solve the problem of primary care unless it is a final transformation of the work day. that require to change the pay systems. here's edward bear coming downstairs now, bump on the back of his head behind christopher robin. it is a forcing of the only way of coming downstairs but sometimes there is an ugly. if only he could stop bumping for a moment and think of the. that's how i felt for 20 years in primary care. i think it's way most primary care physicians do. they understand things are not right. every day was like going to war. there's always chaos. but really, you don't have much time to think about as a primary care physician. even if you could come up with a solution it would matter because of the way your page. basically if you want to do all the good things that they do is you do them for free on your own

time. that is basically the way his. your kids grow up without you at home. so a quick background that i would say there are two key components of the patient centered medical home. one is the old fashion primary care, the kind of things susan mention. first contact comprehensive. the image all of us have of a primary care physician, which is, if you don't have one like that, it would be good to get one. but then there's the kind of newfangled notions, much more about i.t. to take proactive care in an organized way, the entire population. not just the ones who happened to show up in front of you and not while there in front of you, but all the bases, all the time. so what is this transformation i'm talking about? most primary care physicians see at least 25 patients a day, some seeming more than that. but i would say that the majority of those visits are unnecessary. as face-to-face visits.

there are a very high-volume of operator respiratory infection, routine checks or high blood pressure or diabetes or other chronic diseases, much of this could be handled over the phone or by e-mail. some of it doesn't need or by other messes. some of it doesn't need physicians. but if it is is the only way to get paid is for during his visits. so just write about as fast as you can go. some call it hampstead year. and i would say that probably about eight to 10 patients a day is all their primary care physician needs to see face-to-face. that is basically the first visit was a very complex problems or emotional problems or there's something that needs to be done physically. something needs to be examined, listen to the hard for some reason or therapeutic the, need to inject into the joint. of the things people don't need to go for, don't need to get a babysitter, lose half a day of these going to the doctor's office. so how would physicians spend the rest of their time?

they would spend it in e-mail and phone communications with patients and families, without health care providers, and working with the practice, into action. this way, this is not a new idea by the way. many people have said this before me, but he gets very little attention. i have reviewed many, many articles about the chronic care model. if you read anything this has to be the way it is. almost every is explicitly said that primary care physicians need to be seen face-to-face, about a third of the patients they see each day. so i talk about the medical home to practicing physician. they come up to me afterwards and said this looks great. we wish we could do this but we are already working 10, 12 hours a day and this would just add more for us to do. how can we do that? so i think that for the patient centered medical home to change

ever for primary care to be a viable way to function, for the future and also to take care of all the newly insured patients that we'll have that when the primary care, these responsibilities can't simply be added on to business as usual. but most of the demonstration projects that are going on right now actually give little or no extra compensation for being a patient center for medical. you only get paid for the visits that you provide. and there are some practices that have people in them that are really into this annual make a go of his. but this will not be a generalized model in the united states unless the payment system is radically transformed. and how did i do, susan? >> you're on time to. >> i'm done. my main goal was to try to set a model to keep it to our time. >> thank you, larry. [applause] >> thank you, and larry, that

was a great segue in what we try to do in our paper, which was to look at medical homes and try to deduce from all the various demonstration projects, at least a top level of demonstration project what the core features were. i just want to get some kind of framing comments for why we decide to look at this in the white house in particular. so leading up to the development of what subsequently passed into law for health reform, we have been exploited across the country all the different levels of models, including medical homes, accountable care organizations as we delve deeper into these innovative experiments and pilot projects, some of which have been in place for many years. we realized that there were was discrepancy and it was not necessarily now intentioned, but there was certain a number of different criteria, and not give guidance on what a medical home really is. in fact, it became a recurring joke for those of us who work in health care, you know, where is

my medical and what is my medical homelessness, does that mean for me. so we really thought that 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 a look at the various i.t. so in our paper you will see a very kind of detailed look at two of the leading sets of criteria. one from the in situ a, and the medical home index. those are so not the only sets of criteria for a medical home. but they tend to be not on what the public sector as well as mature as the private sector looked towards when you think about what constitutes a quote unquote medical home. so looking at those features, we decided to try to take a step back and say, if we are think about health reform in a very comprehensive context, how can we fully appreciate where we are trying to go, given with what we have. so that gives you -- i want to show you because a lot of people ask me, what were you all

thinking in the administration or in the white house when you did what he did and put together the plan that you do. and i will say that a lot of the work that was done in the pocket is the new term to call it, was done well before president obama took the oath of office to elicit emotion by a lot of the researchers and folks that are in this current issue of health affairs. we really want to look at how the private insurance market as it currently existed and the regulation that we had in place as well as how we could enhance primary care access, come together and also complemented by the public sector. we put together as the secretary mentioned very significant investments in a quality, high powered community workforce, that includes primary care, community health centers, a lot of things than one mention. on top of that we realize the need for improved measures and reporting that was clear that in order to do all this when you do not only a sense of

transparency, but a real sense of accountability. and then finally and not to be late in the game, but we realized that that needs to be capped off with incentives for this type of coordination as well as truly payment for my. so when we go through, or as you go through the law as it currently exists, this was a little bit of a 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 homes, we try, as a major, we looked at the ncqa as well as the community medical home indices to see where we saw overlap. and instead of looking at the criteria against each other or looking specifically at which one met excretory and which one that why criteria, we want to take it step back and look holistic that what were the governments of the model home

and said i could give a look of guides, not just to policymakers but we realize that as we try to take medical homes to steal as larry pointed out, a lot of this would be a failure if we did also think about in sin is for payment. and that was i was taken a striking absence that we knows in the current set of criteria. that is not a fall to those who develop the criteria, i think it's very difficult to add an instance for payments or how we talk about payments to those criteria. but it is essential that if we don't couple that to provide, to hell system as well as to insurance plans on how to design these models and taking into consideration payments, that we will not have the success that we're all hoping we have. so you can scan across this chart to see, there's a lot more detail in the paper,ut ts gives you a sense of how we look at some very kind of large domains that do to ncqa as well

as to a number of other organizations which have developed criteria to give guidance to the professional. and you can see that there are some real kind of themes that emerge. we really identify the common features as you can see, the dedicated care coordinators, the expanded access to caregivers, data-driven analytical tools and incentives for providers. and those four, after looking at not just the demonstrations and the projects that are listed on this site, it's even broader than that when we did a literature search. everything came back to these really kind of core for functions that and i think in the remains of the talk today will have a lot of these things energy. and i think that the incentives for providers as i mention our leader is really a key. and as larry mention, if you don't talk about that and add on top of what a doctor already, a provider already has to do, you are really just giving them even more of an emotional burden.

