it's meant to be revenue stream to support a new business that the primary care practices were going into with a predictable cost and expectation for the revenue stream to make that happen. so that has been really very helpful for us. so, the problem i am going to describe the other 8500 patients or so about 6700 of them have hypertension diabetes or high cholesterol. as all of you know these are diseases where lifestyle changes are has or perhaps more important and the pharmacotherapy. as i say to my patients all the time they don't make money when you start exercising that actually that probably has more benefit for you. you don't see it on tv, you don't see it in the drug store but that is a good direction to go. and clearly for these illnesses, the return on the investment for that is huge and the risk margin is substantially lower. so the idea is trying to get the

patient is to set their own goal preferable to telling them what to do. every time i say to a patient you know, you should eat less and move more i find myself thinking you have to go to medical school to learn to say that? [laughter] like, really? so, the idea of sort of trying to engage in a conversation that is actually a conversation as opposed to a lecture, which tends not to work so well. but the office thus function on a visit fee-for-service system with a lot of time for the doctors or staff to engage in conversations without what the patient might choose to do and everything we know about the learning theory says if you want to drive the if you change that's the place you have to go. so, what do we need to do to make happen the kind of thing we did? well, we had to develop and expand on them on md staff. in a community based market called overhead. we recognize and other forms of

health care system the surgeons who operated is understood somebody has to support the operating room and which it works. if someone does a colonoscopy is understood someone has to support the cost of that instrument and the table which the patient is fleeing. in primary care we have it very well specified with the infrastructure is. technology in teams are a big piece of it and we need to support to make that happen. so, we hired a health educator. the job is 50% wholesale and retail. the retail part is familiar to you in terms of health educators sitting down one on one with the stations to counsel them on lifestyle change but a wholesale part was a leadership role among other things in the project and the project was what if we could train medical systems and the medical assistance techniques and our environment are often people from welfare to work program with perhaps one or two years of post price of education. some of them have been with last

longer but training them in the goals and techniques if you are going to have them take on this responsibility in addition to winning the patients and measuring patience and asking why are you here today, they need more time and rooms if they are going to spend more time in rim's we need more of them so we needed more of them to actually do those. and because they are not that well critically trade we wanted to crystallize the health records to support them so that a patient with diabetes would have one set of lifestyle changes will lead to diabetes. sold restriction might not be as big a deal for a patient with diabetes as high blood pressure. so, we customize the forum where things basically light up with a medical assistant and acceptable health choices for the patient and the medical assistant engages in a conversation with a patient are you interested in these things? would you like to focus on taking around in the kitchen or focus on exercise or on sold or whatever. get them to set a specific goal

and document that in the electronic of record and produce a document that can be handled to the patient so the patient is told at the end of the visit these are good things i committed to a and that becomes a permanent part of the record and two weeks later the medical assistance are calling the patient and saying argue actually managing the ten minutes like you said you would so there's a followup component. but what does that take? i don't know how to customize my electronic of record and it's an impenetrable secret programming language and i had to find a consultant and pay close to ten grand to get them to execute the things i just described whereas they said they would do it in three months they finished in terms of where we could use it kind of like last week and that is a significant problem. but it really has been helpful in terms of allowing the doctors to the patients and medical assistance to have conversations focused on individual goals so

my message here is here's the thing everybody knows we need to do better with patience. we try to do it with a website and with four runs, the patient had other things to do besides go to the website and engage with questions about getting the data on their lifestyle changes and to integrate as part of a visit with at least one model for them but none of this happens without a change in the payment system. and again, i would agree with what lots of people said today that's not going to change everything we need to change our models but if we don't have the resources to lubricate the creativity, we can't deliver what it is the american public is looking for to advance in the primary care. thank you for your time. [applause] >> well, good afternoon. it's a pleasure to be here. this is kind of a dream come true. i've been interested in these

topics for many years and i am going to tell you my perspective may be a little bit different from what you've heard from other people. i live in group health and we've been committed to primary care for all 63 years and yet i'm going to tell you a story about how we needed to be transformed into the medical home was the way we transform ourselves. the principles of primary care are not new. you've heard about them but we had to and we are in the middle of a cultural transformation that i think will link back to larry casallino's earmarks of a need to change work in perspective. in that case the redesign of harnessing the new technologies and again, the theme of this meeting making more efficient use of our teams of people and rethinking what medical care was all about. a little bit of background.

