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there's dissatisfaction and even
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frustration among patients and
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physicians with the state of primary
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care in the US when we're thinking about
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the physicians they're facing low
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managed care fees they're facing
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increasing costs of running a practice
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and that's inevitably leading them to
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spend less time with patients see a lot
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of patients during the day have patient
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wait very long times for appointments
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and that obviously has the potential to
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deteriorate the level of care heard the
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quality and lead to inadequate care
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patients have the same issue they don't
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spend enough time with the physicians
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very little face time leads the
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physician to rely very heavily on
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referrals to specialists and of course
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waiting a long time for an appointment
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has its own problems your condition may
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deteriorate you're delaying very
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necessary care and at the end of the day
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you actually might resort to going to
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the emergency room or or suffer some
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other consequences this is not going to
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get better because this issues with
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inadequate access to care and the fact
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that there's mismanagement of health
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condition is only going to get worse
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with aging population with increasing
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chronic condition prevalence and with
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insurance expansions so with the
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shortened shortage of primary care
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physicians we currently have in the US
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we see regulators we see policy makers
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we see employers and and we see health
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plans looking for innovative ways to
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change the landscape of primary care one
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of those innovation is probably the most
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notable one is the patient-centered
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medical home which we study in this in
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this particular research and we're
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trying to see if the adoption of the
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patient-centered medical home model
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leads to a reduction in the reliance on
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emergency room services
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patient-centered medical home can be
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best described as a model of primary
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care centered on the patient it's a
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team-oriented it relies on accessibility
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to care care coordination and the use of
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IT to provide better care and better
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outcome for for patients most of the
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patient-centered medical homes in the US
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are recognized by the National Committee
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for Quality Assurance or short is NCQA
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unsecure is a non-profit committed to
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improving quality in primary care in
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order to be NCQA recognized the
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practices have to put in processes for
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scheduling appointments with patients
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for communicating with patients for
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organizing documenting and measuring
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clinical outcomes for implementing
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evidence-based guidelines in their
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practices and for organizing and
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tracking referrals and there's a whole
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long list of other things that they need
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to put in place to receive this
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recognition every one of those standards
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elements and factors that are being
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reviewed is getting scored and when you
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aggregate this the score there is a
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determination whether this patient
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whether this clinic becomes a
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patient-centered medical home or not and
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not only that it also determines whether
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the recognition receive a low level or
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high level so there's different levels
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of recognitions if you're a
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patient-centered medical home recognized
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by the NCQA you have access to financial
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incentives that are provided by health
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plans by employers and in kind of in the
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early days of patient-centered medical
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homes which we study also state and
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federal sponsored pilot programs
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we find that practices that went through
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this transition and became a
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patient-centered medical home yeah the
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practice itself becomes the home for the
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patient they're not going anywhere
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there's a team-based approach that
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provides a home for every need that the
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patient has the practices that went
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through this transition have reduced the
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number of emergency room admissions for
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their patients by five to eight percent
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if the patient had a chronic illness if