and speaking of others be mostly burden of providers, i can tell you it's not a good outcome. so i wanted to just touch a low bid on a couple of these programs because i do think that one of the criticisms also is that people always do this in an integrated setting. so we, here, it's easy to do if you're in a very close captivity integrated setting. we think some of these models are remarkable and innovative, and i think that really show promise for the future to scale because we look at very high risk populace and a in particular north carolina which there is a separate paper about as well, that i think taking a close look at how places in states like north carolina in conjunction with not only medicaid in their state, children's health program, but also with adding on private payers have been able to do remarkable things. and as you can see, they're certainly more than just close integrate systems. although one could argue as we become a more integrated

country, it will be easier to do things like a medical home or medical care organization. quickly, i just want to give you some highlights and overviews of the outcomes. and i know that erik larsson is going to speak potentially a little bit more about group health and hasn't updated data. but as you can see, there was a very dramatic reduction across these programs. and i sometimes don't like to call them pilots because we sometimes think of the pilot is something that is not quite ready r pme te. i would argue that a lot of these are not only have they been in place for years, they are more than ready and beyond on time. but i do think we took the vantage point of saint howdy take some of these early adopters and early higher programs. you can see across the board with hospitalization reductions as the main outcome. some of the programs didn't have reported visit reductions that are now in stages whether they are looking at the. and that obviously the total savings per patient is annual.

so this is per year, not per month that i think some of the papers in the journal nature her month savings, taken into account. but all the savings kind of very across settings, but show and demonstrate that you do save money. all of that goes back to canada driving but we had in the white house and any administration that if you don't take criteria, the guidance for providers and systems, with consideration to the financial piece of this, then you're really going to be unable to generalize this. and that was something that we saw as authors was an important point to make. so i will just skip over this to briefly tell you about what we thought were some of the challenges for the future. and certainly i'll say that there's so much to celebrate and to be proud of in what we have accomplished, but as somebody who is very kind of concerned about implementation and what this law means, i will say it is

terrifying to think of how much work there is to do for the future. and we do think that looking, having as we did at the features across the board, it really is important to think carefully about what features are essential as we scale, and and which ones can very. what levels of operability for information technology, for example, are appropriate. no system is going to be a like. so how can we find features that should be common, dedicated care coordinator is and this physical person does always with the team, or a care coordinator that is virtual, for example. how can features like that very in a way that still giddy that same spirit of what we were trying to find in these examples. the other part is the matching of complexity of the skins in this. i do think there's quite a bit of need for technical assistance and and some of his rapid deployment of the system for people are trying to do this in real time. and india, i mean, one of the

remarkable things that we found was the inconsistencies in data across the programs. this is hard enough to ask people to do this, but then how to measure this, report says and how we can aggregate this data in a way that can be forward thinking and help us learn from our mistakes. finally, were to be systemic reforms fit into all that we passed in this law and how can we can look forward to will and might need to do to build on to those reforms. i would certainly argue we didn't do everything in this bill but we set a foundation as a second dimension to build on top of that. and then i had to add this in because we spent a lot of time this morning, and susan kind of kicked off the topic, but the primary care pipeline isn't truly haven't measured the pipes correctly, do we want copper pipes, we decided how long the pipes need to be, there still a lot of debate about how exactly they should staff these medical

homes. and i know that the other prisoners will touch on this, but i would just say that before and ago purposes, when we were around, not only within the white house, but in the administration and look at all these different models, even despite the success, there was an overlying concern in this kind of fear of out if we add millions, that's all, this is everybody wants, that was all well and good, but how do you going to take a of these people. so i will say that even if we feel like as policymakers we can combat that question, we still have a lot of communication and education to do. thank you. [applause] >> great. well, larry has given us a glimpse of the future. and larry, i hope that to implement those changes in my

home institution i have got to see the patient on thursday more. it would be nice if you could make the patients by then. [laughter] >> what i would like to do is take a look back in the past and put on my historian had. so you might wonder why we listening to history, what use is history? history, let me make clear, is not about predicting what's going to happen. as has been said before, a prediction is very difficult, especially about the future. but rather, history is good for examining how and why change happens. historical analysis can demonstrate that the fundamental assumptions that unlike our present health care system, 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 at specific times in specific places. and that the choices that have been different. in other words, the world we live in today is not inevitable

but could've looked very, very different than it does today. so the forces that lead to change and the contingent nature of those choices are not always obvious, though at the time the choices are taking place. and it is the role of the story and to clarify the choices. so let's start with health care a century ago. if you became sick you could choose to get care from people who were a wide variety of different health care ideologies. end user only one logical choice to go if you got sick and want to be taken care. hospitals and technology were simply not very relevant. most medical care was delivered in the home by a sole practitioner using only what she or he could carry around with them. us, almost all medical care was at that point primary care that although people did call a primary care, they just called it medical care. so what happened?