group of the summer of 63 years. we are consumer government called a co-op. we are based in seattle and at 620,000 members and we are growing. we of 26 primary care centers, six specialty units and one tiny hospital. 960 positions and we contract with a large network of over 9,000 physicians and 39 hospitals. i'm the director of the research institute which is an in-house but public oriented not for profit public-sector research group and with a chronic care model developed and you'd think the group health would have no problem with primary-care but in fact we have our own struggles and one of the points of today's meetings would be it's going to be worked to transform primary care and will probably be worth our offspring and their offspring because it isn't easy

to deliver good primary-care. but we have something in 2002 which we called the access initiative and i would guess that most of the things we did were published in the health affairs. many of them are things ordered spoken of the conference. we want to read this on primary care to best practices. what we did is say in the appointments and productivity incentives for positions so they would see more patients and leni, not rich but leni primary-care teams. we thought we could do this because we had a great electronic medical record and somehow that would solve everything for us. in fact it did solve some things. patient access improved. people loved ability to see their doctors or communicate with their doctors the right away. but quality and continuity of care did not improve and if we

look at the church that is on the screen you will see that there is an increase in the emergency room visits and increase in a hospital admissions. we put our doctors and to a squirrel cage treadmill mentality they saw a lot of people but they did not transform the way they practice medicine. and also, a side effect was the doctor's and members of the team were burned out. people were saying we can't do this. this isn't working for us and so what we clearly said is we want to invent primary care and it didn't do what we wanted to do and that was the basis for the work we've done and i will describe today on the patient centered medical home. and i will say that we base this on the literature of the day as well as our own work and we had work groups that included patient that included the doctors and other members of the team that worked in the pilot clinics which is victoria.

so the basic design is shown on the slide right here. the idea is we start from the home of being the place where primar ce is so the whole system is designed around primary care. you heard about denmark. people came from denmark to look at the group health and we had to go back to denmark to rediscover the home has to be primary-care. patient centered is the promise of all primary-care and we realized we can't dustin provide access to deliver good primary-care in today's world it has to be comprehensive and coordinated patient centered and is a continuous healing patient doctor relationship is the core principle. we also looked at coordination and collaboration inactivated patient as we figured out a way to design this and we look for the notion i think that larry was alluding to and which richen described in his paper which is

a lot of the care is done outside of the home. outside of the physical stave to do the work so family axises, critical privilege river 24-hour consulting nursling and all of this is connected to electronic medical record. we also have a ray of tools and here we are fortunate because we've been building these four decades to have the patient education materials reminders and post visit summaries have been sort of deep green sold for a long time at all of this is metric. we metric it as best we can without being too burdensome on ourselves. what i will describe now is what we did and this is what is in the article and today's health affairs and i'd like to give credit to my co-authors and participants listed on the head but it is katie coleman, eric johnson, paul fishman, mike and

michael erickson. but we did was changed the way we used the work force and reduced the panel size from 2300 to 1800 patient spur physician. visits were actually increased from 20 to 30 minutes. the teams were led by physicians but the value of the team members was judged to be in a way that had equity that every member of the team had an almost equal statute whether you were a nurse, for mrs. come and nurse practitioner or a medical assistant all contributed as a part of their task. we made a major change in how physicians were paid and had their days scheduled in that they were paid to do what we called desktop work so e-mail, phone call, coordination of care, those were scheduled in to the day just as you would

schedule the time for a patient one on one visit and the expectation was rather than catch up at the end of the day with all of those phone calls you are often called up at the beginning of the day or during the day to do phone calls at e-mails and we expected that more care would ocher out of the office than in the office and we would do that predominantly through the use of the etechnology. we were not sure how well this was going to work we did a before and after evaluation of the formal research, which is what this is in the article where we looked at the baseline surveys which were done by the survey department of patience and members of the team. but pre-defined measures and out comes and we did a to group design and sometimes using the entire group health as a control and sometimes using a smaller sample of clinics and it is a qualified experimental study.

some of these changes were big changes for physicians and you will see this in the article in health affairs. it was a matter of what did it take to get people to think in a new way after having been successful in adapting to the old way for so many decades in many cases. these are 40, 35-year-old practitioners. i think the way this worked is people use a lot of back-and-forth interchange along the way and if i had to say what is the biggest barrier for the physicians and the way it is the management measurement burden that we put on our providers and i think there is a lesson there i am not sure what it is but the burden people with administration measurement and that can be troublesome. what did we fight? what we found was pretty dramatic improvement and we were

