to the health in both the health and well-being and as susan said also the economic well-being of our country. i am george thibault of the macy foundation and we began planning over a year-and-a-half ago a conference on this very issue because it was clear to us in spite of the evidence susan and others have cited that countries that invest in primary care and systems that invest in primary care actually deliver better care over cost. and in spite of the evidence overwhelming evidence that that's what people want we as a nation have under invested in that. so we began planning a conference in which we would pull together leaders from across the country and across the provisions that provide primary care. that is md professions of internal medicine, family medicine and pediatrics.

doctors of osteopathy, nurse practitioners, physician assistants, all of the key professionals across the spectrum of career trajectories, leaders of academic medical centers to leaders of clinics to the teachers, policy people come to those involved in communications. commission papers, some of which are in this wonderful issue of health affairs. bring people together for structure discussions to address this very question who will provide primary care and how will they be trained? we are principally an educational foundation interested in how we will educate health professional work force that will better meet the needs of our public. was a remarkable meeting. i think it was unique for the diversity of career path place and positions the were represented and remarkable that given the difficulty of the discussion which sometimes was contentious, given the complexity of the issues we

reached remarkable consensus on the import complaints. i am going to highlight for you a couple of the main conclusions and several of the key recommendations. the whole summary is available out on the table. this dream publication. it is also available on fees' macy donation website and full monograph that includes the papers and a summary of the discussion will be coming out in the next couple of weeks. the highlights of the conclusion create a sense of urgency that the group felt. if we are going to fulfill the nations promised to the public and if we are going to produce the health care work force required to accomplish our goals we will need to enlarge and strengthened the primary care sector of the health system. there is great risk that if we do not do so a significant portion of the population will

be continued to be without access to high-quality and efficient care and health care costs will continue to escalate with dire consequences for the economies of individuals and the nation. there is great urgency in addressing these issues. failure to act now could put the health of our community and the economy of the country in jeopardy. the second deals directly with the issue of the health professionals. we will not attract and retain the sufficient number, more achieve the needed geographical distribution of primary-care providers unless there is a greater proportional investment in primary care. our students and trainees must be educated throughout their clinical training in practices that deliver first comprehensive integrated coordinated high quality and affordable care. that is the health care delivery system and the educational

system are inextricably linked. we will not produce the kind of care providers we want more will they choose those careers if we change them in dysfunctional systems. these practices require teams of professionals who give care that a listened patient provider satisfaction or conditions of clearly defined roles effective teamwork, patient engagement and transparency of outcomes. these being the conclusions, i will highlight the recommendations that were overall about a dozen recommendations with another dozen sob recommendations. i've chosen to consolidate them into seven key recommendations. first, expanded the primary care work force by improve recruitment, who we bring into the profession, training, the content and the financial incentives. all three are necessary. fixing just one without the other won't be sufficient. and allow all primary-care practitioners to practice at the

highest level for which they are trained. second, implement payment reforms and more appropriately recognized the value of comprehensive primary care services their reward quality outcomes for patients and populations. feared, require into a professional education for all health professionals. we need to change the paradigm of education so that we actually educate and train health professionals together. and we need to remove the regulatory eckert addition of reimbursement barriers that limit members of health care teams from learning and working together. fourth, academic health centers must lead the way. this can't be done around them. must be done with them. they must provide leadership to develop new models for care delivery and improve educational opportunities and primary care. they must form a stronger tie

with community health centers and other primary-care sites in the communities they serve. fifth, greater investment is required in the primary care infrastructure that's already been alluded to. not only by electronic medical record, but other tools that are necessary to provide this comprehensive care. sixth, there is an important government role in this and the secretary has already addressed that, and i'm very, very heartened by her leadership and by the wording that is in for recent reform bill. the government funding through title vii must be used to provide incentives for careers as primary-care providers and teachers. we need the teachers as well. in the area of health education centered programs should be expanded. and finally, we do need more research. we need to study which models work and don't work. and we need to follow what has

worked in developing highly specialized medicine by creating centers of excellence that will be magnets for research and study and will draw all the leaders of the future. this is a critical moment in time. i am incredibly excited and heartened by the level of interest and the quality and fought that we've brought together, and the emerging consensus across so many different professions and different positions that this is the direction we must move in. ..

without payment reform. we then heard from kavita about the effort that the white house and undertaken to pinpoint the critical features of the medical home model that seem to work and seem to be uniform across the variations on the model, care coordinators, expanded access company said that attribute analytical tools. and then it can importantly incentives to providers. again, none of this works again without a worry for them. kavita mentioned she was terrified to think about how much we have to do in the future to implement all of this. and we will come back to that a bit later. we heard from jewel at primary

care as a concept really was invented as a response to sheltie medicine. it was only as the wardrobe and the other investments nih trophic researches specialty medicine do we address the need for what is going on in the night 10th century that close contact with patients often in their homes. and i guess tool, in a friendly way, told us that we didn't need to publish this issue of reinventing primary care as primary care will be reinvented with a republish on this or not, things are going to change. as a consequence of social and political relationships largely shaving. we heard from bob but we have been at this for quite some time. the definition of decided going back to 1996, probably we have not advanced the ball one iota since that definition was arrived at, notwithstanding the

foundation of the secretary mentioned has now been laid. and again, as we know that a lot of it is going to be about financial incentives coding fitzy mullan on the way follow screen. but how critical it is what we saw that map of the shortage areas across the country how critical it is that we get the green during the wait into those directions soon. and then finally from georgetown to hearing about the commissions recommendations, the conference recommendations of all that we need to do to get there to make a greater proportional investment of primary care coming to expand the workforce, to allow all members of the team to work at the top of their licenses a feature will be hearing more about later today, that the educational system, as much if anything has been a barrier to getting to where we need to go, do we really have to start training people to operate in teams. we have to get rid of the accreditation of other barriers that keep that from happening.

we have two of payment reform as he said, the academic health centers have got to be the way on this and that we've got to continue at the academic centers and other areas to do more research, to continue informed of invention process mitchell assured us is going to cost anyway. so with that, let's just take another break, a formal break, let's stop here for just a few moments of questions for this panel. and i guess kavita, i want to come back to you, to your terror of implementation on this in particular. what you see as the prospect that we are going to move forward on some of the things that we've just been talking about, the payment reform, the creation of medical home expanded pilot, all the authority now inherent in the secretary shells. are we going to do with? >> afraid the answer to that i'd be getting paid a lot more money than i ever had in my life, but if you think that what the

secretary said is exact to that. it's a great foundation, but also something that joe mentioned in his talk about this being a social and political issue is where i think we as professionals and people who provide care have to than take-up of all. and i don't think we've dropped the ball. i think we've been so busy looking at everything on the ground that we've kind of lost sight of how as professionals we probably no need to have an even more act a voice in this implementation. and they'll tell you that professionals, just like most coming in okuma people have so much on their plates but it's hard to think about these meta-issues of implementation. what does that mean because so much of our database concerning. you're in the hamster cage. and so i worry that even despite all this law puts into place, but if we don't till was not the social contextual issues and that's not something we should

regulate nor should the federal government he kind of the driver of that. that has to come from office. we are doing this work, then we're not going to be able to do this in a way that gets to utter patience state, which is what all of us ultimately want. >> torch. >> i think there should be a time for innovation. and i think incentives can and i think are going to be provided by the government to do that, but there also have the leadership of all of our institutions that are permissive and supportive of innovation and then i agree with kavita the profession at self bears a responsibility, not only to the those innovations, but to study them, to evaluate them coming to be honest when it works and when it doesn't work here but i think this is a golden moment in time. and if we don't seize this, we're going to be frozen in time and i don't want to think what the consequence of that will be, but i think there is enough now

consensus that we need to do some new things. there is an agreement about what all those things are. and so it out to be a time in the educational sphere and in the delivery sphere, in which we innovate to change things for the betterment of the public. and that has to always be her touchstone. and sometimes it's a profession we've been too inward looking. we are worried about our own standards, i run it, are an institutional needs as a measure of whether what we do is the right ignore now. this is a moment in time in which we -- excuse me, should be much more outward looking. the test of whether were to the right thing or not is whether the we've met the needs of the public and the incentive for us to changing now is the clear evidence that we've not been meeting the needs of the public. >> joel, just quickly, obviously for the specialty medicine movement to take hold of it

there is clearly somebody was leading the way on that. i didn't just happen of its own volition. can we learn any lessons from the leadership that led to that incredible surge of specialty medicine and applies to any of those lessons towards today what's needed in primary care. >> well, i think that's -- i don't think it was a leader per se. i think as a family incentives that talked about science and technology and the notion that more and more specialized was necessarily better and better. i think that is what is to some of the inequities and discontinuities that we've seen today in the wake of a couple of examples. you know, we tend to value highly and reimburse extraordinarily well, as we've seen interventions that in many

instances, water clearly a good thing resulted in very little increase, so you knew chemotherapeutic agent with simon with cancer for six months is obviously good. but how many more times is that worse than there is an and eventually somebody early in life to do something that will help them with a much longer and more productive life. so the other part of the system i was talking about, just it's developing in the room i don't think it's been addressed. of health care costs are going up in it for going to give more to implement primary care reform, somebody's going to get less. and the people that are going to give lesser the people who were not delivering the high-technology care that provide commercial benefit and that's going to be a huge political fight. and so the social and political i was talking about this in fact involve some kind of central leadership of decision make them. i don't think we claim they were going to save enough money for the high-end county salaries can