weekend date the convention of modern medicine. we note the rise of hospitals which became center for medical care and education. we note increasing technology invention of truly spectacular new tools like the x-ray machine and the electrocardiogram machine. we can no dramatic changes in the medical practice, the discovery of insulin, the ability to routinely, safely, painlessly perform surgery, usually in new hospitals. we know the tribe of medicine, what we now call him the medicine that the kind of mess and i now practice as i do think most of the of the duke it. and the reform of medical education. to health care by the 1930s was quite different from health care in the 19th century. and one could argue with a set of core assumptions that are fundamental level are essentially the same as today's health care in the 21st century. and yet, despite all of these

revolutionary changes, primary care remains central. in the form of the general practitioner. so the first historical point i want to make is that changes in medical and scientific knowledge have not and probably will not lead directly to change in the health care delivery system. so what did? to answer that question we turn to world war ii and afterwards from the 1940s to the 1960s. world war ii was a new war. the army medical department in 1943 was three times the size of the entire army in 1939. army leaders face with his dramatic increase in the size of the medical department could have chosen a a lot of different ways to organize. they chose to organize it on the races of medical specialties. physicians who entered the military's as a general practitioners went home looking for medical turn. there they found opportunity in new programs and a new va

hospital, all of which lead to growth and opportunities for specialty training and specialty care. that is also dramatic increase in funding for the national institutes of health, which help to stabilize and encourage specialties as well as facilitate the balkanization of medical department into subspecialties. the reimbursement structure changed to favor specials and procedures. and all this led to the demise of the general practitioner, who was essentially extinct by 1960. but action to generate reactions. national committees took note of the demise of the general practitioner, family medicine became the '20s medical specialty, but it was new and politically weak. general internal medicine i acquired a stronger voice, and sometimes in a 1960s and 1970s came the invention of a new concept called primary care. and the point i want to make here is that primary care was invented as a response to the

steadily increasing dominance of specialty medicine. and 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 that the health care system is likely to be heavily influenced by the technology, as we heard our live this morning from the secretary. but anyone who thinks they can accurately predict what does new technology is and how it's going to be used i think need only roll the tape back five or 10 years and see how difficult that sort of prediction would be. historical analysis suggest that organizational change is unlikely to be driven by the scientific knowledge, though it may be justified. 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 in her act. the relationship between physicians and nurses, and the

increase in salary for primary care providers is likely to lead to changes in the salaries for other providers and reversing that political minefield will be difficult. any increase in reimbursement or chain for primary care physician 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 endocrinologist every two or three months. she has problems with her pap smear so she sees her gynecol is every two or three months. when you talk to her primary care, after those two key question. it's not their pictures somebody who is insured, he was seeing a doctor, essentially every month or two but she's not getting primary care. my guess is there some extra added to give primary care and they will immediately be claiming to provide primary care. will they? i don't know. so i would like to conclude that

while historians cannot accurately predict the future, we can be certain that things will continue to change, and that the meaning of this thing called i make it is likely to be invented and reinvented, that those changes are likely to be as much social and organizational as much as they are scientific.

>> thank you very much. i really appreciate the opportunity speak today. the macy foundation as those in preparation for the conference, to develop a paper about the definition of primary care. because clearly people in this country think they are still a primary care is, but they really don't. as a jolt which is pointed, the doctrine i prepared this. i want to start here with the definition at this is the institute of medicine definition. it is probably the best one in this country. it his pmaryare is the provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and in the context of family and community. so in that definition is not just about t personal care provided to someone. it's about turning it into a relationship, putting that in context of the family and community. and it's that definition that

the iom says the logical foundation, so here we sit almost 15 years later and having that implemented that into our own peril. because as the world health organization put out a decade ago and commonwealth fund sense, despite spending twice as much as our nearest competitor in health care spending raise, we are ranked 37th in overall in the world. and if you add in the adjustments for disability and lack of life expectancy, that is finally because her palm of not and say what primary care is and not implementing it. one of the biggest problems we put in a paper is the weakness of financing that you hear that routinely today. you have heard from at least three speakers already. but that financing is driving students and trainees in medical

school and residency programs are as, white follows green. so their choices are very much strongly influenced by the average income of specialties. but guess what? those personal incentives are important. they certainly are. but it's also affecting the marketplace. is affecting what academic health centers are doing in the training pipeline. so we have seen an erosion of almost 1200 primary care training spots in the last decade. and that same line is therefore what's happened with the build out of residency training programs in the country over the last decade. this isn't about the personal choice. this is about market-based incentives. so the academic health centers are building out those pieces of their business model that make them money and staffing it with the lowest, cheapest labor they can't this is what happened there to see an erosion of the low-end. pedirics femist have lost to income in the last decade. dermatology has increased its

income by 40%, rheology over 20% of the same thing. this isn't bad behavior. this is market driven behavior. so what's influencing the decisis, h tak us from producing a third of our positions in this country and primary care down to about 22%. the financing is important. so that most of the country that is in shortage. most of that is the distribution issue. was a sector was making today about expanded committee hosted a national service go will help us. but what we're facing is a real short over the next 10 to 15 years because of that strength each of the pipeline. the shrinkage of the production of primary care in this country. with 30 to 40 million more insured people of the next decade we can afford to have that shortage. what we will see quality go down for the. will see cost go up at this time of transition for health care system we can't afford it. so realizing the full definition of primary care, and moving the

market to support that is going to be essential if we're going to meet the needs of the country, and for going to try to lower costs. if were going to try to bring our country up in the rankings we can afford. thank you. [applause] >> a thank you. it's a pleasure to be here and to see this audience so interested in this crucial and central asia for the health and old the health and well being, and as susan said, also the economic well being of our country. i am george thibault, president of the macy foundation. we begin planning now over a year and a half ago a conference on this very issue. because it was very clear to us, in spite of the evidence, that susan and others decided, that countries that invest in primary care and system that invest in

primary care actually deliver better care and lower cost. and in spite of the evidence, overwhelming evidence, that that's what people want, we as a nation of have underinvested in that. so we begin planning a conference in which we would pull together leaders from across the country and across the profession that provide primary care. that is, m.d. profession, family medicine, pediatrics, nurse practitioners, physician assistants, all of the key professionals, across a spectrum of career projectors are leaders of academic medical centers to leaders of clinics, to teachers, policy people, and to those who are involved in communicate and. . . complexity of the

issues we reached remarkable consensus on the important points. i am going to highlight for you a couple of the main conclusions and key recommendations. the hole summary is available on the table which means publication. it is also available on the may see foundation website and a full monograph that includes the paper and a summary of the discussion will be coming out in the next couple weeks.