a bit surprised because in the first paper we didn't expect to see changes right away so when we saw them in the paper at the one year result we thought this could be a in a fact and maybe it will go away and now what you see is i think a more enduring affect effected by and large the experiment was quite a success. the terror was better by other measures. the patient experience was better based on the surveys that we did and the most striking finding was the absence or the near disappearance of the patient physician and provider burnout and we had people who literally changed their retirement plan as a result of how well the clinic worked and in terms of the content on care we get fewer primary care visits so we changed the principal encounter from a face-to-face visit to essentially a dramatic increase in the messaging and

encounters and overall there was a far greater level communication between the providers and the patient is. we saw 26% fewer visits and the patient sits in the pilot clinic versus the controlled clinic and 6% fewer hospitalizations and almost all of the hospitalizations reductions were in ambulatory care sensitive submissions and this is of course the bottom line for us it was financially successful. our member costs went down by $10 on average and that was driven by the reduction in the inpatient er visits. so our roi was a dollar invested yielded at a dollar 50 game for the system and because of this, group health is now taking the medical home to all of its 26 clinics and we will have that

challenge in a large group was done in a small group. we are also trying to work with contract providers to transport the medical home. so what are my recommendations of the end of the day? what i want to leave you with is the strategy to put more resources into primary care is a strategy which will lower cost. it will improve the quality-of-care and it will increase patient satisfaction. i think there is the unquestionable truth to that conclusion. more specifically, do you have to invest in primary care. hiring enough commissions of all sorts so they can serve their patient as well as you have to involve teams and patience when you redesign team you can't read the sign it in some sort of top-down or formulaic way because you seen one primary-care practice you seen one primary-care practice.

you have to engage in the effective leadership that really believes and what the -- what they are supporting because it involves dealing with what the patient wants, and you have to have managers willing to accept the change in small steps. this is not something you can do overnight. for policymakers i think the key is going to be as has been said over and over again we need to reimburse people for more than just the traditional visit and figure out a way to do that and we have clearly needed for doctors, physicians' assistants the wonders practitioners and pharmacists. not just of the numbers with the competencies' to work in teams that we need to work with our federal partners to make sure meaningful use of electronic medical records isn't just about storage but it's about what the patients want and what they can get from their electronic medical records. i said earlier on i was delighted to be here.

partially it is delighted that seeing these kind of results and this kind of interest because i do think that if there is hope on the horizon for a primary care and the country's health care it is probably patients entered medical. thank you. [applause] >> i want to start by thanking health affairs for including ereferrals and college michael -- on a full stomach. [laughter] you might wonder why are we talking about partial lists at an event that is focused on easy with that and to get back to an article that elliott

fisher published 18 months ago in the journal and sure many of-years-old buildings and medical neighborhood for the medical home and if you haven't read it i would encourage you to do so because it lays out a compelling case for why we can't despite the fact the tension on the patient centered medical help is long overdue if we only focus on the medical home without paying attention to the specialists and hospitals and pharmacy benefits, health at home all of those of their colleagues that take up 17% of the nation's gdp we are destined to fail so we have to be on the patience and her medical. uh-oh, did i turn it off? to i pushed the wrong button? okay. so, like kaiser, the va, group health, despite to the to the six scribes' debate to discuss your access care. in the vast majority of

practices there are full practice is still paper, of telephone and fact based that kids too clerical where they're scheduled regardless of clinical urgency. a lot of inefficiencies exist in the systems including often the wrong the clinics. someone may refer someone today diabetes clinical they should be going to an end to current glenna or vice versa. unnecessary referrals meaning the patient with hypothyroidism i should be about to manage with a little bit more information or guidance from a specialist that really doesn't need to go see the specialist. premature folds where if i had done before the work on the first visit the specialist wouldn't have been spent filling out that the forms and x-ray forms. then obviously things like an ability to discern the referral questions. at the san francisco general hospital we are the customer so we take the of injured patients and a large portion of medicaid patients and this exemplifies

what the system was five years ago. in addition, because there are a lot of mismatches between the demand and supply are anywhere in between four or even months for the routine visits for certain specialty clinics. so, this -- i keep on pushing the wrong button. this was actually the result of the system. and this is a successful result, where someone filled out a form, faxed it over and got received. the fax machine was working. someone got it. the patient was scheduled, the patients showed up, the specialists saw her and wrote a response back. you can even see i don't need the cover of information because you can read most of it. [laughter] this was the best case scenario in the system and the question really boils can we do better? and the response was to develop ereferrals which is an electronic referral service that importantly it's not just i.t..