continue to love and will give more to primary care and some health care costs are going to come down. that's a wonderful fantasy, but i don't think it's likely to be true. >> and less as was mentioned earlier a lot of chronologies decide to be primary care specialists and focus on running medical homes. so larry, we need a whole new fetish, clearly according to joel. we made a fetish of back to basics. do you see it happening? >> i think it's going to be very difficult because of the reasons joel just sad. i do want to just emphasize that i think the distinction clearly to be made and i don't want this to get more between how much primary physicians are paid what they're paid to do. i don't personally tank that if primary care physicians need to be raised for the incomes need to be raised to the incomes of the cardiologist for us to get

into conflicts in primary care physicians, and in a separate question about the relative pay scale should be. but i think it's only partly a matter of how much primary care physicians are paid yet again, if it gets even more what they're paid to do. so i think of the primary care physician were transformed in a way that she didn't feel each day that you are just scrambling around the constant interruptions, knowing all day long, every day that you're actually not doing what you ought to do in europe even such a way that it needed possible for you to really take care of the patients and their practice, then i would think that h.r. in primary care income were not that much above. i think more people are going into primary care and they'd be a lot happier, would be lowing costs and increasing quality. >> bob phyllis, let's get the last word on this panel to use speaking from the standpoint of a family physician as much as anybody. what do you see?

>> i think some of the health reform options on the table are going to be helpful for the distribution problem as i mentioned. there's a lot left out the race but not appropriated that will -- like the primary care extension program to agricultural extension put someone in every county to put practices transform. a need that kind of facilitation as well as the financing. so there's a lot left on the table i hope will get the financing it needs to help with this. to the question you asked the tool about this -- the value that's assigned to specialty and primary care, i think a lot of value of primary care is so distant from when it happens that we don't see it. so if you get someone to change their behavior, if you help them to control their hypertension at all realized towards the end of their life and it's not right there like removing a tumor, the pretty man stands someone's artery. part of the fetish that it

creates, we do need to be fetish primary care and we need to assign value to what it actually does down the road. i know we've got to build towards that. to larry's comments about income, i mean, i don't want to be hearsay and this is all about income, but we need to let costs of medical students that leaving millions of dollars in the table of sections the option out of the room. so we've got to figure that piece out of not just about income, but how do you put money into those practices so they can become more complex, more comprehensive and build the teams that means. so there is a financial piece of this equation that we've not yet dealt with. >> so we know what the next health affairs briefing will be handing out primary care fetish dolls for people to carry around with them. in the interest of time, we're not going to take audience questions or comments now. we'll hold those over until after the next panel. so pase join me in thanking

the anil for kicking us off on a terrific start. virtually from paul gandhi whose ibm director of health care transformation and in this really develops and executes strategies that support ibm's health care industry transformation initiative. he's also president of the patient centered primary care collaborative, which is the coalition that he led ibm and creating in 2006 to advocate the use of the patient centered medical home. today that collaborative represents employers of 50 million people across the united states as well as physician groups representing more than 300 or a thousand medical.there's leading consumer groups and the top seven u.s. health benefit companies. we'll then hear from katie merrill is a senior research scientist at the center for health research and policy of social and scientific systems inc. here she's been studying physician payment issues and where they did issues for 20 years. she was part of a team that was

led by the urban institute and funded by the commonwealth fund and the american college of physician has studied the medical home model and its cost in her paper in health affairs deals with paying the medical home. we'll finally here on this panel from troy brennan who's the executive vice president and chief medical officer of cbs caremark. and this role he directs cbs caremark to be clinical affairs and oversee strategy development. before joining cbs caremark whose chief medical officer at not from 2000 until 2005 he served a president ceo of reagan and women's physicians organization produce also professor of medicine at harvard medical school and professor of law and public health harvard school of public health. he's a member of the institute of medicine of the national ademy of sciences. so paul, will turn this over to you. thank you. >> thank you very much, susan.

and i just want to personally thank you for everyone here for the tremendous leadership are you in health affairs have really had in this whole arena for some years and it's much appreciated. so joel made the comments that this really is going to take a social and political movement to make this have been. i can't agree more. that's why we formed the primary care collaborative to do exactly that. for us, you know, this is birmingham, the current system of health care delivery system is a form of violence and we're going to change it. so that's our conversation today. it really is a multi-stakeholder effort movement. the authors reflect senator kay hagan of the political side of the house. it reflects the leadership from the consumer groups with the

president of the aarp. it reflects the academic health community and primary care with kevin cronbach. so it's a pleasure to be here with you today. so from the standpoint of the large buyer of care, 47 mass large corporations and tri-care cuts together in a weird about three or four years ago and decided to actually take social and political action around this. i think this best exemplifies the story. i like stories. i was driving down the street to visit a major hospital in new england. and it was a chinese sign on the road good and the sign said, you know, we choose the best heart surgery in the state. i went into that room with all the shows, the cms, ceo.

and i said, you know, we're not going to put another job in this community. it isn't going to happen. in fact, were moved in our jobs out of the community. we want to sign on with us as we deliver the most comprehensive, integrated, coordinated care in the state. it is so accessible to your employees and your families have half the rate of heart disease as any other community in the state. and by the way, we need heart surgery, we do the best. i mean, i fundamentally understand what that sign says, you know, that science as we know where the money is and we're going after it. last night and now, and were not going to tolerate anymore. frankly speaking, you know, we have organized ourselves in a large collaborative to say, you know, it's going to change. and joel is absolutely right. it's going to take social and political movement make this

happen. so we do rescue care. we do heart surgery. we do more of it than anywhere else in the world and we have to because we fail to do the kinds of prevention and robust primary care to prevent them from happening. and it isn't just true globally. it's true internally in the united states. i mean, we do data, duplicate data. i have populations that literally have as much heart disease. can i ask myself some fundamental questions around why and what that about. what i discover is that there are places where there subdiscipline around at the livery of health care. there's some attention to the abc's, aspirin, blood pressure, would really. i have one of my employeescome up to me and say, i went to the system where i get my health care system and i went to get my glasses.

and the receptionist said you're not going to feature classes until you go down a plea or hypertension prescription because you're not doing that. someone is following up and following through. there subdiscipline around the livery. it is not about where we can make the most money because we do the best heart surgery. it's about comprehensive integrated coordinated and accessible care. so we began to look at what was fundamental, what was foundational, what we were doing running around the care we were buying. and we decided a bunch of stuff we were doing wrong. we really -- we really had failed to understand the need to have a comprehensive, having a healing relationship with our employees and with their families. that whole historical trend that you just heard about from jolts of place and we kind of lost the baby with the battle.

i happen to have caught up in africa, you know, i understand the traditional healer. is this hugely powerful relationship between a healer and the person who needs healing. that's the second most powerful relationship in society and we just intermediated it. i want to buy that back. i want to buy a relationship of strain in the relationship of healing that allows honest and frank conversations around end-of-life, around other things that doesn't exist unless you have trust, right? so, we think fundamentally what has to be at the foundation of anything we have is the relationship from a comprehensive this too is allowed to provide comprehensive care. so the other big problem we have in this country, we can't conclude as we have the best

partial list i think in the world. and we have folks that really specialize in a part of body and to relieve bell. we've been at the acoustic from japan flying over here to get their livers replaced, right? we really do good partial t. care. and there are places in the united states were to cost me as much as $117,000 for the last six months of life and other places $17,000 for the last six months of life. and when i look at what's under the covers around those communities, i discover that i have five partial list doing five different things, nobody talking to each other. we have the best best ballplayers in the world. we put them on account a few months the government got watched by the albanians. what was that about? last night they did know how to team. they couldn't pass the ball. they didn't have discipline.

you know, so the comments i make into the hospital, to, or macon as buyers of care if we no longer want to pay for apoptotic, uncoordinated care. we want coordinated, integrated care. you know, we understand how to get it. we have the minister of health from spam that came in top was that the pcp cp about a year or so ago. they went from being dead being within the terms of their delivery system and we asked them what did you do? well, we recognize that we had to have a focus, specialty of comprehensiveness and recall the community and family medicine. we developed this specialty. it's a specialty of people who are trained to be comprehensiveness.