the highlight to the conclusion creates a sense of urgency that the group fell. if we were going to fulfil our nation's promise to the public and health care work force required to accomplish our goals we will need to and large and strengthen the primary care sector of the health care system. there is great risk that if we do not do so, a significant portion of the population will continue 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 in the nation. there is greater urgency in addressing these issues. failure to act now could put the health of the community in the economy of our country in jeopardy. the second deals directly with the issue of the health professional. we will not attract and retain a

sufficient number, more achieve the needed geographic distribution of primary-care providers unless there is a greater proportional investment of primary care. students and trainees must be educated throughout clinical training in practices that deliver comprehensive integrated coordinated high-quality affordable care. the health care delivery system and educational system are inextricably linked to. nor will they choose those careers. these practices required teams of professionals who give care and provider satisfaction under conditions of clearly defined roles, effective teamwork, transparency of outcomes. these being the conclusions i

will highlight recommendations and overall dozen recommendations with another dozens ofrecommendations. i have chosen to consolidate them into seven key recommendations. first expand the primary care work force by improved recruitment of, who we bring in to the profession, training the content and financial incentives. all three are necessary. fixing one without the others, allow all primary-care practitioners to practice at the highest level for which they are trained. second, implement payment reforms that are prepared the recognize the value of primary care services and primary outcomes for patients and populations. feared, require interprofessional education. we need to change the paradigm of education so the we educate and train our health

professionals together. for, academic health care centers must lead the way. this can't be done around them. it must be done with them. they must provide leadership to develop new models for care delivery and improve education opportunities in primary care. they must form stronger ties with community health centers in other primary care sites in the communities that they serve. fifth, greater investment is required in primary care infrastructure that was alluded to. other tools are necessary to provide this comprehensive care. sixth, there is important government role in this. the secretary already addressed that. i am heartened by her leadership

and the wording in the recent reform bill. government funding for title 7, 8 and other mechanisms let's provide incentives for careers as primary care providers and teachers. we need teachers as well. health education center programs should be expanded. finally, we need more research. we need to study which models work and don't work. we need to follow what has worked in developing highly specialized medicine by centers of excellence that will be -- for research and study and will draw the leaders of the future. this is a critical moment in time. i am incredibly excited by the level of interest in this, the quality of the thought that we put together and the emerging consensus across so many different professions and positions that this is the

direction we must move in. thank you. [applause] >> we heard the key themes we will hear again and again throughout the day. let's briefly summarize what our distinguished panel told us. first of all, we heard from larry the kind of zoology and primary care to day. you talk about edward bear bumping down the stairs, who can't see or his or her way out of doing things differently and larry made the key point that wonderful characteristics of the medical home model need to be brought to bear but none of those can be actualized without payment reform. we heard about the effort the white house has undertaken to pinpoint critical features of the medical model that seem to

work that seem to be uniform across variations on the model. care coordinator is, expanded access, data driven analytical tools and importantly incentives for providers. none of this works without payment reform. terrified to think about how much we have to do in the future to implement all of this and we will go back to that a little bit later. we heard from ole that primary care as the concept is invented as a response to specialty medicine. wooley as the wardrobe other investments, specialty medicine that we read discovered the need that had been going on since the nineteenth century that close contact with patients in their homes. goal in a friendly way told us we did need to publish this issue on primary care because

primary care will be reinvented. we heard from bob that we have been at this for quite some time, going back to 1996, we have not advanced the ball one iota since that definition was arrived at not withstanding the foundation the secretary mentioned. a lot of it is going to be about financial incentives. how critical it is when we saw that map of shortage areas across the country. agreement drawing away into those directions soon. hearing about the commission's recommendations or conference recommendations of all we need to do to make a greater

proportional investments to expand workforce to allow all members of the team to work at the top of their licences, feature we will be hearing more about today. the educational system as much as anything has been a barrier to getting where we need to go. we need to start training people to operate in teams. we need to get rid of the accreditation and other barriers that keep that from happening. we need to have payment reform that academic health centers have to leave the way on this and we have to continue academic health centers and other areas to continue to form of the invention process that dole assured us is going on anyway. let's just stop here for a few moments of questions for this panel. to your terror of implementation

on this in particular, what do you see as the prospect that we are going to move forward on some of these things we are talking about, payment reform, creation of medical home, expanded pilots, are we going to do it? >> a lot more money than i ever had, what the secretary said is exactly that. it is a great foundation. hall of whom -- we as professionals and people who provide care have to pick up the ball. we have been so busy looking at everything on the ground that we have lost sight of how all as professionals we now need to have a more active voice in this implementation and i will tell

you that professionals just like most people, so much of our day to day is concerning. even despite what was put into place, on contexture will issues, not something we should regulate or federal government be a driver of that. that gets to the patient's needs. >> there should be a time for innovation. incentives provided to do that but there has to be leadership of all of our institutions that

were supportive of innovation. it bears a responsibility not only to lead those innovations but to study them, be honest when it works and when it doesn't work. this is a golden moment in time and if we don't see is this we will be frozen in time and i don't want to think what the consequence will be but i think there is enough consensus that we need to do some new things. there is a time in the educational sphere, in which we innovate to change things for the betterment of the public. that has to always be our touchstone. we have been too in were looking. we worry about our own standards, our own institutional