i.t. is an enabling. what is is staffed by the specialist reviewers so every referral has a live person specialist on the other and either an m.d. or an m p so this is what works. >> i am not usually this technologically challenged. [laughter] >> there's always three buttons. [laughter] >> okay so i just realized there is a clearly defined aero. [laughter] >> [inaudible] [laughter] >> the entire function. it initiates the referral and goes into the queue and

oversight thanks so it peals of the clinical data and attends it to the actual free text fields we don't have a lot of algorithms' or guidelines that really is the pcp putting in with the referral is and then it gets reviewed by the specialists and it is true. they will look up is complete and it is an urgent it is scheduled routinely and if it is urgent it is overbooked. if the pcp can manage it with guidance in the medical home context or if the referral work isn't complete or the specialist isn't quite clear what the reason for the referral is it goes back to the pcp and the use the system everything in bed in the program to communicate in an injured fashion back and forth until they decide to get their whether the patient needs an appointment or not. so some of the appointments get scheduled referrals and some of them are never scheduled.

so the impact has been decreasing rate times and all of the medical specialty clinics had dramatic decreases in the week times and it went from 11 months to four months without any additional resources and that is because there were some referrals that were read erected for example the liver biopsy could go to the ir clinic. they could be managed by the provider with a specialist. in the beginning, our specialist champion actually was a pending book chapter so the referral program until we were saying you know, just make it short and summarized. we can't do the whole article. but it's an educational tool as well. and then lastly, the premature. we've been able to tree of urgent cases for some of the clinics with longer wait times for example in the beginning of to 36% of the referrals were overbooked. whereas before you actually had to call and page and make your

case to get the patient seen earlier than the next available. improved specialist efficiency we had a significant improvement in the appropriate, so this is only a long the patient so were determined to need an appointment. when they got to the clinic we asked the specialist how appropriate was this referral and in the surgical clinics, the referrals are deemed inappropriate on 10-2% in the percentage of referrals where they couldn't figure out with a complicated question was, it got from 40% -10%. it seems a little bit crazy that we have to remember the system only was it paper based but we had significant low literacy and 40% of patients are being referred for their back up their knees examined. that ultimately happened in old system. some of this improved efficiency is due to legibility and then become the new-found ability to actually track the demand and waite times.

just to conclude. some of the challenge is to spread in the thinking about the other systems, which have actually worked with every county in orange county would develop similar systems and we are working with l.a. care which is the nation's largest medicaid plans we will do a pilot with them. a group from the u.k. actually came and was interested in adopting this because they were choosing the bouck model, which would be very exciting. but really similar things that made it successful in our system which are not widely available access to a common echart and access to the fire but because of the specialists are used to education. it's not just, you know, train the patient and resident fellows, the fellow primary-care colleagues. and lastly and this ties back to what you have heard all day today which is when we surveyed primary-care clinician's they reported that the echart resulted in better care but was more work. before if you think about it as a few -- the analogy of the tennis court as we are lobby on the referrals and some of them

are getting over the month and some of them returned aids on the ground and we don't know where anything is. it is a rocket ball court and most of the time we were much of the time the ball was in the primary courtside so it is entering the field. all of these things responding to the service requests making sure that the evaluations are completed so again, it goes back to can we do payment reforms and a visit read these lines to support this kind of model? thank you. [applause] >> ibm i.t. challenged. i medical director of the you might call center which is the you might beat the unite here and the new york city and was founded by the ilg in 1916 so it is a unique setting. it dovetails on the discussion about medical assistance and that is what i wanted to focus most of my talk on as i work

with medical systems. but i think all of it speaks to how much those of us working on the ground need to figure out who should do what and all of what is going on in primary care and i loved your opening remarks about what practices should be. and my ah-ha moment came. we have patients coming in every day and became an for three days and we took pretty good care of patients those three days and all of us were sort of stunned by that and so a lot of what we are doing we could really transform. it is similar to a service center. we are primary care specialty. we have most of them are union members or families, retirees from the work of united, unite here. they are low wage, mostly immigrants, most earned less than 150% below the federal poverty level, internet be employed.