and everybody has a comprehensiveness and abroad have access then there's some adult supervision. [laughter] so, when we let globally as a buyer of care, i mean, new zealand for example compare to the united states, my employees but the seven times more likely to be hospitalized for a chronic condition diabetes than they woulyou new zealand. and when i look at the data across the united states, i will find places where i can buy care here that's as good as new zealand. that's where we are moving our jobs. that's where were focusing. it's got to happen that way. if we're going to be serious about this, you know, as larry pointed out, the money's got to follow, right? it's got to line up. so when we kind of came to the conclusion that we wanted really to change the covenant between

the buyers of care and the providers of care and that we've been making a tremendous amount of mistakes about how we try to organize ourselves to address that, we decided, let's stop trying to work around the system. let's work with the system, partnered to make that transformation. so 47 large companies plus tri-care company get together with the primary care providers and we said let's change the company. we don't like to come in if we have now. this change it. doug henley, the head of the afp looked across the table at me and he said let's your heart. you know, we the primary care society have reached the same conclusion. we think what you're paying for is pretty silly. any think what we're delivering is pretty silly, but that's because that's what you're paying us for. so, without understanding that we both wanted to reach the same

place, the healers, the people who should be the comprehensiveness want to deliver comprehensive integrated coordinated care. we want to buy it, but we were missing. the trains are passing in the night. so we the buyers said to the providers, it's your business, you're the deliveries of care. you need to have a set of principles that you agree on. we are going to leave the room, we're going to ask you to write down those principles and we're going to come back and we're going to have a discussion around a changeup up in it. so the principles are really powerful. the principles are really powerful because they are agreed upon by the entire house of primary care. they are agreed upon by us, the social and political machine trying to drive change along with government, based on a set

of principles for the first time everybody present a set of principles or the whole house of primary care that's been endorsed by the house, the anc and the ama. by the way, it is a strange set of principles. it's a standard in the european union. it's not a standard of the veterans administration and the standard in the dod. i mean, it's not anything unusual. it's really powerful what we really want to do is move to superb access. we want to move away from -- only 26 of my employees can access their primary care providers here after hours and 100% can in denmark. what's that about? you know, we want to move to care that's coordinated. we want to make sure that

there's engagement, that there is data, that there's feedback, that the consumer is engaged, that they're centered on the patient. we won our practices to move from delivering solo based on the master builder to a team-based i work with the team, i have discipline. i'm now building a skyscraper, not a cathedral. i mean, the world has changed and it's going to require discipline to change. and so, you know, we're driving not as a social and political ideas. we are seeing profound results. you'll hear some today. i visited a few of these cuties myself and it's why i wanted to mention them here. but we're seeing the kind of data that you saw from kavita across the country. in shelby county, iowa, he said in a small community hospital there in the parking lot meeting with the ducks of 11 primary care physicians. he sent a 48% reduction in

hospitalizations and a 32% reduction is the average. but what was really powerful, because an idea what all the license plates have counties marked on them was that there were people coming from four counties away. and if anybody knows me, i never meet a stranger. ask everybody in the world questions. and i was asking people to park and not, why did you come from four counties away? and they said because i have a doctor that answers an e-mail, that will seem in the same day, that will follow-up and involved but stopped dropped through the cracks. it's differentiating them. it's differentiating nonhospital. the same thing in michigan, in battle creek, michigan, the community of reaganites themselves around the concept of more comprehensive care and we're seeing a profound impact. whole country, right?

that the danish really started this perhaps 15 years ago and when i asked the teens, is that how did she really, ms. marvel, this concept of? they said we said in the united states and read the literature. and i asked the spanish. i said what did you do to reach this? they said we heard some consultants for the united states of america. [laughter] so it's not as if we don't have to do it with just about the political and social will to do it and so we're going to try to help to do that. so, we have been going day to stay for the last four years working at a state level. mississippi two weeks ago was the 39th state around the medical home. it's having profound impact on the level and in the communities. you've heard about community care of north carolina and you'll hear many more today.

the one thing that we're really proud of is the change that's happening in the federal systems, the veterans administration and the dod. they declared that every dod member lothian medical home. they actually have a course of action. i sat in a room with students and others at the macy foundation meeting and we went around the room and the federal buyers that cherry from the va and others were sitting there. and we all said we want comprehensive integrated coordinated care. and by the way the academic medical centers you have to train the kids to do that. because that the product we want to buy. so you know, where the buyers. we the community that's organized with the providers are going to insist on that. no new nih grants were offered for centers that don't deliver

that. i mean, we were serious about this. and we're going to work with our senators, with the members of the legislation to make certain that we begin to move because just as joel and larry said it takes social mess. so we're beginning to see some real changes from the employer side. knowing just announced a 20% lower cost for patients in a medical home. we have companies building is that they can't buy. probably about 10% of employers and employees are no-name and oklahoma have been built in communities if we can't buy it. you know, i think that, you know, you're either part of the problem or part of the solution. so for those who want to be part of the solution were actively engaged. the collaborative has three

meetings a year. our next one is on the 22nd of july. this is about social change, social engagement and it got -- it's really exciting because it's got everybody. it's got hospitals, employers, insurance companies, providers of all kinds the decree on the change. so companies like ibm have moved to first primary care. we pay free up in primary care. we encourage it. we like others are seeing a third lower cost and our employees webby meaningful relationship with a comprehensive list, 19% lower mortality, 12% lower obesity, 7% lower smoking rates. we don't think that it's because the healers are doing all of the health. we think it's because the healers are amplifying what we and others are trying to do around her wellness programs and other things.

so again, this is social change. this is a social movement and we're in here for the long haul for you guys. so thank you drainage. [applause] >> good morning. let me see if i can i get to do a head talk again. i'm katie merrell and the paper that's in today's issue called structuring payment is my co-author bob parents at the thurgood institute and it was funded i bet paramount fun. and this is the third how i got in this bigger project for a couple years. he forced her to want to make a point. larry castling those started with key points and i'm starting

to decide this is key points. we share one thing which says we give more talks at the university of chicago university of chicago than enough and you never get past the first by their peers of the whole talk is on the first night at the university of chicago. i don't want to do at that. very calm election were to die while i'm a publisher and example. what is going to say my whole talk in two minutes before you in about, was that payment incentives are going to shape a prevalent in which we take a pipe providers, payers and the attractiveness to patients. and it's going to affect the evolution. what a medical home takeoff, what they look like in five years is going to really matter how we pay for them to share and make sure that you're after. who's on this team come with the task fire and how their value or so i feel like incentives matter a time. it matches either living to feed out how to pay for it. and when i say pay for it, and all mean finance it.

anyway to check to somebody today for something they did recently maybe. there are many ways you can structure payments. i like thinking about alternatives and make in a with them what we do in the paper, we paid for stores, for approaches that shall come back to. there's the typical one that's been widely used in his been very, very little scrutiny of its particular role on how the demos work and what you've learned from the demos just on the care process of outcomes and things like that the payment structure itself is going to try some of that i believe and there's very little experimentation in the current set up demonstrations in alternative models. in a few doing different names that haven't been that we found much careful study to have this payment structures are going to affect incentives. and what you see when you do that process is an outcome of valuations. we're kind of advocates for the candidate who do little more. not because the note should like, but that we should be

looking at it. and finally the medical home recognition quality measurement and accountability will be built-in and payment can be closely integrated. in fact, we need to be. and over time the things about recognizing his medical home, the levels of medical homes, those kinds of things. what is cluttered look like, how to measure and report it and payment can be closely integrated in ways that are very self reinforcing and they're not completely different project reads, but if that can be closely related. so that's my type you cannot get to give it again because you didn't interrupt. larry, shush. i want to start with what i think is the payment toolkit and i will be very quick i promise. sort of the paradigm with the fee-for-service versus capitation. you could pay for everything you do, every face you see during the day and larry have seen too many of them versus capitation

coaches the notion of getting a check at the end of the month whether he saw anybody. and their strength in the misses, lots of literature about that that those are fundamental structures that we talk about is the core payment strategies. we learned a lot of ways to try to enhance from assorted enhance the strength and mitigate their weaknesses through complementary policies. we have a thick risk adjustment in the case of competition. we all really pay one amounts per dies. there's guys who look prefix are willing to pay more per month just so we hope someone will lecture take the money and put them on their payroll. so we've come up with tools to mitigate the weaknesses of these two sort of underlying systems, risk adjustment in the case of capitation for performance which i think he's many things to many people, but ever present the notion of target incentives to a particular process for outcome goals and begin sort of focusing attention on specific things.

quality measurement again whether for the providers are publicly reported, but there's a lot of interest in measuring quality in using that information. and other targeted incentives like fleischer's savings and other mechanisms that can typically need to mitigate the weaknesses of whatever that core system was, what is the fee-for-service or cup team system. the search will succumb to be layered onto kind of hope work better and get us closer to where we want to go. that sort of the toolkit and the question is how we deploy that oversimplified toolkit and the topics and sort of the norm right now is the fee for service process, business as usual for offices. it's whatever you are doing your office visits and a monthly payment. and the monthly payment can reach me few dollars a month for general population to over $100 month for very specific, you

know, high chronic disease can of population. and so, that sort of the way it seemed to work right now. if you look at no demonstrations conduct hazard in their fee-for-service or visit in some of the capitation, some of the demonstrations include the enhancements in some kind of paper performance or other kinds of installments and some of them don't. but their alternatives. their alternatives but i'm not going to go there. for the purpose of this expedition kind of just a newspaper layout three alternatives, kind of starting from the simple fee for service on two things and going back to the scale to capitation. unmissable fee-for-service and is the idea of enhancing for and this has been used in some cases. and if you are qualified as a medical home, you get 10% more for one of those 99 to 13th, whatever it is.