needs as a measure of what we do is the right thing or not. this is all moment in time -- excuse me -- to be much more outward looking. the test of whether we are doing the right thing is whether we met the needs of the public and the incentive for us to change right now is clear evidence that we have not been meeting the needs of the public? >> obviously for the specialty medicine movement, somebody was leading the way on that. that doesn't happen of its own volition. can we learn any lessons from the leadership that led to that incredible surge of specialty medicine and apply any of those lessons and primary care? >> this mike isn't on. all right. i don't think that it really was

a leader. it was a consensus that -- the value of science and technology and the notion that more and more specialized was necessarily better and better. that has led to some of the inequities that we see today. let me give a couple examples. wheat and to value highly and reimburse extraordinarily well interventions that in many instances were clearly a good thing result in very little increase in life. a new chemotherapeutic agent for somebody with metastatic cancer for six months is obviously good but how many more times is that worth than larry's intervention with somebody early in life to do something that will help them live a much longer and more productive life? the other part of the system i was talking about, that i don't

think has been addressed. if health care costs are going up and if we're going to give more to implant pride -- someone will give less. people who are going to get less will be people who are delivering the high-technology care that provides marginal benefit. that will be a huge political fight. that does involve some leadership decisionmaking. i don't think we can claim we will save enough money that high income salaries will give more to primary care and health care costs will come down. it is a wonderful fantasy but not likely to be true. >> unless it was mentioned earlier. a lot of endocrinologist decide to become primary care specialists and focus in medical homes. we need a whole new fetish according to dole. we need back to basics. do you see it happening? >> i think it is going to be

very difficult. i want to emphasize the distinction needs to be made and i don't want this to get lost between how much primary-care physicians are get paid and what they are paid to do. i don't personally think primary care physicians salaries need to be raised or incomes need to be raised for an influx of primary-care physicians. it is only partly a matter of how much physicians are paid. it is even more what they were paid to do. is the primary care physician was transform the way that you were scrambling around with cost interruptions knowing all day long every day that you are not doing what you are taught to do

and in such a way that it was possible to take care of the populations of patients, they were not that much above. we have more people going into primary care who would be happier and increasing -- >> the family physician, as much as anybody, what do you see? >> helpful for the distribution problems. there is a lot left of that is authorized but not appropriated that will -- like the primary care extension program, to help practice but transform. there is a lot left on the table. i hope the financing that helps with this. to the question about the value

of the scientists, specialty and primary care, lot of the value of primary-care is so distant from when it happens that you don't see it. if you get someone to change their behavior, that is all realized for the end of their life. it is not like removing its tumor or putting in a stand in someone's coronary artery. that value and fetish that it creates is we need to -- down the road. we need to build towards that. to larry's comment about in come. that class of medical students means leaving $3 million on the table over their career it sucks the oxygen out of the rule. we have got to figure that piece out. how do you put money into those

practices so they become more complex and build what they need. there is a financial piece of this equation we have not yet dealt with. >> the next health affairs briefing will be handing out primary care fetish dolls for people to carry around with them. in the interests of time we won't take audience questions or comments now. we will hold those until the next panel. please join me in thanking this panel. we will hear from paul grundy whose global director of health care transformation. in this role he develops and executes strategies that support ibm's healthcare industry transformation initiative. he is president of the primary care collaborative which is a coalition that he lead ibm in creating in 2006 to advocate the use of the patient center medical home. that collaborative represents employers of fifty million

people across the united states as well as physician groups representing more than 300,000 medical doctors, leading consumer groups and the top seven health benefits companies. we will then hear from katie merrell from the center for health research and policy at social and scientific systems inc.. she has been studying -- physician payment issues and related issues for 20 years. she was part of a team led by the urban institute and funded by the commonwealth fund and american college of physicians that study the medical home model and its costs and her paper and health affairs deals with paying the medical home. finally on this panel we will hear from troyen brennan, chief medical officer of cbs care market. he directs clinical affairs and overseas strategy development. before joining cbs caremark he was chief medical officer of

aetna and served as president and ceo of women's physician organization and professor of medicine at harvard medical school and prof. of law and public health at harvard school of public health and from the institute of medicine of the national academy of sciences. paul, we will turn this over to you. >> thank you very much. i personally want to thank you for the tremendous leadership that you and health affairs have really had in this full arena for some years and is much appreciated. jolt made the comment that this really is going to take social and political movement to make this happen. i can't agree more. that is why we formed the primary care collaborative to do exactly that. for us, this is birmingham.

occurrence system of health care delivery is a form of violence and we are going to change it. that is our conversation today. it is a multistate effort, the authors reflect, senator kay hagen on the political side of the house, it reflects the leadership from the consumer groups, with the president of the aarp, reflects the academic health community and primary-care, it is a pleasure to be here with you today. from the standpoint of a large buyer of care, 47 of us large corporations got together in a room about three or four years ago and decided to actually take social and political action

around this. this best exemplifies a story, i like stories. i was driving down the street to visit a major hospital in new england. there was a giant sign on the road, we do the best heart surgery in the state? i went into the room with the ceo, and i said we are not going to put another job in this community. we are moving our jobs in this community. we want a sign on the road that says we deliver the most comprehensive integrated coordinated care in this state. it is so accessible that your employees and panels have half the rate of heart disease of any other community in the state and by the way when you need heart surgery we do the best.

i understand what that sign says. that sign says we know where the money is and we are going after it. and we are not going to tolerate any more. we have organized ourselves in a large collaborative to say it is going to change and joe was right. it will take social and political movement to make this happen. so we do rescue care. we do heart surgery. we do more of this than anywhere else in the world and we have to because we failed to do the kinds of prevention and robust primary care to prevent that from happening. it isn't just true globally, internally in the united states, i have -- we do data, we look at data. i have populations that have as much heart disease. i asked myself some fundamental

questions around why and what is that about? there are places where there is some discipline around the delivery of health care. i went to this system where i did my health care to get my glasses. the receptionist said you are not going to get your glasses until you fill your hypertension. somebody is following through. where we make the most money, we do the best heart surgery.