it is funded by the contract with different unions. we have internists, family practitioners commanders practitioners, 30 specialists in surrounding hospitals, radiology, mammography, older son, flout south, pharmacy, and we serve about 10,000 patients per year. we have had an emr and part of the reason we've been able to do most of our work is because we are funded primarily by the competition from the union. we have some contracts that are fee-for-service and fee-for-service for the retirees. but all of our innovation can from the deficit funding and we never would have been able to do most of what we have been doing since about 1999 but for that payment structure. and the other thing that is nice about the health center is because we work with unions we can noodle with the benefit design of the member plans so we encourage patients of chronic disease to come to us by adjusting their co-payment for medications if they use us and don't wander. so we hit that to work in the

universe which it is unusual. it's also a union health centers they feel like they own it and it gives us a different feeling i think than some places. so we've been, you know, since 2000 we were involved in multiple readings on projects and advanced access and we did those sorts of things and then got involved in diabetes work and we decided to pilot a program to figure out how the medical systems could work more effectively on the team. so i think of my contribution here is to just go through in detail what that was because we've been doing it for a long time and have felt comes from those projects. you know, our medical assistance or how year in most states they have about 1,000 hours of didactic work in schools and then three months internship and high school diplomas. so we are at interim -- internship sites for them and develop our own curriculum that takes place over 9-12 months of

medical assistance about three hours a week and we do didactic teaching on all of the chronic diseases with them. we do role-playing, we have interactive sessions so we teach medical assistance how to teach self management skills to the patient and then help them learn how to facilitate behavior change with patience and then we've also spend a lot of time coaching them and teaching them how to be successful team members. ..

and at the health center at the lead most groups. and so what they can do is communicate back to the primary care providers about what they're do these patients to the template we develop. and they do a lot of the work with payments on the blood pressure checks, but sugar checks company do goalsetting in chronic disease management. we had been to a foot exam for diabetics. the primary carriers sign-up i'm not, but their clinical pieces we've actually sort of handed over to a medical assistant. and then come the medical assistance of course review a lot of what they've done come either before the day in our huddles are at the end of the day to these flags in the primary care providers. so that initial work with their medical assistance nomological health center and we are now at level three accredited nct weight accredited patient centered medical home.

and we have outcomes for some of the diabetic since we started this program. we're usually following about 1000 diabetics, but their 500 in the group to we follow between 2005 and 2009, where we have parameters that are your thoughts they were there. and there were statistically significant improvements in all those parameters in the diabetic patients that were followed your tenuous parallel to the thousands of the 500 group we follow closely. and then, the other statistic your stress those were poorly controlled, which is the hemoglobin greater than i'm coming you can see that health sector wide in turn. at a consistent number were not well controlled, so we continue to recruit inpatients who was not the more controlled, but those who reduce the overtime at significant improvement in the perimeter. one of the things we also were able to do was we analyzed the health and welfare data for one

local, where there were 3000 members who we've been following and those who were followed at the health of nearly 17%% decline in their pm costs, compared to those who wear. and we also looked coming out, we could dig into those numbers and you can see even the er pm costs a kind of that. it was 50% less between those at the health center and those who hadn't. so we really believed that the fact that the medical assistant share a lot of the backgrounds of patients and they can really develop this sort of trust and comfort between the patience in themselves and it's really allowed us to make a substantial chance that these patients who have chronic disease. it comes at a much lower cost of course releasing some of the providers that are traditionally used for health education. it's also created an interesting career pathway for medical assistant. they get promoted to the health code and promoted to be for coordinators who helped run the floor of the clinic.

with the hospitals closing, there's a lot of interest in having medical assistance obviously participating more in primary care environments. and the other is that, you know, i've really been interested in physician retention primary-care community health centers and a lot of the talks decors are talking about how to push as far as we can the responsibility that different people hold your in the intention here was not to take attention away from the primary care providers in that business. we've been able to loosen up some that time again because were not paper nearly on a fee-for-service basis. so the environment that they're practicing and has been much more rewarding. and you know, you think it's something we should consider as we look at redesigning primary care practices. thank you. [applause] >> well, good afternoon.

i had the book and with what susan did earlier this morning. the last speaker of the afternoon. i'm very accustomed us to go in on that, so it's only appropriate. i can want to thank susan, health affairs, what do thank all of you for saints of the gordian here what i have to say on behalf of quadmed and what graphics. hopefully i'm not challenged here. okay, i've got a work out. i wanted to focus my discussion. obviously were on the practice profiles in the titles of ours is an employer directed health plan that seeks to re-energize primary care. it was a size that reenergizing peace. but what i've put up for years today is kind of the direction that we're headed with this health care microsystem called quadmed. population health delivered from an on-site primary-care platform. i'd be remiss if i didn't think my co-authors, dr. tom vangilder

and dr. link on friday. he's my immediate predecessor of quad graphics. you might know an illiterate sound and not quadmed, a family owned company. quad graphics is looking into it. it's the third-largest printer in north america on its way to becoming of a second largest printer and that makes the whole question of what the heck of a printer doing in health care? well, i'm here to tell you that as my boss, ceo joel quadrant she has said he would've thought that health care would become a competitive advantage for a printer? okay, so this is a little bit about us. it's obviously a mantra for no real venture given not the entrepreneur founder of quad graphics ventured out into health care as well. but it's not actually edit your