so it's an add-on that just sort of says thanks for doing that, we think it's good that we know there's something else going on behind the curtains when you're not seeing the patient and we're going to pay for some of that through this enhance trade. so that's a simple low-hanging fruit. it's easy to understand and to secrete a lot of administrative burden. but it still keeps that encounter at the core of the payment, which seems antithetical to the notion with a medical home means there's things that should be face-to-face. so it's kind of easy, but it doesn't necessarily send the right signal. sort of going a little past that is this notion that we cannot cpt codes for things that are being done. the concern of player he can spend a statement that they should be doing because it's not billable, let's make up and then you can go for it. so maybe you can think about discharge planning code that makes more sense to people than what's available, where you're supposed to know your patients being discharged from the hospital and there needs to be a

care plan and there needs to be medication reconciliation and things like that, but you don't necessarily need to see the patient at the time of the district aired a simple example is logically worth considering. keep your thoughts to yourself. but again, just sort of dinky and through, it's easy, it makes sense to people in my filson of the gaps in the short run. the place we are right now is his third place where we have fee-for-service and related care and then we have this month decapitated payment. you can imagine some changes to that which which we might come back to time permits. but then the fourth one weeks for the papers as capitation from primary care. put it back in one big pot and having two of my capitation for primary care. the point of this is not that anyone is the right answer. but that impact us were thinking

about incentives of the strengths of this. so in fact we would say there's a right answer except to what we do will matter. and so, there are these trade-offs among accountability cost containment like stability and administrative burden. each one of these capitation models is attractive because it really says do the best job he can with the idea that patient centered care is what we're all about, whereas if i make a list of codes, then you have to build these codes and i'm building some boxes, which says i know this is what it should look like in there some trade-off among those things. but the bottom line is that the panel will affect all of us as a model and how it evolves over time. so we just again and encourage the notion of more experimentation or demonstration. not to say and pay a different way the thinking through more carefully how that payment structure might affect what we

should expect to see if outcomes in the demonstration. thanks. [applause] >> so a lot of talk today about sort of primary care issues and what i'm here to talk about is basically the convenience care retail health care with all particular brand called minute clinic and i give you kind of what we're doing this morning. so the model is really based on the fact that there doesn't seem to be a shortage of primary care in this general sort of agreement about that today. and as a result of that thursday release for all alternatives models and the other point is try to get consumers to take charge of their health care. so those are sort of the twin

issues that were most interested in. on the third i say this as we tell them the pharmacy benefit management side of our business and more and more into behavioral economics try to understand patient behavior and provider behavior, thing that comes through is convenient and that's what we're trying to offer is a very convenient approach. impact of the most of our sort of retail pharmacy model is a son. so those are the three things. we're trying to drive savings in the health care system both by improving quality and without sacrificing quality. so you can't read the thing. it's too small for me to be on top of that. but the basic components of our model that we use are board certified nurse practitioners who are trained to basically take care of acute and chronic illness. and then we have a medic position that does certify medical supervisors who oversee the care being provided for review of 10 to 15, up to 20% of

the charge that the nurse practitioners complete for quality purposes. the nurse practitioners based on electronic records were completely 100% electronic. there's really no paper except that whenever anybody is a primary care your we see, we get that information with a primary care doctor. the primary care doctor tends to prefer faxes at this point. so anybody who gets seen by us with primary care doctor gets information that were falling a number of ways which are trained to alert tronic into whether medical records and that's actually starting to come through. for cho certified peer plans go from magna status from the american nurses association, so were trying to do their quality through various different kinds of certification. this shows that we are cho accredited. the guidelines are sort of built

into the electronic medical records so you can't get off guidelines. and that's important because we were going to build to do is provide a regular service for people to come on, both agents and their doctors can count on. these are the first for the medical homes which is basically redo disease prevention, health promotion in the perjury of other services. the primary care doctors are doing today, but are nurse practitioners are highly trained to do. so we follow the national standards apart is basically coming from a variety of different locations. we also adhere to the afp and ama is iraq's retail. afp has now appended these, but they make good sense, so we're continuing to sort of adhere to them. and we think it's important because some of things emphasize the importance of sort of fitting together the primary

care. and think when people they're concerned about is convenient scarcest kind about their and minute and then not integrated. and that's our key issue really is how we integrate this care into the individual primary care so that people aren't disintegrated rather than integrated. that's why we're spending so much time and effort trying to understand how to make these information technology connections. as i said, the whole thing is basic proposition of the factoring of primary care doctors and sort of everything we see from the emergence of more diseases associated with the abcd and diabetes as well as primary care workforce and more people moving into so-called concierge practice and seen down a number of patients that they see. and even sort of the rights and reduce medicaid and medicare patient so there's going to be some physicians who don't take care of patient and payment mechanisms. we think there's going to be sort of a lot of people who are going to need every cared and

you weren't going to be able to access. so we've seen about 7 million patient, our volume growth in 2009, which is about 49%. so i come from a health care services background and will use about chimeric care and any other business we were usually very happy and nice voltages. so this growth is really extraordinary and we see that sort month over month basis. also recognition of the concept is increasing dramatically over the course of the last six to eight month period so we don't think there's going to be any real shortage of business you up with better satisfaction scores. we the same system we aussies in the hospitals that we perform sort of extraordinarily well on that because people are pretty happy with the care provided by the nurse practitioners that they're going to have some discussion about that today is certainly in the volume about the quality of care rendered by nurse practitioners in the primary care setting.

suffice it to say the evidence is unavailable at the quality of care is excellent and certainly our customers are appreciated. so we've got a fairly highly satisfied customer base. we've also have some information on sort of quality of care. as i said we'll regroup up 15% to 20% of our church to get a good view of what's going on with regard to quality inherent to structured guidelines and that's reflected. there was a paper in this issue, but last year they published an article in internal medicine which is the provide most of the convenience care, but we didn't have anything to do with it and it was put together independently by the authors. we've no idea they were really doing it. what it showed was that the care that was provided was high-quality, and frankly a little bit better than urging care and certainly virginia department karen also less expensive. that's what were trying to do is

render evidence-based guidelines right into the care that's provided to follow protocol, make sure that care is high-quality and is less expensive, fits a particular niche of primary care, which has not been sort of wall served right now and probably not going to be well served going forward without these kinds of clinics. so the way in which were thinking about the medical homes as i suggested is this sort of first floor, so basically people who have chronic diseases and that's our focus. our focus in the past about acute disorders and will continue to do that in flu shots even in the direction of diabetes hypertension, high for hypertension, hyperlipidemia with service testing and comprehensive follow-up for those types of disorders. and as i said comeaux working on connectivity right now. we provide rate it collectivity with most medical records for with more record to sort of

integrated directly in with the physician's office information and the like tronic medical record. but we feel like that's something that feels like we've got a real handle on. with about five or six pathways that were pursuing and i suspect over the course of the next two years will be very supplicating information back to the primary care doc airs is really the key affair. this gives you some sense about how we talk about primary care tenderly anybody else would think about chronic care. but it does emphasize what it is that we would be doing in terms of counseling, out of reach, health promotion type activities and integrating that with some other services that we would offer in the retail clinics. in the last thing is that we need specific affiliations. and ran about 18 metropolitan areas right now. we've got 500 of these clinics had any to those we're reaching out to integrate delivery systems to work directly with them. for mutual referral purposes, but more importantly for us is that we have sort of primary care medical homes at the

second, third and fourth floor as well as secondary and tertiary care that we can refer into. and those discussions are going very well. you know, at first i was little of that because i thought people would say why would want to talk with you, but it turns out most of the leadership of these integrated delivery systems can see this is not an area in which they've excelled in the past and they're probably not going to sort it do in the future. if you look at the payment mechanisms, if you think about sort of a set capitation approach where we take on this workforce that capitation, that's something that if your cat potatoes of any sort of aclu are going to be interested in having a partner to work with especially because we can offer the convenience a reasonable number of sort of locations and we've got highly trained nurse practitioners providing the care. so we have relationships with unlikely that can cut the cult quest and probably with a chorus of the net 16 weeks will announce another eight, 10 to 12 of those kind of affiliation for

my kids as a whole set of partners with whom we can work in terms of making sure those got this integration with electronic medical records. once we get those completed will begin to expand the number of the retail clinics because we think that there is going to be sufficient demand out there for it. so i think that's my last flight. and when we stopped there. thank you. car caught mac >> thanks, troy. just quickly read co-author of a paper about some activities going on in rhode island where buyers and purchasers have come together to inject more money into primary care. perhaps you would want to say a few words about that as well. >> well, actually i'm sort of an observer, but chris kohler, whose the insurance commissioner after, good thing about rhode island as you get anybody who sort of involved in health care one way or another roundtable --

