This is the fourth in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for one more!
Transforming Primary Care Practices in Pursuit of the Triple Aim: How Great Leadership Can Make or Break the Deal by Marci Nielsen, PhD, MPH
October 17th 12-1:30 PM
Jennifer Hodgson and Barry Jacobs: This isn't their first rodeo
Barry Jacobs (BJ): Sprightly, buoyant Dr. Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, opened her talk by stating that the American public doesn’t know the term “Patient Centered Medical Home” nor “Triple Aim”. It is our responsibility, she said, to help people understand these ideas and to bring their voices into the national discussion. It all comes down to influencing people who are voters and who are concerned that healthcare costs too much. We have to make the case that healthcare transformation is good for them.
Jennifer Hodgson (JH): Dr. Nielsen opening up her plenary to talk about the importance of leadership in enacting the Triple Aim. She advocates for Health System Transformation using the Triple Aim as the roadmap. She said our job is to translate what we do to the public so they can be brought in as real stakeholders. Healthcare Transformation is about “people.” She stated that the Affordable Care Act has been a great platform for payment and delivery reform but we have consumers that have no idea what their role is in all of this. Our job is to make sure that we are doing this as a part of our work.
BJ: She commended New Yorker writer Atul Gawande, MD for his skill conveying these complex healthcare concepts and through stories. She cited a Gawande speech that stated we train doctors to be “cowboys” and that we ought instead to be training healthcare professionals to be “pit crews,” valuing humility, discipline and teamwork.
JH: Dr. Nielsen pointed out that Atul Gawanda, MD, delivers this to the public via his incredible stories. She stated that we train our physicians to be “cowboys” and independent. She said Dr. Gawanda thinks we should train physicians to be members of pit crews instead. However, this requires changes in our values where we become more humble and allow the leaders to be those that can address the patient’s need at that time.
BJ: She said there are yet gaps in evidence about whether PCMHs work. She also said we need primary care in addition to super-utilizer care, as well as partnering with everyone else in the healthcare system and community. The US is one of the few countries that seems to believe that health and healthcare are the same thing. A lot of this comes down to politics. Many politicians think that the free market can fix all of our problems; many people in government believe that it is all up to government programs. She says that it needs to be all stakeholders pulling together. We have too many people defending the status quo. We have to convince them with data, stories and changing our values to make healthcare more patient-centered.
JH: Believes that we need both super utilizer and Patient Centered Medical Home data. She reminded us that primary care is only 5% of our expenditures. PCMHs need to be partners though with everyone in the healthcare system (e.g., community centers, schools, employers, faith-based organizations, and public health).
BJ: Dr. Nielsen pointed out that employers are frustrated not just with personal health costs but also the impacts of behavioral health and other problems on worker productivity. But a recent Health Affairs article stated that only 14% of ACOs currently have perfectly integrated behavioral health. 43% have some behavioral health integration. She says that that’s our opportunity—to help those ACOs integrate more fully and benefit in terms of return on investment.
JH: Dr. Nielsen shared that there are more healthcare expenditures per person requires industry and government solutions. If half of all healthcare expenditure dollars in the US are linked to private and the other half gov’t, we need alignment of both camps to develop solutions. Noted we have to change the way we fund healthcare….we are fragmented and siloed….overused and misused. It is very frightening for the “haves” to have the “have nots” be a part of the solution. We need to convince them (the “haves”) that there is room for everyone at the table. The key is to focus on “the patient.”
Employers are focusing on productivity (absenteeism and presenteeism) …we need to focus on patients’ quality of life. The top 5 conditions employers spend their money on are related to behavior health issues. Stated 14% of ACOs have integrated behavioral health but 43% total have started.
BJ: She argued that primary care is still incredibly undervalued. And that primary care must include behavioral health. Reported outcomes for policy-makers have to include costs. Presentations to patients and families have to focus on improved quality.
We are moving, she said, from a volume-based reimbursement to a value-based reimbursement system. We need to push this with policy-makers with data and stories. PCMHs and ACOS have to join forces. We have to partner with people we’ve never partnered with before. Public health and behavioral health have seats at the table now that they never had before.
JH: Barbara Starfield’s research tells us primary care is effective but Dr. Nielsen believes primary care is still undervalued as evidenced by only 4-5% of healthcare expenses being in primary care services. Job of Patient-Centered Primary Care Collaborative (PCPCC; www.pcpcc.org) is to share evidence in a way that is useful. They have a website that maps the programs and evidence in each state. This is helpful when talking to policy makers.
The number of PCMHs has quadrupled. To sustain this model we need to change from a fee for service to a value-based reimbursement system. Need to partner with healthcare specialists, pull in care coordinators, and public health specialists. We have to know when to “raise hell” and “hold our fire” to be able to work together effectively and align our interests vs being diametrically opposed.
BH: Lowering per capita costs requires hot-spotting. But we can’t stop there. We need prevent people from falling in the river in the first place. We have to be convenient and compassionate. We also have to work on the population health level through data sharing and improved care coordination.
JH: We have data on how to lower healthcare costs…with first initial savings done with hot spotting but DON’T STOP THERE! We also need to be preventing people from getting to the point of high utilization. This is all relational! We have to also be convenient – group visits for example!
We need EHRs/technology that unifies rather than divides care! Period!
BH: There are PCPCC slides on behavioral health in primary care that are available for download.
JH: Three types of models: Consultative, co-located, and collaborative (embedded) ….this requires partners between all types of medical providers and behavioral health providers… with health coaches/care managers being the glue.