your for a now deceased founder, carey quadrant she to do so because if he saw something that he didn't like and couldn't buy a value of the market, he was endorsed us. so quad graphics at the talking company, logistics company, technology company, et cetera. so we're not that dissimilar. and this is kind of our mission statement. we provide innovative high-value health care solutions to companies improving the overall health and productivity of their people. mostly we focus on quad graphics other main sponsor, but you're kind of friends and family we evolved into a bit of a boutique operation where we have a few other companies. but when asked what is kind of the gist of our success and how we do it, i'd like to tell folks that a small investment in primary care needs to a significant payoff with a decrease in the overall spent here and that's kind of the thing was evolved over 20 years at quadmed with quad graphics.

harry, now deceased, founded quadmed in 1991 and his actual words at the inauguration of the first clinic he said will keep you well and by the way to get sick will take care of that too. so you see really from its inception, bless you, even 20 years ago, harry was looking for something different. he did not -- he was tired of business as usual and paying large sums. and if you remember the health care inflation curve in the late 80's, double digits, much like what we came through here recently. so not knowing exactly what he was given with a large check was being written year-over-year for health care commies that i can do any worse myself, so you have a doctor and a nurse and started on this path. and it's going to be a fairly substantial. i like to refer to the model for quadmed as something of a three-legged stool prince of the three legs are as you see them here. it's a concept of wellness, so it clinics that exist at the work site.

these are primary care clinics in their heart of hearts. yes, we do take care of workman's comp, but it's all driven by disempowered model or re-energize model of primary care and even though we've had this 20 year track record and it's only been recently that the verbiage around patients on a medical home has really entered into the consciousness, we look at the definitions around patients on her medical home and say gosh that's what we've been doing for 20 years, so it's very easy for us to embrace that conceptually. the second leg of the three-legged stool be innovative management and that's really kind of across the board. it certainly can't claim can also tell you that not only are we self-funded, but were self-administered, so we are in essence i don't health care insurance company as well. so we've been sourced the tpa, the third-party administration function and that's really helpful source of data for what we do. we run an analytics data

warehouse against our claims and pharmacy benefits with information. and we were one of the pioneers in southeastern wisconsin with electronic medical records. in fact, won her second generation of emr and i have to tell you it was more painful converting from 1:00 p.m. archway second emi sent from paper to the first emr, so just fyi, choose your first emr wisely because you're not going to want to move away from it too quickly. and we do have some internet portal stuff that little bit immature, but what is very interesting is the most popular aspect of your patient's request for refills. so it's part of the dialect that's going on to the portal. and finally, the third leg of the three-legged stool is benefit design. and this could an hour-long lecture on truthful to my promise not to do that to you at the end of the day. were all about value-based insurance design and that is again kind of one of those buzzword type things. i want to tell you a little bit later in my remarks i think

about our premium structure and how we work with the calder leaving you and well you programs. but we're balancing patient choice against steerage. in one of the ways we do that which ties in nicely to the remarks referred earlier about many clinics is that if somebody is still after hours and i'm not going to be accessing our on-site clinics for whatever reason during the typical hours, they have a 50% out of pocket up to a limit of $400 regardless of the venue of, you know, the nurse practitioner base clinic, urgent care or the emergency room. so they are tied to pick wisely. so there is a little bit of consumerism and steerage there. and also balancing personal responsibility for lifestyle choices. it's going to cost you more if you're a smoker for health care. strategically what does that mean to us?

well again, we provide on-site primary care and just a handful of cases, where we now have this kind of confluence of forces in milwaukee, where we have several primary care clinics, we've selected specialty care that comes on-site. affidavit cardiologist from a full-day of an orthopedist, et cetera. but the main focus is on prevention and wellness at every visit. and what was just mentioned earlier on this panel about the restructuring of the delivery of primary care, at group health. we do something very similar. we salary or providers, we take them off of the hamster treadmill of toxic research and methodology, don't get me started here that's so prevalent in the fee for service realm. so we've slowed down the pace of care with the salaries providers. we give them plenty space-time. minimum time is 30 minutes for a visit.