>> and a small table at that. >> although they don't talk very loudly. nonetheless, but it's interesting to see what happens because there's a lot to talk about. there's medical homes and health care organizations of conflict that, but the cash that's one right now is probably not very substantial. what chris says is that we're going to look a sort of some good systems like i said sure. the percentage of the total dollar succumbed to guys and over primary care and they came back with estimates of 11% to 13%. and they looked in rhode island what are going to primary care. they said 6%. and so what they did a set of a five-year period of time are going to increasing 16% to 13%. so which are theirs and increase the that has to be spent in primary care. there's only two big insurers. united and blue cross blue shield of the landing exactly dominate market. and so, what they have to do is begin to identify ways and which they were going to sort of pay

for it new kinds of services by primary care doctors. and they have this new money coming in and they had to sort of figure out what to do with it. and sort of shows that if you actually certify cash on the barrel, it is to sort of lubricate creativity. and so there's a lot of really -- >> amazing how it works. >> amazing things going on there and so we wrote that up in the volume. great >> great. well, let's reflect again on what we've heard from this panel. first of all, we heard from paul, making other symbolic of the patient's other primary care collaborative has truly launched a social and political movement. i don't know do not say a fetish have fetish dolls that they carry, but it is a movement. it is a movement to essentially move from the world's best partial list only to the world's best comprehensive. and as he mentioned, are partial

dissent is extraordinary, such that even japanese gangsters come here to get their livers transplanted here it i didn't know that, paul. we might have to reset up as a health affairs story article. but when he's describing is essentially not unlike what went on with the auto industry were w. edwards deming figured out how to do quality bean production and nobody in the united is listen to them but the japanese did and it became the toyota production system. and we can clearly hear how some consultants and others basically informed the samples of spain and denmark and other stupid and place the kind of comprehensive primary care systems that we should than instituting all along. as paul said with a clear incidence where you saw the lower house of the admission rates, lower we admission rates across the board i'm essentially an boeing announcing a 20% cost reduction from the patient under medical home.

one third lower cost overall for employees and ibm who have a relationship with the comprehensiveness. so they should be a slam dunk at this point. now, you've been hurt from katie that there's going to be lots of different ways to pay these models and is not going to be any single right answer, but we can let the flowers bloom. anything for the q&a that came out of the 1990's care to capitation, this is somewhat reassuring that there could be other ways of being paid to don't necessarily result in all the negative incentives of the managed-care arrow. and then we heard of course from troy about how cbs caremark is attempting to be the first floor of that medical home, but also more broadly attempting to build a kind of comic davidian coordination capability that we all deserve throughout the health care system. and with 49% volume growth in patients, troy, in 2009 i guess something must be working. you must be concluding that cbs

caremark. so i guess the question then is back to you, paul. the search recommend what to open this up to questions from the audience. you've got a lot of people engaged in the social movement. we've got now the capacity for the government to step in and institute pilot projects unaccountable care organizations and patients and medical homes. but it doesn't look like we're quite at the tipping point yet, or maybe we are. what do you think? if what you describe is really out there and have been, we could begin for just phenomenal in the organization of the delivery system a change in the next two years and probably o the curve, but are we? >> i think we are. i think we really passed that tipping point a year or so ago. i think probably one of the dod and the da both stepped up and

said this is our future, this is the workforc we need. and the social engine that they have both had, you saw what the dod and the va did after world war ii. i think they have the same social phenomenon. and i think that the large employers really stepping up and say we value comprehensive primary care. we value the primary care providers, the comprehensiveness and that's what went to buy. if you would pass the tipping point. i think the train has left the station. i think those systems that are embracing this in the earlier to do so this are going to be the future mayo clinics. they're going to be the ones that really succeed a center authority showing that and i think those that don't will fail. a phenomenon that i don't think americans understand is that i spent quite a bit of time in denmark and the gains have gone from 155 hospitals in 10 years to 25. a profound change where chronic

diseases are no longer things that happened in the hospital. this prevented or care is provided at home. some remote monitoring with technology that delivers information that's actionable, right into the medical home. that technology that the 60 billion that's coming down the pipe right from that era is going to do to the doctor's mind about what x-ray has done for their vision. ..

and private practice how do you deal with getting the primary tagging to the interests cities? i don't think there are any models for the symbol of by some jerk or may look like getting to the inner cities. on the other hand, we have got in the pocket and mandate for 2013, 2014 that medicaid pay primary-care doctors medicare rates. obviously that is a start up but how do you get the integrated system? >> also the capacity for medicaid to offer the medical ho model and to join that authority >> anybody want to touch that?

>> i think that is an important and fundamental question and i do think that it takes real looking at how we attract folks going into delivering comprehensive care and it also takes restructuring of the model as we talked about. i think for the first time in history we are no longer going to the geographical tracked where the doctor is. my employees in denmark have 70% of their encounters asynchronous lee using portal solutions and technology. sprick meaning they are sitting in their home or office is and having e-mail or teleconference contact with primary-care providers? >> that's correct. i visited a young physician and florida who has gone from an average of one patient hospitalized for an asthma tuzee wrote in 19 months and i watched what happened and that

phenomenon. and in this case the folks were using their text messaging phones and in power by the primary care provider to do a better job of medication management of integration. i sat in that office and watched a care coordination nurse talk to an asthmatic the mother of an asthmatic inner-city person about medication in power met and management. those kind of tools we are not even thinking about them that they are there already and being used in the parts of the world's we will see a fundamental shift of how the delivery is done. >> i think in the context chicago, and i don't know how much it generalizes, part of that is going to depend on how the command of the health center ramp up works and we've heard a lot about increasing the length support for them and improving their footprint and how they didn't agree to or not into bigger systems ^ least in chicago it's great to be a big

piece of the answer to your question. >> for us and nearly we've already made the investment in terms of inner-city retell pharmacies, the invested capital was already there and it is a good model. medicaid payment is fine. the critical thing for us is working with the community health centers and we are working on a set of experiments right now within the week of community health about how we coordinate care. we want to pull off their care that is where we need to integrate especially for a medicaid population in the inner city. >> another question let's take a question right here in the front and get a microphone over to you >> i want to know what dr. grundy and merrell think about the clinical concept and

how it fits into everything in the medical home aspect. >> a cui just let another elephant into the room. go ahead, paul. >> i personally think that if it is used as an integrator rather than the value and address some of the issues about projecting into the inner cities and other places like that. again could be potentially powerful. i think if we don't increase it in an integrated way as a purchaser of care i don't necessarily want to pay for that care unless it is integrated. i don't want one fragment or integrator so we are working hard across the system to the integration and i know that

detroit is as well. >> let's introduce the word convenience into the equation because as troy mentioned the analysis suggests convenience is a huge motivator for people to access and you talk to doug in marketing 24 slash mix of and access and it's not possible to have 24/7 access unless you access the choice is either of the emergency department or the urgent care center. >> absolutely. when my survey my patients they want access and convenience and a relationship. those are the things they tell me they want in the care they get and they can't get access to your convenience is difficult given the way the current payment structure is. so access certainly can be satellite facilities. they can be systems that have afterhours clinics, convenient clinics. they can also be a portal with

an e-mail and in the danish model it is telephone and access 24/72 a physician said every comprehensive test can cover for every other and the response time is two minutes. so you can call your primary care provider and if your primary care provider doesn't want to call the terms of the clip but he will answer on behalf of large, what can i do for you. [laughter] a couple of names at random. [laughter] so, you know, there are ways of doing this, much more convenient ways of doing this with technology as well as with points of convenient access that a minute clinic can provide. >> katie? >> they represent evidence of the demand for something in the health care system and it is convenient, location, whatever it is and because i think like

an economist that is going to persist whether it sits in to whatever the paradigm is so if we move forward for the definition of a medical home and you're supposed to see this particular guy or practice so it doesn't have access or convenience you are still going to go. there's still demand for that and disconnect between what people want and what is created and to me as a payment it would affect the nature of the contract and one of the things we haven't talked about at all but i still can't get anything to talk about maybe so i am a topic vv combat the topic is what is the command that on a patient side if i am getting a monthly payment whether it is a small marginal one or a bigger primary-care one how do you get me, katie merrell to sign on and never promised to see anybody else and you are getting a few dollars a month as my medical home i need to honor that and not see him. but if we don't figure out what

the accountability is on the patient side and it's the mechanisms that it created don't suit the patient there will still be demand if they are not integrated into part of the answer and you are going to get a bunch of money for eyes for no reason and i am going to still go see troy. for me there's a canary in the coal mine about what people want what they are getting it or not and whether they become a part of the new into the system or not. there is going to be demand or not depending how the mechanisms suit the needs they are currently meeting. >> of 50% of the kids and 50% of the adults don't have a primary care doctor, you know, so there's a huge medical homelessness out there and we can act as an integrator on that and by trying to get people plug into primary care. >> and if you do for personal experience i know this is the case. let's take a question back here

and then come over here. >> san francisco general hospital and this is a follow-up to both of the previous questions at a primary or practicing comprehensiveness. and after work on the terminology in the inner city with fascinating and promising to think of the minute when access to technical urgent care initio site want to ask troy what is driving the shift of the current year? is it people are coming into this saying i want my mammogram or buckson nation or i want my diabetes check or is it they are trying to capture these people as they are coming in for their sore throat and spring ankle? >> we think there are on matt needs for the population we feel a lot of people don't have primary-care doctors and there is a lot of untreated illness as well as you look at the sort of

literature on how people are doing with regard to the simple things they should be taking their medication and been on the right medication. we have never had at six months people are chronically ill about 50% at year end so they are not taking their medication and from the evidence based guideline literature about 50% of the time you are on an effective regimen. you have per se especially when we are dealing on the site where we are basically the pharmacy benefit manager for large corporations or insurers what we're seeing is we can get people on basically generic medications the will treat chronic disease and all of that brings down the cost on the healthcare site. to some extent that is what we're interested in, where health care cost it's also a business model because we think there is so much on matt need. that push is easy. it really forces us into the integration because what happens is we began to do that and find a lot more sort of underlying