we failed to understand gave you, that lost the baby with the bath water, i grew up in africa. pioneer standard traditional healer. there is a hugely powerful relationship between a dealer and a person who needs healing. the second most powerful relationship in society. i want to buy that that. i want a relationship of feeling that allows honest and frank

conversation around things that doesn't involve trust. this provides comprehensive care. we have the best part celeste's in the world. we have the it to the from japan to get their livers replaced, we do good things. and when i look at the covers of

those communities, i discover five partial list doing five different things, nobody talking to each other, we have the best basketball players in the world, we put them on the court and got warped by the albanians, for comment i am making to that hospital, we no longer want to pay for episodic, and coordinated care, we want a coordinated, integrated care. the minister of health, about a year or so ago.

they went from being dead last to being fourth in the world. what did you do? we recognized, as specialty of comprehensive tests and we called it community and family medicine. there is some adult supervision. ..

>> we have 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, partner to make that transformation. so 47 large companies plus striker, we got together with a primary care providers, and we said let's change the company. we don't like the covenant we have no. let's change. doug henley, the head of afp

looked across the table at me and he said bless your heart. you know, we, the primary care society can have reached the same conclusion. we think what you're paying us is pretty silly. and you think what we're doing is pretty silly, but that's because it's what you're paying us for. so without understanding that we both want to reach the same place, the healers, the people who should be the comprehensive us, want to deliver comprehensive integrating, coordinating care, but we want to buy it. but we were missing. the trains were passing in the night. so we, the buyers, said to the providers, it's your business. you're the deliverers of your. you need to have a set of principles that you agree on. we're going to leave the room.

we're going to ask you to write out those principles, and we're going to come back and have a discussion around a change of covenant. 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 as social and political machine trying to drive change. along with government your based on a set of principles for the first time everybody agrees on a set of principles. the whole house of primary care, and it has been endorsed by the house. by the way, it isn't strange set of principles. it is standard in the european union. it is now stand in the veterans administration and d.o.d. it is not anything unusual. it's really powerful. and what we really want to do is

move to superb access, we want to move away from -- only 26% of my employees, 100%, what's that about? you know, we want to move to care that is coordinated. we want to make sure that there is engagement, data, feedback, that the consumer is engaged and centered on the patient. we want our practices to move from delivering solo bass, i'm a master builder, to routine base, i work with a team. i have discipline, i am now building a skyscraper, not a cathedral. right? the world has changed. it will require discipline to change. so we are driving that as a social and political. we are saying profound results.

you will hear some today. i visited a few of these communities myself, and it's what i wanted to mention them here but w are seeing the kind of data you saw across the country. and shelby county, iowa, i sat in a small community hospital there in the parking lot meeting with the docs at 11 primary care physicians that they have seen a 48% reduction in hospitalization. and a 32% reduction for aimless. but will was really powerful, because in iowa all those license plates have county smart on them. was that there were people coming from four counties away. and invite knows me, i never meet a strange. i ask everyone questions. and i was asking these people in the parking lot, why do you, four counties over? and they said because i have a doctor that answers the e-mail that will see me the same day,

you know, that will follow, that will follow through and will let stuff drop through the cracks. it's differentiating the. it's differentiating, that hospital. the same thing in michigan and battle creek, michigan. the community organize themselves around the concept of comprehensive care and we're seeing a profound impact. whole country, right, but the danish really start this perhaps 15 years ago. and when asked the days, i said how did you come on this modicum this concept. they said we did a scholarship to study in the states and we read the pediatric literature and look at kaiser, right? [laughter] >> and i asked the spanish. what did you do to reach this. they said we hire some consultants from america. [laughter] >> it's not as if we don't know how to do it, we just haven't had the political and social will to do it. and so we're going to try to help to do that.

so we now have, we've been going state to state for the last four years working with a state level, michigan -- mississippi two weeks ago with the 39th state to pass a law around the medical. it's having profound impact out at the state level and in the communities. you've heard of that committee care of north carolina and you will 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 d.o.d. they are declared that every that -- every d.o.d. member will have a medical home. after have a course of action. i sat in a room with susan and others at the macy macy foundation meeting al qaeda what around the room, us, the large employers, and the federal buyers, jerry from the va and

others were sitting there. and we all said we want comprehensive integrated coordinating care. and by the way, the academic medical centers, you have to train the kids to do that, train the students to do that. that's the product we want to buy. so, you know, we, the buyers, right, we the community that's organized with the providers. are going to insist on that. no new nih grants for academics is that don't deliver. seriously, we are serious about this. we are going to work, you know, with our senators, with our members of the legislation to make certain that we begin to move. because just as joel and larry said, it takes social movement. so we are beginning to see some real changes from the employer side. boeing just announced a 20% lower cost. we have companies building this if they can't buy it. probably about 20% -- 10% of

employers, employees are now in a medical home that is being built in communities, if we can -- we can't buy it. you know, i think that you're either part of the problem or part of the solution. so for those who want to be part of the solution, we are actively engaged in primary care collaborative, has three meetings a year. our next one is on the 22nd of july. you are welcome to a. this is about social change, social engagement. and it's really exciting because it's got everybody, it's the hospital, employers, insurance companies, providers of all kinds that agree on that change. so companies like ibm have moved to first over primary care. we pay nothing for primary care. we encourage it. we, like others, are seeing a

third lower costs and our employees who have a meaningful relationship with a comprehensive list. 19% lower mortality, well% lower of the sea, lower smoking record so we don't think that it's because the healers are doing all the public health. we think it's because they're amplifying what we and others are trying to do around our wellness programs and other things. so again, this is social change. this is a social movement, and where it was a for the long haul for you guys. thank you very much. [applause] >> good morning. his slides are more exciting than mine. this is me.