he say what gosh, that's a luxurious amount of time, why do you waste so much time? you know, you could be seeing 30 patients a day. well no, we want our providers to see 12 to 14 patient and how those behind quality because of the inter-or small relationship is that face time coming up, with your pcp whether that be a bubble or a physician provider. that's at the heart of the teachable moment for prevention and wellness activities. and of course we can't do it all on site, so then we craft a narrow for high-performance network of specialists in providers around the primary care clinics that we have on-site. and many folks have talked about process improvement activities, but we've really tried to study from the manufacturing side, having a parent that has grown up on a toyota production system is, of course nowadays that's kind of pejorative. maybe we should be talking about

the honda production system and set up toyota. anyway, we're very custom and talking them in terms of what kind of translated that into direct patient care as well. and of course redo workers comp. now, anybody here know the word discombobulation? is that in milwaukee word or is that not -- okay. well, i call this the discombobulation flight. actually, it's a complete site were at least in the lucky when you come to the tsa and you're putting your shoes back on and find your wallet from your cell phone, gave a big sign that says recombined relation area. [laughter] so anyway, this is the combined relations slide and in the lower left, you see the way to health care nonsystem is kind of array today. with centers of excellent, good men and women are cannot come up but necessarily always correlate with the the handoffs and everything. we strive to be a little bit more combat related or not. and so in our model, the patient is at the very center of our

universe surrounded by primary care. but primary care at both the surrounded by a whole host of things that it may not ordinarily get in the community. again from the direct contracting for the peace is streamlined to focus on preventive care and wellness at every visit. support services. a ton of support services. we been sourced pharmacy, dental, vision, fitness, wellness, and dietitian and are certified diabetic educators. those are just off the top of my head, occupational medicine, get integrated into the care experience. and i will tell you that most of our employees who come through doesn't matter if they heard there back in the garden or on the shop floor, they just know they have a sore back and they come into the clinic. and in those rare cases when there might be an issue about secondary gain for causality or something, our primary care providers do have a nice outlet where they can refuse themselves

of occupational medicine. again the robust information system to lead us measurable outcomes of service. this is just our clinic for print. so about half of our businesses for the quad graphics, for a handful of other folks. a little bit about the benefit design, which is emphasized here there is just one plan, okay? but it has three tiers and its tiered in such a way that again you have choices, but, you know, we're trained to steer towards the most cost effective and that would be the preferred tier where we have the squad med clinics on site, on campuses of our printing plants. are you only have a $7 co-pay for a visit or if you go to a specialist is referred by your provider is a $30 co-pay. and everything is really covered a 100% beyond that. the middle tier again is a pure point of service to him. middle service is just a ppo that the peace. there it's more like a 75/20

plan with deductibles that kick in and out of network adapter 65% benefit, but people do have the opportunity to go anywhere they want to embarrass some coverage available. the premiums are relatively low. but the interesting thing we do is we stratified the premiums against participation with our incentivized wellness program, which we call leading the e.u., which is a terrible pun can a terrible play on the wing manufacturing staff, but people are conversant with that kind of verbiage, so that's where we've gone. so, somebody who hops into about 75% of our population does, they ought to into the program. they can take back $11 softer their already low weekly premiums. two bucks for just signing up, $9 for testing of their tobacco free. so again, it's about 75% of our population.

the other thing i'll say very briefly on a value-based insurance design is we have one fairly mature the bid around diabetes and recall that well you for diabetes. and the way that works, all of our diabetics who opt into that program and sadly only about half of them do. and i think maybe he was brought up earlier, probably some significant comorbidities with depression. why wouldn't every diabetic want to take a program whereby they got, you know, a higher degree of coffee or service my service educator who helped them to maintain medication adherence and keep up with all of the myriad of things you need to do to be a healthy diabetic these days for my exams to put exams, et cetera. so when they do that, and faithfully adhered with the assistance of diane, are certified diabetic educator, they get a $0 co-pay for their mad and test strips, which on

average leicester was $540 per diabetic. so you know, again, what we're trying to get at tier is the primacy of primary care. but by doing this in over 20 years this has been a track record financially. the bottom of the two lines here and start with the quadra fixed line and we've enjoyed significant success when compared to our bench line, which is midwest manufacturers. in none of the last four or five years, the trend has spent a little bit more and that's i think possibly due to some of our wellness programming, but also i think it's got more expensive of the community as well. so in summary, a thing for one thing it's just delightful being able to say in conclusion and know that you're the last speaker of the day. [laughter] a lot of talk today about patient medical home which we

