What Is A Health Care System For?Investing In Primary CareMichael Fine, MD

Senior Clinical and Population Health Officer

Blackstone Valley Health Care, Inc

Presenter Disclosures

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Michael Fine, MD

Stock ownership or options: Stockholder in HealthAccessRI,.

Missed public health opportunities in Rhode Island

• 133,000-156,000 smokers1 • Too many unnecessary deaths a year

– 596: heart disease and stroke– 200: colon cancer– 300-400 prescription and other drug overdoses

• 75-100 unnecessary new cases of HIV2

• 650 kids born to teenagers3

• An infant mortality rate twice what it should be• 50 to 200 avoidable deaths and 300-1000 avoidable

hospitalizations from influenza4

• 500,000 Rhode Islanders unimmunized against influenza• Significant disparities in infant mortality, adolescent pregnancy,

and life expectancy by race, geography and physical and behavioral abilities

In a state with no local health departments, our only access to the population denominator is through primary care. . .

And population focused primary care deserves public investment

Primary Care has a public purpose.

Primary Care deserves public investment

But Primary Care Practices and physicians are being tasked with more and more administrative

responsibilities

HIPAA EHR Meaningful use CLIA Patient Portal PMP ETC

The Business Model of Primary care is built around fixed costs, which is challenged by

variable fee-for service income Rent Salaries Malpractice

insurance Utilities IT and computer

maintenance Telephone service

In a market created around perverse incentives…

OUR GOAL must be to leverage the political process and change payment so that

it rewards both the best patient care and constant

improvement in public health outcomes

What primary care services are likely to show return on public

investment?

• Open Access and extended hours

• QA/QI for Population Health Indicators

• Population penetrance

Open Access and Extended Hours

One way to approach unnecessary ED and hospital utilization

May contribute to better population health outcomes by • allowing early identification and

treatment of infectious disease by allowing rapid assessment of complications of chronic disease

Can help improve vaccination rates

QA/QI for Population Health Indicators

Smoking Prevalence Opt out testing for HIV Substance use via SBIRT Hypertension and hyperlipidemia BMI Preconception counseling

Population Penetrance

Increasing the proportion of the population of a place that is enrolled in primary care

HOW high performing health care systems around the world achieve good outcomes at affordable costs

Many of us would be happy to do this outreach if only someone would support this work

What form should public investment take?

Capitation for enrollment Capitation for producing clean practice

population data on public health indicators Sign-on incentives to participate in Rapid

cycle change Rewards for achieving practice population

outcome goals

Who will pay us to do this work? State Departments of Health/CDC

• As funds consolidators for health plans, including Medicare and Medicaid

• Using CDC grant funds• Using State General Revenue Funds• Using Private Foundation or even corporate

investment Multi-payer collaborations Individual Payers, directly negotiated with

practices and practice groups

Red State Solutions Direct Primary Care provides capitation for patient care

• Market pricing of capitation• Will require changes to ACA and health plan designs so that

DPC services are considered essential services not duplicated by qualified health plans DPC payments are counted toward deductibles of high deductible plans Community rated high deductible plans are incentivized on state and federal exchanges

QA/QA for public health indicators funded by• State and local Departments of Health, using CDC and Genral Revanue funds• Self-insured employers• Private Foundation or even corporate investment• Multi-payer collaborations• Individual Health Plans, directly negotiated with practices and practice groups

Population Penetrance funded by• Medicaid and Medicare• Health Plans• Self-insured employers

Blue State Solutions

State Primary Care Trust provides capitation for patient care• No one left out• Administration simplification

Reduced practice negotating power QA/QA for public health indicators funded by

• State and local Departments of Health, using CDC and General Revenue funds• Self-insured employers• Private Foundation or even corporate investment• Multi-payer collaborations• Individual Health Plans, directly negotiated with practices and practice groups

Population Penetrance funded by• Primary Care Trust

HOW can we stimulate this investment?

Talk to patients, and build a political base Talk to one another, and learn to speak

with one voice Work at the State level with government,

Medicaid, and other payers• To help them see the return on their

investment Occupy CMS LEADERSHIP. LEADERSHIP. LEADERSHIP

Summary and Conclusions: What is a Health Care System For – Investing in Primary Care

Primary Care has a Public Purpose• Improved population

health outcomes• Affordable costs

Investment can come from different sources

Investment should be directed at services that are likely to produce return on investment

We can not do this alone!

“If you can see the invisible, you can do the impossible.”

-Bernard Lown, M.D. Nobel Laureate

“The Arc of the Moral Universe is long, but bends toward Justice.”

-Dr. Martin Luther King, Jr. Nobel Laureate