i am katie merrell. and the paper in today's issue of health affairs. the work was funded by the commonwealth fund. this is the third of product out of this project it would be more going for a couple of years. before i start i want to make a point. larry casalino start a slide is a key point. we share one thing which is we've given more talks in university of chicago for anyone else. you never get past the first slide there. so the whole talk on the first light at the university of chicago, you guys seem to let us proceed. i don't know. i don't know what to do with that. larry, you worked out well and i will follow your example. what i was going to say before you interpt, was payment incentives are going to shape the prevalence of the model by which my providers, the pairs and the attractiveness of patients. it's going to affect the evolution of the market medical

homes take off, what they look like in five years is going to really matter how we pay for them this year and next and the year after. going to affect was on those teams, what the tabs are and how they are rewarded. so i feel like the incentive matter in time, it's not just all by the way, we need to see how to pay for it. when i say pay for i don't mean finance a. i mean write a check to somebody today. for something they did. there are many ways you can structure payment. i like think about alternatives and making a long list. what we did in the paper, we take for sort of approach is which i'll come back to. there is a typical one has been widely used and has been very, very little scrutiny of its particular role on how the demos work and what you learned from the demos. just on the care process, things like that, the payment structure itself will drive from that i

think and there's very little experimentation in the current set of demonstrations and alternative models. there are a few doing different things. that we have done much careful study as to how those payment structures are going to affect the insist that any what you see when you do the process and outcome any violations. so we're kind of advocates for just looking under the hood a little bit more. not because we know what it should look like, but that we should be looking at it. and, finally, the recognition quality, whatever, quality measurement and accountability will be built in antenna can be closely integrated. in fact, they need to be. over time, the things about recognizing, the level of medical homes, those kind of thing, what does quality look like, how do we measure it and report it, and payment can be closely integrated in ways that are very close. they are not completely different subject rate but, in fact, closely related.

so that's my topic but i get to give it again because you didn't interrupt. [laughter] >> lead, shush. i want to start with the payment, the payment toolkit and i'll be very quick i promise. but i can use in a whole course. is sort of the paradigm where i use the fee for service, you can pay for everything you do, every patient you see during the day. and larry has seen too many of them. versus capitation which is this notion i'm going to get a check at the end of the month whether i saw anybody. there are strengths and weaknesses, lots of literature about that. and that though still kind of the main fundamental structures that we know how to think about and talk about in sort of the core payment strategies. but we've learned a lot of ways to try to enhance the strength, and many gave their weaknesses through complementary policies. so have things like risk adjustment in the case of capitation. we don't really do want about the guy. we create a bunch of nice and

then just a we hope someone will ask we take them on and put them on the panel. we have come up with tools to sort of mitigate the weaknesses of these two sort of underlying systems. risk adjustment in the case of capitation, pay for performance which i think many things to many people but it represents some notion of target incentives to meet a particular processor outcome goals. and again, sort of focusing attention on the quality of measurement, n., whether it is set back to providers or public the report but there's a lot of interest in measuring quality and using that information. and at other targets like shared at things and other things. aiming to mitigate the weaknesses of whatever that core system was, whether fee for service or capitated system. these are tools that tend to get layered on to kind of help make them work better and gives closed-door we want to go. so that sort of the toolkit and the question is how we deploy that oversimplified toolkit in

the context of medical. the norm right now is this fee for service process, sort of business as usual for office visits, 9913th of whatever in your office visits, and a monthly pay. those monthly payments can range from a few dollars a month for general population, to over $100 a month for a very specific, you know, high chronic disease population. and so that's sort of the way it seems to kind of work right now. to look at most demonstrations, doctors are typically getting stupid fee for service for visits, some mildly captivated about that some of the demonstrations include some of those enhancements i talked about. some of them has to be some kind of pay for performance are the kinds of incentives. but there are alternatives, and theirs is an alternatives but i'm not going to go there. for the purposes of this, just

kind of in this paper layout three alternatives, try to start from the simple fee for service into things and then going back to the scale to capitation. on the simplest fee for service, enhanced fee-for-service rate. this has been used in some example, some cases. if you get qualified as a medical home, whatever that might mean, you get 10% more for every one of those 9913th, or whatever it is. so it's an add-on to sort of says banks are doing it. we think is good and we know there's something else going on behind the curtain when you're not seeing the patient and we're going to kind pay for that through this enhanced rate. so that's a simple kind of low-hanging fruit. it's easy. physicians understand. doesn't create a lot of new administrative burden, but it still keeps that basic, at the core of the payment, which is the notion that we think the medical home needs the things that should be face-to-face. it's kind of easy but it doesn't necessarily send the right

signal about how to spend your time. sort of going a little pass that is this notion that we can add codes that are being done. the concern is that larry can spend his day doing stuff he can't be doing because it's not billable. let's make up a code and then you can go for it. so maybe you can think about a discharge planning code that makes more sense to people than what is available where you are supposed to know that patient should be discharge to the hospital and the need to be a care plan and medication reconciliation and things like that. but you don't this is a need to see the patient at that time a discharge. simple example, and i know it's logically worth considering, deeper thought to yourself, but again, just sort of thinking through, it's easy, it makes sense to people, and might feel some of the gas in the short run. so the place we are right now is this the place where you fee-for-service for the office

visits and related care, and we have the monthly capitated payment. you can imagine some changes to that which i might come back to if time permits. but in the fourth what we export in the papers, this capitation from primary care, but all back together in one big pot and have a do over untying capitation for primary care. the point of this is not that anyone of these is the right answer. but that, in fact, it's worth thinking about incentives of strengths and weaknesses. so in fact would say there isn't, except that what we do will matter. and so there's the stray dogs among accountability cost containment, flexibility and administrative burden. each one of these, the capitation model is attractive because it really lets the flowers bloom. to the best job you can with the idea that patient centered care is what we're all about, where as if i make a list of code and you have to build these codes, i