very much in price. a little bit about the verbiage we also embrace. i would maintain for you that if you take and post it here, paul grandi mentioned when he visited wisconsin last month that pc and i are opposite sides of the same coin and i really talk down to that. i thought there was a great medical construct. you take your pc mh and wrap them with a high-performance network as much as we have a nice data, book your enterprise and it's way more efficient in what we've been doing for the last several decades. so with that, i'm done. thank you. [applause] >> great. well, susan started us off with that great quote. those who say it cannot be done should stop interrupting those who are doing it. you will be heard today was those who are doing that. and i was flashing on all of the

conversations we've sat through the post-health care reform era, where people have asserted we will not than the cost curve in the accountable character will never been the cost curve. well, most of these folks pentecost are. so, we should stop interrupting them and let them get back to work. before they go, however, just to summarize in everyone of these presentations you heard the same thing. team orientation, a slowing down of the pace, longer visit, more john via phone and e-mail and through dhr and patient portals where possible so that longer visits can be had with the patients who really needed it. different payment structures, smaller referrals, et cetera. all of it put into a big package on resulting in savings. and in the curb the board. so, it's a pretty obvious set of conclusions that we can take away from all of this. and i guess the only question

is, what is it going to take to replicate more of this nationally? in manchester time, let's go right to complain of questions before we let everybody get back to work. over here, yes. >> craig west, medpac. i was just interested, eric, and whether you have any residence running through your group health? >> good question. yes, we do have residence in the pilot clinic and the resident clinic at else's running three group health. and i will also add that the word is out and if you want to recruit residence for your product is, i have a patient centered medical home. we got her most successful recruiting your server since having the medical home. >> and i think i recall reading in your piece, as well as in the report and repeal piece we did, eric, that you not only have had

as she did earlier enrollment in anonymous amount of interest in newly graduated medical students wanting to come to work for the system. as you just said was the case with residents. so, the market is going your way. was there another question? okay, if not, let me just -- yes there is over here. >> in several of the cases, you've managed to link in the visit and see fewer patients. so, what happens to patient demand? to have to train using e-mail where they otherwise would've visited. do they have longer waiting times and some of them just get to give up and how does that transition? >> all-star, but i think that patient demand is a bit of a misnomer. patients want care. they don't demand it

face-to-face. and that they can get care in a much more conveniently and have their demand satisfied, everybody is happy. and i practice and i use e-mail a lot in the phone and basically i think a patient demand actually goes down when it's satisfied in a convenient way and in a timely way. so patient demand is not a problem. the real problem, you know, that people don't think about is how you reorganize the panel because if you're thinking about going from it and able panel of 300 to 1800, some patients are going to have to remove the nuts and medical challenge that i don't think a lot of people have had to deal with until we've actually made that transition. >> how did you deal with that briefly? >> well, we let the doctors decide. in any patient who wanted to stay with the pmo was allowed to stay with the panel. and we've thought the doctors

would come you know, they're some patients were more difficult than others, so you would think i want to make their life easier. in fact, just the opposite occurred. people allowed the fewest visits with, the lowest level of relatedness to for the ones that were most likely to be repeatable. >> and just in terms of training patients, i recall it in a note in a report from the field piece that we ran. there was a report of one patient who was getting e-mail messages from his provider, but wasn't opening them. and so, group health dropped into the mailer postcards and please open up and read your e-mails. another patient knows exactly how to keep in touch with group health, which is via e-mail. >> question here. >> mark borden from ecuador and connecticut. i'm wondering if you can speculate on how the panel management access this issue plays out and a much broader

population being covered? so rather than just your 1800, when we bring in 32 million more people, how does that play? >> well, you know, that's a very good question you do know, we're talking here about the spread, access to decent primary care. and i think that's what this meeting is all about. i would hope that we go from this meaning energized to come you know, develop a population of providers who are skilled at doing this. because right now it's not really conceivable that you could turn a screw and suddenly of patients that are medical homes for all americans. but it's within sight if we set our minds to it, i believe. >> richardcome at you and to add to that? >> sure, i think that it the profound question, 60% of all encounters are happening in groups of four or less in the united states today. so there's really two pieces. physicians need to think about

rear commence in their practices to meet that on fire, which is a critical issue and its teens, technology they have to do that. but when you talk to physicians and they could you reorganize your practice, they say, not in a common environment i can't. so unlocking them is going to be key and i think the major thing i would say it's bad when policy people approach positions in the situation to discuss these pilots, they should understand that it a mutually beneficial negotiation. it's not a charity project. it's not a let's do something friendly for them. nor is it a sharp edged negotiation because what she wanted was by primary care cheaply. you don't have to change anything. so i think that understanding that there's a kind of social problem up there to solve a limit group of people who can solve it in trying to engage them in addressing that problem by making it possible for them to redesign t