disease and then we need partners. you can't operate at an isolated acute care model of the planned. you need good sets of hostile physician partners to the will to work with. >> you are a essentially going to have to make referrals to higher levels of care. sprick any organic relationship and that is what we are building with our carrier partners. >> looks to a question here. >> craig and matt pact. i want to follow up where katie was before but with paul. what is coming on in terms of how the reimbursement is in denmark also with what is going on in boeing in terms of medical home and patient responsibility in those places. >> under the danish model first because that is a pretty

interesting model they looked at how do you fundamentally enhance the occupation relationship and how do you reverse against that so they put their money there. in the danish model the primary care providers, the company insists are competing against each other in the commercial marketplace could build their own business and all of the partial lists were out of hospitals as consultants and they are all salary so that is the beginning and they are considered a cost center so the company insists build their own practices and are reimbursed on three mechanisms about three each. it's about service delivery. so how efficiently and quickly and effectively i deliver service is about one third so they are paid more if they see a patient in two hours or significantly more if the answer

their e-mail in 20 minutes and they are paid more of the 24/7 coverage as part of the integrated coverage system which decreases the amount and one is capitation so they are paid in order to make sure that the population is a sense of who belongs to the medical home. so i traveled denmark and i asked every danish who is your doctor and only once did somebody say i don't know the name of my doctor. i should but i just called them by their first name. [laughter] >> so the third component is fee-for-service which is about one third and that is to incentivize certain services to be delivered as the primary care level. sofa mole is being removed, colin a speaking scope and they are considered a primary care services and the partial lists, specialties of the part of the body are salaried and they're

dependent on the feedback the system gets from how well they service the comprehensiveness and the patience so it is a system of transformation. here in the medical home models that have occurred that are in a lawyer based, you know, some of them i would call corporate concierge medicine where we build our own and paid for eight and we hired their own physicians. the example was a contract relationship with group health in seattle and they basically paid for that. some of us, many of us have been part of all of these pilots. ibm is part of a number of them and our other large employers and we work with our health care plans. they pay more, they add that component of the fee-for-service or capitation per month so $12

per member per month or something equivalent to that to prime the pump. but it's been part of the last three or four years to do what we call the four process to begin to change health the doctors have the money to change the systems we have been doing that in various pilots. we now have i think about 44% of employees the largest corporate employee on vermont. 44% of our lives now enrolled in the home in vermont and the patience love it. they just love it. it's phenomenal. and the doctors, many of these practices the doctors feel more satisfied about the care. in rochester we work with the two largest employers of the mayo clinic and ibm and we work with them and actually have built out nurse practitioner

based convenient care facilities in the community and we've migrated care to the medical home model for both our employee population and over the past three and half years we've seen a zero trendline in cost that was on abc news. it's phenomenal because you see of the cost escalations were talked about 46% increase etc. being passed on by some of the health care plans now cover zero trend line in three years. >> or as by singer as seen five to 7% of the curve through the medicare advantage payment model and the medical home. there was one hand back here. what's to the last question and then move to a break. >> melissa clark medical director called access health management and one of the things

i haven't heard touched on all lot here and there is chronic care and health care a lot of it really is self care, the behaviors that are going to prevent diabetes and heart disease from happening down the line. to what does it extend lagat models of primary care profession that emphasize the healthcare aspect and health care can be provided and extended beyond the office visit either through health coaches or other kind of models that provide more real-time support. >> you will probably could borut that later on today as we talk further about the model that you are absolutely fried and i think it has been one of those agencies that's really benefited to the cadet at the forefront of figuring out how to project those kind of models at the point of care. it's pretty interesting what

you're doing. i've been watching and paying attention. and i think you're absolutely right on. the example of the asthma and asthma control was all about self management and in power in patients to do something. and some of the work we are doing for dicing are we are going beyond providing information and providing predicted in formation about what has been happening to you if you don't do this and that's really going to be useful. but i think it's about in power in the the patient to do better medication. i visited a clinic in iowa. chris kozinski and i think there is a paper on here, very powerful. it was an 84-year-old nun who came the day, a diabetic, and chris starts asking this leedy

about her lessons and then after two minutes of relationship building with this patient, the patient and nurse care coordinator go next door and design a plan for the whole year and there's a whole discussion about in power mad and disease management and exercise and how we are going to have discipline to follow-up with you and follow-through on you and how you were going to follow-up and here we are going to beat you up if you don't. so there was a plan and discipline around that plan, and we see phenomenal results. we move to thousand 500 jobs to iowa. we are putting our money where our mouth is. >> are you treating offenders practitioners to be disciplinarians? >> well, no, but davis certain number doing the diabetes education course for example and we are trying to do not exactly how to integrate that with the

retail pharmacists and how they become part of the medical home and we think that is an important intervention as well. the only thing we are trying to do is the number of the disease management firms are working directly so we can do some complex with their twin on the phone and everything is tested. they have not panned out in this particular area of reducing cost services. we've got relatively capri of studies going on so hopefully we will not evidence how they work relatively shortly. >> agreed. spking of healthy behavior we are going to take a break now so that you can engage in some of them that our most urgent. we will see you back here in 15 minutes to reconvene the discussion. [applause] [inaudible conversations]

>> we will now move into our discussion about teams and you've been hearing a lot about the concept earlier from george thibault and his call for the educational system to begin to train people as team players on down the and we are going to hear first from louis sandy the vice president of clinical the advancement at united health group and united health again foundation having been an important founder for this issue. lew promotes efficient and effective health care to provide tools and information to the doctors and patients to promote health and foster the growth of evidence based medicine. previously executive vice president and chief medical officer of united healthcare and before that an executive vice

president of the robert johnson foundation. she's and intern and senior fellow with the department of health policy and management at the university of minnesota school of public health. we will hear them from eric holmboe for research at the american board of internal medicine. the foundation also having been a supporter of this issue. eric cleaves this section on a clinical performance services and oversees the board's research on evaluating the ongoing education of the decisions in internal medicine and some specialties. before he joined ibm he was assistant professor of medicine at yale medical school and also served as a director of the robert wood johnson clinical scholars program. then we will hear from joe wan pohl professor reck university of michigan school of nursing, and over the past 30 years has held faculty positions in the nurse practitioner and doctoral programs at michigan. she's also directed the adult

nurse practitioner program and served as an associate dean for community partnerships. recently she served as president of the national organization of nurse practitioner faculties. she also maintains primary-care practice in one of the michigan school of nurse management health centers. we will hear from jim cawly from the school of public health and health services at the george washington university and also the director of the joint position assistance master public health program and professor of health care sciences and the school of medicine. he is a certified physician assistant and has been for 36 years and practices primary care at the johns hopkins hospital as well as having had faculty appointments at johns hopkins, stony brook and yale medical school. and then finally we will hear from marie smith, head of the the part of her missing practice and clinical professor of ehealth at the university of

connecticut school of pharmacy. her teaching and scholarly activities include working with multiple health care reform policy makers to address public policy issues concerning the health and informatics as well as an can significations safety and improving patient adherents. she was formerly vice president for e strategy and integration at pharmaceuticals north america commercial operations. so, let's turn things over to lew starting on the discussion of teams. lew? >> thank you command good morning everyone. i appreciate the opportunity to participate in this symposium and on behalf of the united health foundation which is an independent foundation supported by contributions on the united health group, we are really pleased to have been able to provide support to this issue and to the symposium which i really think it's incredibly

important incredibly timely in the post reform era. in thinking about how to frame the up my comments for the purposes of our discussion about teams, rather than talking kind from a policy perspective i guess i thought it would be better to share a kind of expert initial view of teams. susan says kenneth like the mayor matters narrative for health affairs because i've been -- i practiced primary-care internal medicine for over 20 years and i practiced in a variety of settings with a variety of different structures. and i thought i would kind of tell you about that as a kind of set up and share some perspectives based on that experience. i want to go all the way that i was in an integrated premedical program at the university of michigan and my first experience really with clinical medicine i didn't come from a family of doctors. i was -- i had a course called

the impact of illness on families, and as a part of that i had to go and follow a family around and understand how they interacted with the health care system. this was before i knew anything about anatomy or physiology or anything like that so i went up to a small town in the upper peninsula called crystal falls michigan that was a tiny little place and the entire medical community was constituted by a family physician, surgeon, a nurse practitioner and a pga. and what i found was a sort of early in printing in my experience was that this was the medical care team the had to practice as a team because there was no alternative. that was it. they took calls every fourth night, etc., and worked in a very interactive way. so that was kind of early in printed of the idea of teams from my perspective. i did my internship and residency at the hospital in

boston, and i went there because it was a very strong the clinical program in internal medicine. i haven't really realize until i was there that it really had a strong focus on nursing, the idea about a primary nurse, this is the work that george clifford and many of you may know pioneered and they also had a firm system of kind of medical home for the inpatient care which is fairly common these days and the nurses came around and interacted and the nurses provided continuity so i kind of learned early and in the middle of my medical training kind of how nurses work to provide comprehensive care in a very different way not a physician centric wave away many traditional medical programs are taught. after i did my fellowship, i wish to join the harvard community health plan and at that time the entire care model for primary care was built