know this is what it should look like, and there's a trade off. but the bottom line is it will affect all aspects of the model and how it evolves over time. so again, want people to be more mindful of it and encourage the notion of the maybe experimentation and demonstration. not to think this pay to give away, but thinking more carefully how the payment structure might affect what we should expect to see as outcomes in the demonstration. thanks. [applause] >> so i want i want to talk today about the primary care issue, and what i'm here to talk about is basically all convenience care retail, health care, our particular brand of cds market your just to give you

a shot of what we're doing. so the model is really based on the fact that there doesn't seem to be a short the primary care. there's agreement about that today. and as a result of that, these are alternative models. and the other point is to try to get consumers to sort of take charge of their health care. so those are sort of the issues that were most interested. as we dealt with these other pharmacy benefit side of our business and more important the behavioral economics to try to understand patient behavior and to sommerset provider behavior. i think cancer is convenience. that's what we're trying to offer it is very convenient approach. in fact, that so most of our retail pharmacy model is based on. so those are the three things we are trying to update the drive savings in health care. both by improving quality and without sacrificing quality. you can read this and think it's

too small. it's too small for me to read off of that thing. but the basic component of the model are board certified nurse practitioners, who are trained to basically take care of acute and chronic illness. and we have physicians who act as our medical supervisors, who oversee the gift that's been provided, with you about 15 to 20% of the charts of the nurse practitioners complete for quality purposes. the nurse practitioners are basically doing electronic, there's no paper except whatever has a primary care doctor, who we see we get that information on the primary care doctor. the primary care doctor tends to prefer facts at this point. so anybody who gets seen by us, that's a primary care doctor gets information. were pulling a number of different ways in which we're trying to integrate our electronic medical record into other electronic medical

records. that's really starting to come through. we are certified. we are trying to basically sort of demonstrate like many health institutions do their quality through various different kinds of certification approaches. this shows that we are accredited and we follow guidelines. the guidelines basically built into the electronic medical record so you can get off the guideline. and that's important because what we want to do is be able to provide a sort of regular service to people can count on patients and doctors can, so our position is the first floor of the medical home which is basically we sort of do these prevention and health promotion and a variety of other services. they are doing today, but our nurse practitioners are highly trained to do. so we follow the national standards of practice in the

basically coming from a variety of different locations. we also adhere to the af p. s. now a band. they made sense. we think it's important because some of these things emphasize the importance of sort of us needing together a primary care. i think one thing people are concerned about with regard to the so-called convenience care, it's kind of out there, and then it ends and it is not integrated. and that is our key issue really is how we integrate this care into the individual primary care. so that people aren't disintegrated instead of their integrate. that's what we're spending so much time ever trying to understand how to make these information technology connections. as i said, the whole thing is basically a position on the fact there are enough primary care doctors that sort of everything that we see from the emergence of more disease associate with

obesity and then diabetes as well as aging of the primary care workforce, more and more people in primary care moving into other practice, and even sort of on the horizon, reduce medicare and medicaid patients. there will be some that just don't take care of those patients. we think is going to be sort of an lot of people are going to need primary care, and who aren't going to be able to access that. so we've seen about 7 million patient and our volume growth in 2000 i can which was about 49%. so i come from a health care services background, and when we used to think about the primary care, we were using, happy if we're in the high single digits. so this growth is really extraordinary. and we sit on sort of a month over month basis. so also recognition of the concert is increasing dramatically over the course of

the last six to eight months. so we don't think they'll be any real shortage of business. on the right hand side, we used the same satisfaction choices and we always used in hospitals. we perform sort of extraordinarily well on the. people are pretty happy with the care that is provided by the nurse practitioners. so i think you have some discussion about that today, and certainly in the volume about the quality of care that is rendered by nurse practitioners in the primary care settings. suffice it to say that the evidence is unsalable. that the quality of care is excellent, and serving our customers are appreciating it. we have a very highly satisfied customer base. and we've also had some information on sort of quality care. as i said we would you about 15 to 20% of our charts so we get a good view of what's going on with the quality and here's to structured guidelines. and that's reflected -- those of paper and i believe a paper in this issue, that last year they

published an article in the internal medicine which was based in minnesota where we provide most of the convenience care. we didn't have anything to do with the paper, and it was put together independently by the authors. we have no idea they were really doing it, but what it shows was the care that was provide with high quality and frank of a bit better than urgent care and certainty better than emergency department care. and also less expensive. so that's what we're trying to do, which is basically try to render evidence-based guidelines right into the care that is provided to follow protocol, make sure that care is high quality and less expensive. 50 particular niche of primary care which is not being sort of well start right now, and probably not going to be well served, sort of going forward without these kinds of clinics. so the way in which we are thinking about the medical homicides, yes, it is similar to this sort of first floor. so basically people who have chronic diseases, and that's our

focus. our focus in the past have been acute, but increasingly were moving in the direction of diabetes, hypertension, other testing and copperheads a follow-up for those types of disorders. as a similar looking on electronic activity right now. we still have more effort to make in or to sort of integrate it directly in where physicians want this information in the electronic medical record, but we feel like that is something that feels like we have a real handle on. we have about five or six pathways. i suspect over the course of the next few years we will be very supplicating information back to the primary care doctors is really the key effort. this gives you some sort of how we think about chronic care if it's not a difference in the what anybody else in medical thinks about chronic care but it does emphasize what it is what would be doing in counseling outreach, health promotion type

activities and integrate that with most services that we would offer in the retail clinics. and the last thing is that we need specific affiliations, and were in about 18 metropolitan areas right now. we have 500 of these clinics. and we're reaching out to delivery systems, to work directly with them. sort of mutual referral purposes, but more important for us we have a primary care medical home with a 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, when we first started and i was a little bit hesitant about people would say, you know, why would we want to talk to you. but it turns out most of the leaders of these integrated delivery systems can see this is not an airy what they are probably not going to do in the future. so the payment mechanism that we just went through, if you think about the subject edition poker we take on the sct