around teams, nurse practitioner teams and i think very exciting and i think our panelists will talk of some of the commonalities and some of the differences for example between the nurse practitioners and the p.a. in a primary care setting. then i made a shift into philanthropy and joined the johnson foundation. i was there for 12 and a half years or so and many of you are familiar with the rwj investment in the work force not only primary-care but in the mt and p.a. and nursing in general. when i was there we were heavily involved in chronic care particularly the ed wagner chronic care model which as you know, many of you may know essentially emphasizes plans protective care for people with chronic illness based on a team approach. so again, very good. we supported the demonstrations of that model. so in addition to further investment in nursing and things

like group visits and other approaches to the team, the beginning of thinking about how the relationship between the practice and redesign and teams. in 2003, i switched over and moved to the united health group, a diversified health and well-being company and this predates my time there but united healthcare had been innovators in the role of kirkuk ordination and treatment decision support really using -- and this came up as a question on the last panel the use of the telephonic these nurses that deal with the fragmented care and the unorganized care that is very common and is the mobile practice of care and medicine not everybody unfortunately gets their care and places like guy sinner, group health were permanently so this was the way to help facilitate and build a different kind of team, and extended team that goes beyond the walls of the practice to

organize and promote primary-care services. fast-forward to 2007, 2008. you heard previously about patient centered medical home. my apology for the typo, the acp is the acp in the slide but i suggest the pediatricians may be to rename their organization the american academy of comprehensiveness pediatrics or something. [laughter] or just fix the slide, either one. but my apology there. the principles of the patient centered medical home, and i think one of the things i was so gratified by in that experience is not only the initiative but the collaboration between the primary care societies and us in the design and to the limit of the primary-care models the that you heard about previously. there was a different kind of team of organizations working to get her to advance these models and really kudos to the primary care societies and i really want to make a shout to paul grundy

and his leadership of the primary-care collaborative. that really had a huge impact in helping advance this as well. then finally, this year coming to the present, just a few weeks ago, we launched a long and collaboration with ymca, walgreen's and the cdc the diabetes prevention and control alliance, quite innovative model of not only diabetes prevention working with groups like the body or the ctc but a diabetes care management program in collaboration with walgreen's and another example of the use of the pharmacists and we will hear on the panel about that as well where community-based forests can play a critical role in care management we believe and this is kind of a new iteration of quite an old idea. the idea of community oriented primary-care. so that has been my lived

experience and i guess it seems to me when you think about teams, the question is to be absolutely fundamentally need primary-care the answer is yes and you were obviously manifested in that. does it have to be delivered in teams? the answer is yes it is going to achieve the goal that we seek improving quality having effected access and bending the cost curve. it has to be delivered in teams. there's more than one configuration of teams, however, and that is what this panel would start elaborating on and responding to the questions. i think in conclusion it seems to me this idea of primary-care we really have a diverse set of models and we have an opportunity in the post reform era to accelerate the process of social change that paul grundy said and we have to. it kind of reminds me of winston churchill who said you can always trust the americans.

in the end they will do the right thing after they have eliminated all of the other possibilities. that is where we are writing and primary care. and again, thank you. i want to thank health affairs and the authors for their contributions to this volume and i look forward to the panel on the discussion. thank you. [applause] >> i want to thank health affairs and eric holmboe from internal medicine and thank the research colleague who is the anthropologist to lead this study. he said in the audience today with us. some of the key assumptions that we've been making i think that hour we agree to the truth is that health care is delivered by teams. however, they are rarely recognized was supported especially in the inventories of things we talked a lot about that and my own experience much like lew's is there is the net

team in there but it's not been explicit in the way we necessarily work together all the time. we also know and believe team work quality is linked to the quality-of-care, patient safety and provider experience. so with that context, we thought we would do some field workers mostly to inform our own work at the board from an assessment perspective as how do we begin to develop an assessment approach that can help physicians recognize the importance of teamwork skills so they can actually use the information to improve care. a couple of the questions we had going into the research were held to the health care teams actually working context? and in thinking of the words from lew delude it to the fact when you see primary-care practice you've probably seen one primary-care practice. our own experience in another study that is in this issue is that if you look at the medical practice their highly heterogeneous with very different set of types of populations they actually care for. and how might the concepts approached the state current

practices? what can we learn everything about devolving this and moving forward? swedes performed it at the graphic research study where we put people into three different offices for about a week where we both observed and interviewed people if they were going to their care policies, talk with staff within the clinics as well as the physicians. you can see here that we picked three practices. one was a solo physician, one was a multi md university practice that it would trainees and we also had a small group practice that had qualified as a level three medical home. and what do we find? well, in reality what we've looked at these practices against a small sample but certainly consistently unexperienced there was little professional team work. physicians tend to be isolated from the staff also from each other. what we kind of label this was a frantic bobble and if you think back to larry's comments earlier about cramming in 25 patients a

day that kind of resonates with the general interest, some of general in terms like myself by treading that if that is when you are doing that is the hamster of what is the frantic a bubble and we also found that with the interests tend to have weekly schedule something on paper and a plan for the data that's not the actual schedule they experienced, right? so it's kind of this interesting experience physicians are living but some would silo from the other staff and the other office. the staff do collaborate. very creative in being able to fix and be adaptable so we call them the flexible team but most of the work during the day was not interacting the general physicians any kind of explicit way sciu could solve problems, but there wasn't any kind of planned activity during the day. some of them have staffing but what happened during the course of the day was for the position and the staff adapting to keep things and keep the train moving so to speak. so the patients we found many of them often feel disoriented.

we caught them in a limbo and what is not common for the patient to ask the researcher would do i do next? [laughter] where do i go? so what we found is there often was that a whole lot of shared communications here in the decision making and so i think that this is really kind of the current state i sure for many of the practices and it certainly was for me when i was a big deal primary care and this is what we are trying to change. and just want to highlight this slide again as a kind of mental model for the introductions are very important. one thing we haven't talked to as much about as important of competence, the people within the syst and the team. you can just put a bunch of homer simpson's into the practice. as much as i love homer by the way and expected to work. people have to have confidence and i assure you will hear from the people that follow the people do need to work up their level of confidence. i was very pleased to see from paul from the medical center where i was actually the chief

of medicine and we implemented the widener model the 11 years ago, and what i learned the hard way was i wasn't taking fuller advantage of by other staff including my 22 year old koren so i found they could do great job on the screening is better than physicians could do it. in fact most of my diabetics got the most important coaching not from me but from the nurse, had funders practitioners and that put me to work and we had to learn how to work with each other and and new interactive ways and in the clinics of diabetics as larry pointed out in the closed system i could make the case i would only see eight patients a day because i was right to take care of the complexities for the group but i could do that certainly in the team system of the military that i was set harder for practitioners to the those are hard lessons for me to learn. i had to basically give up some of my current ideas. and i also might not the confidence also matters with regard to clinical skulls and diagnosis. i am reminded of an article that paul wrote about one of the staff who basically got a workout for non-cardiac chest

pain over $100,000 although he is the primary care physicians would have helped the competent physician would have thought, too, they had a good history making proper diagnosis about $125,000 earlier. so i think this is a fema that has come up today. this is another way of looking at it and a chilean village stand philosopher said the blind spot of contemporary science is experience. what he meant was if you leave from what you know when you're past is really hard to envision a different future. and i think part of what we are talking about is giving up our path assumptions to create these new care models and that's where to be the hard part so i think part of it in addition to the important stuff that leary and others talked about is going to mean an attitude shift. i certainly have experienced what from 11 years ago i had to change my attitude about how i was going to do my work. i will just leave you with this rtoon. sometimes i think a

collabut y. [laughter] not the way to turn it over to the people that made my clinic work in the military. thank you. [laughter] [applause] >> first call i want to thank susan for her leadership on the conference today at health affairs. i absolutely didn't think i would see this in my lifetime so i am very pleased to be here and i also to thank the macy foundation and george thibault's leadership because the paper in health affairs that i and my co-authors wrote is a commentary and a shortened version of the much longer paper there will be out in the macy piece in just a few weeks. i actually plan to use the health affairs addition with my students in the classroom as i look through it as well as the macy manual when it comes out. primary care is the foundation

of our evolving health care system. you know what i can't even see that. [laughter] interesting. i didn't think i was that short. [laughter] primary care is the foundation of our revolving health care system in this country. i also didn't think i would be able to say that in my lifetime. if access to primary care for all as a goal while containing costs and focusing on quality of comes, then the nurse practitioners will be crucial to achieving the same as. let's face it, in the current system there just aren't enough primary-care providers to go around and meet the needs. with an additional estimated 30 million people having access and needing access to care based on the patient protection and affordable care act we will need additional providers more than ever. physicians are not choosing primary care for very complex reasons. we've heard about those this

morning and there are more papers in the health affairs addition on that. on the ever had, a strong majority of nurse practitioners enter the nurse practitioner program because they want primary care. they ask for them specifically to provide primary care to the nation just as i did more than 30 years ago. in our paper, unleashing nurse practitioners full potential to deliver primary care and lead teams, we argued that two areas in particular must be addressed before a nurse practitioner will be able to fully contribute to primary care delivery nationwide first, they're must be changes in the state by state scope of practice laws and regulation of nurse practitioners. this is because the diversity of laws and regulation of nurse practitioners, this is because the diversity of state regulations on the scope of practice and prescribing authorities have been a major

barrier to fully utilizing the nurse practitioners and providing increased access to quality cost-effective primary care. many of these regulations or outdated and not based on any evidence that care is better or safer for the nation. second, they're must be substantive change health professional education that will foster true collaboration not like your slide their three the true collaboration and teamwork among physicians, nurse practitioners and other health disciplines in general so as to capture the full benefit of diverse competencies' inherent in the true team. the nurse practitioner role is relatively new having started about 45 years ago at another time there was a physician shortage especially around pediatric primary care. currently there are more than 150,000 nurse practitioners nationally.

66% of those are practicing in primary care, very different picture from physicians and 20% are practicing in floral areas. interesting primary care continues to grow so that yearly there are now about 7,000 new graduates who are prepared for primary care rolls and the number is increasing yearly. there's a substantial body of literature over the past four decades that consistently support quality, safety, cost efficiencies and very high patient satisfaction with nurse practitioner care. nurse practitioners achieve outcomes that are equivalent to or sometimes superior to the outcomes of the professionals and match and exceed national benchmarks in measures around chronic disease. nurse practitioners are pleased and ready to fully participate in the solution of the current shortage in the national needed.

however, the hodgepodge of state regulation present enormous barriers to the full utilization of nurse practitioners and access to care. removing such barriers to practice makes sense and the wealthy in peace to practice to the fullest extent of the preparation and practice under their own license, not under another profession's license as is currently the case in many states. it is critical to point out that removing the barriers does not result in exceeding nurse practitioner academic preparation in any way. it simply allows them to practice to their fullest preparation. there are barriers to reimbursement as well with some insurers refusing to reimburse nurse practitioner care and others requiring hourly and necessary physician supervision that again is not based on any evidence the patient care is better or savor with the supervision.

and in reality it is virtually impossible to sustain such supervision in actual practice. this on necessarily supervised care based on outdated regulation is also more costly. we believe that nurse practitioners must play an enhanced role in primary care as members and indeed leaders of interdisciplinary teams dedicated to coordinating and providing pension centered care. np's have made strides in only 45 years towards self regulation that now includes standardizing educational competencies', accreditations and certifications. standardizing license regulations across states is just reasonable. there is no evidence that restricted regulation protect the consumer. there is more than enough work for all of us to do. we can do that working together in teams and sharing responsibility for the patient's

health. this is not about competition. one provision versus another. it is about leveraging the resources and skills to produce a more effective system that produces better health and better care at lower cost. although the recommendation to remove practice barriers is necessary it will not be sufficient if our aim is to enhance primary-care work force. key to the discussion in the paper and especially the discussions at the macy meeting -- and i do want to stress this is an emphasis on the need for the professional education. increased access to safe and quality care will become available to more people if medicine, nursing and all other primary-care disciplines are able quickly to pioneer more substantial interdisciplinary educational experiences so that this team that we envision becomes the expected norm.

the ability for all health disciplines to practice to the fullest preparation and in full collaboration must be the optimum gold for patients and providers. the truth be told, quote the primary care is really by its nature very collaborative. no one individual or discipline can do it alone anymore. we recommend substantive change in the way health care professionals in all primary-care disciplines are trained, regulated and held accountable for the care each delivers. most importantly, we recommend that primary-care providers be required to develop skills and support effective collaboration with each other, with patients, families and communities. if we accomplish these goals we can dramatically improve access to primary care, create health care systems with lower overall health care costs and improved health outcomes. thank you very much. [applause]

>> are too would like to extend my thanks to susan and health affairs for the opportunity to be here this morning. p as part of the health care team and we are created as a part of the health care team and it's my task this morning to tell you a little bit about the p.a.. first foul acknowledging michael officers, rod looker and bill from the american academy of physicians who share data with us to tell you of a unique attribute of p.a.. but before i do that i wanted to add a bit of historical addendum to dr. how will's presentation. he enjoyed with the demise of the american gp there was the

rise of family medicine and several other approaches that were designed to augment the delivery of primary-care. and one of the notions was the physician assistants and some of you may remember one of the giants of academic internal medicine, dr. james, had the notion that the epa and the m d would be a team that. and it turned out to be pretty successful idea over the past 40 years. and as we know, we are closely linked with physicians so we are sort of bye nature team players. so i want to tell you what's happened a little bit over the last 40 years or bring you up-to-date in terms of what has happened to the p.a. professional over the last 40 years that we too have changed but remained a central members of the team but also to describe to you what some people refer to as the capability of the p.a. to

move along specialties. we call this clinical flexible a. some have also referred to the p.a. as medical work force stem cells in that they can go in different directions. and the policy implication may be very important and i will mention the fact i will describe what i think the policy implication of that capability may be. unlike the profession when it began, the p.a. profession like the medical profession is not predominantly women. 65% of all of us and young women make up the primary recruits to the profession. we are still a young professional age 42, and most of us who have been trained as p.a. remain inactive clinical practice. but we've been affected by specialization and as was described with regard to the medical profession, this wave of

specialization and sob specialization has only affected physicians, but it's also made a significant impact on the utilization of the p.a.. more and more of my colleagues now are working in some specialties and specialty practices and the reason for this that i believe is similar to that that was stated with regard to physicians, the level of debt of the p.a. students is substantial and physician assistants students tend to get the same messages as medical students with regard to specialty and sub specialty practice. some of specialist physicians have more wherewithal to hire your physician assistants and pay them higher salaries. our students want to relieve their debt more quickly so that the same forces that affect medical students and early physicians in their careers through terms of specialty choices affect physician assistants and as a consequence, now of 65% of all physicians

assistants are working in specialties and specialties and we are not about a third and primary care but i do have a solution and hopefully i can convince you that this may be possible. this is an incdibl complex slide, and i don't want to intimidate you or i don't want to cause you pain in trying to read it. but the point is physician assistants, unlike physician colleagues and on like actually the colleagues in the nurse practitioner profession, have this capability over the course of their career to change specialties. and if the data that we have in our article is the first attempt to document the movement of physician assistants between and among the various medical specialties. this is a unique capability and if you look just at the second to the top bar you will see the percentage of physiciany medici.

i believe it is 53% and 53% of vara coleworts of the p.a. initially chose family medicine and have remained in family medicine. but the subsequent bar going across horizontally show the percentages of the physician assistants who went from family medicine into other specialties. and you will also, if you look, you will see that there are percentages of assistants who started out in the emergency medicine who later on in the course of their career moved into family medicine or other types of family or general internal medicine or primary care specialties. so the notion here is a physician assistants have the capability to go from primary-care into specialties that is amply demonstrated. but we also have the capability to go from specialty practice into primary care.

and as you can see there is also a fair retention of p.a. who remain in their belly practice or general internal medicine. the policy implication here is the pa can be a solution to primary care problems and primary care, the shortage of primary-care providers. if policy makers provide incentives for physician assistants to go into primary care or to re-enter the primary care we can provide some strength to the primary care work force in the short term. as we all know, the pipeline for physicians and physician training is lengthy. we can treat physician assistants in two years. the model was one where it is of general medical training and one that is closely linked to the physician and this is key to this clinical flexibility attribute. so my hope is that you not only

have gained a little more appreciation for physician assistants contributions infil merkel workforce but policymakers will also consider the notion of providing incentives for not only physicians and more physicians to enter primary care practices and choose primary care residencies but to include the p.a. in the picture and provide incentives for them not only the new ones coming out of the individuals who may be in primary care or may be in specialty practice who may want to come back and become primary care providers. thank you. [applause] >> good afternoon. i think i'm the second vertically challenged speaker that we have today. [laughter] but i have a little slide you. first of what is a thank you to health affairs and also to the co-authors on the paper for many of you know well. david and paul and have worked

within the past. let's see we will get started. the title of the paper given by the editors is why pharmacist's belong in the medical home. however, coming from you, we do take team work pretty seriously up north. so i like to think from conversation purposes of a team sport so that is, if the analogy that i will use and i thought the first thing i was hoping another speaker would beat me to it but we didn't have the face of the patients i will tell you about a case study. this is a 90-year-old white male who has a cardiac disease and has had a bypass surgery and taken seven chronic meds a day had he read and can be verified as being accurate and as a primary care doctor and five partial lists i guess if we look at paul grundy's word goes to a pharmacist with antiquigley some clinic which is kind of novel in the long practice, not something

that is ubiquitous by any means, has multiple prez garbus, very motivated self management there is a question earlier about the pieces of management and house an extremely good support system when you think about it and has a spouse that she would say -- or he would say she is the adherence coach in the family model and s three daughters who are cared coordinators it navigators. and this patient has great access and tremendous coverage. so those of you who know me in the audience know i don't practice, buckles and you are going who is this person? well, this is my doud and this guy doesn't get away with much when it comes to the case management. and the other side of the story that i know as a person who is one of his care coordinators and navigators who happens to be a pharmacist is that he's had multiple preventable medication misadventures would be the nice y