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the patient did not have a chronic
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illness there was absolutely no
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reduction this is the primary finding
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and then when we drill down and look at
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the different chronic conditions we see
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that a lot of those benefits and the
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biggest reductions that we see happens
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for patients that have either
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hypertension or diabetes in addition to
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that a very interesting thing that we've
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looked at is what's the mechanism that
00:05:11
leads to this reduction in ed admission
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and one of the finding we see is that
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the reduction in the admission is not
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very sensitive to the timing of the
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visit and what does that mean is that
00:05:24
the reductions in ED admissions are not
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coming necessarily from the fact that
00:05:31
the the patient-centered medical home is
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open for longer hours or that it has
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more accessibility but actually from
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better management of chronic conditions
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that basically means that even if you
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seek care in the emergency department on
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weekends when most of those primary care
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clinics are closed you would still have
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the same reduction the same benefit and
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that tells me that your chronic
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condition is under control and it's
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better managed
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I believe what sets our researcher part
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is its scale we look at four hundred and
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sixty thousand patients over four years
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in 280 patient-centered medical homes
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and this this was never done before
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nothing on this particular scale 115,000
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of those patients we see them each and
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every year in our sample and that allows
00:06:32
us to do things that again we're never
00:06:34
done in the literature so it's not just
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that we can see what happened to the
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patient population when a practice
00:06:41
decides to switch to a patient-centered
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medical home but we can see what
00:06:44
happened to an individual patient when
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their practice switches to a
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patient-centered medical home and follow
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the patient and see if there is a
00:06:53
different experience for that particular
00:06:55
patient doing that that particular
00:06:57
transition
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previous research is very mixed on this
00:07:06
issue of the benefits of
00:07:07
patient-centered medical homes so we we
00:07:08
didn't really know what to expect I I
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see our findings as somewhat comforting
00:07:14
because we see the effect where we
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expect to see it and we don't see it
00:07:18
where we expect not to see it let me
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give you an example patients that don't
00:07:22
have a chronic condition we don't expect
00:07:26
the patient-centered medical homes to
00:07:27
have a big impact on on ed admissions
00:07:30
the main reason why a person ends up in
00:07:33
the emergency room whether they don't
00:07:35
have a onic illness is things like
00:07:38
trauma a motor vehicle crash there's
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nothing in the patients that are come
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centered medical home that makes you a
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better driver that they're not claiming
00:07:46
to do that on the other hand if you have
00:07:48
a chronic condition a better management
00:07:51
of that condition using all the
00:07:53
processes that ncqa puts in place in the
00:07:56
practice can have an impact and it's
00:07:58
very comforting to see that five to
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eight percent of admissions to the
00:08:03
emergency room are being avoided now we
00:08:05
have a lot of research that documents
00:08:08
that many of the visits to the emergency
00:08:10
room can be prevented it's either that
00:08:13
the visit is legitimate somebody has a
00:08:16
problem but if they had better
00:08:17
management that visit could have been
00:08:19
avoidable and we still have a lot of
00:08:22
visits to the emergency room where the
00:08:24
setting is wrong you could have went to
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your primary care physicians or to
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another setting and received care you
00:08:30
didn't have to go to this high level of
00:08:31
acuity a type care
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if the patient-centered medical home
00:08:40
model is the poster child for innovation
00:08:43
in primary care the stepchild would be
00:08:47
at least judging from the lack of
00:08:49
interest among researchers would be a
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variety of retainer based medicine
00:08:55
models also known as concierge medicine
00:08:58
models where the heart of those models
00:09:01
there is a monetary transfer from
00:09:03
patients to their physician in the form
00:09:05
of retainer fee which averages about one
00:09:08
hundred and fifty dollars per month in
00:09:12
return the physician is able to reduce
00:09:14
the size of their panel from what we
00:09:17
said before about 3,000 patients to no
00:09:21
more than 600 this allows the physician
00:09:24
to spend more time with the patient have
00:09:26
extended visits about half an hour
00:09:28
visits you know make sure that patients
00:09:32
can come in on the same day so enhance
00:09:34
accessibility to care and then patient
00:09:37
can call their physician they can email
00:09:38
their physicians so the service aspects
00:09:40
and the convenience aspects are enhanced
00:09:45
the retainer base models stem from the
00:09:50
same dissatisfaction of frustration that
00:09:53
the patient-centered medical homes
00:09:54
models stem from but retainer base
00:09:59
models have not received much attention
00:10:01
not in the literature and and you know
00:10:04
to some extent in the media but not all
00:10:07
that favorable attention and you might
00:10:09
ask yourself why well there's two main
00:10:11
reasons why one people view this as
00:10:14
medicine for the reach this a little bit
00:10:18
ignore is the fact that most people who
00:10:20
receive services nowadays in in those
00:10:24
concierge practices and retainer based
00:10:26
medicine models our middle class and and
00:10:30
and one hundred and fifty dollars a
00:10:32
month we can debate that but for a lot
00:10:34
of people this is considered to be
00:10:36
affordable the second and probably the
00:10:40
biggest criticism of retainer based
00:10:42
models is its sustainability we have a
00:10:46
fixed supply of physicians if every
00:10:47
physician downsize your practice we're
00:10:50
just going to exacerbate the shore
00:10:51
stage of primary care physicians this is
00:10:54
a valid criticism but it ignores a
00:10:58
couple of things one many physicians
00:11:01
especially at a certain age in their
00:11:03
life contemplate retiring contemplate
00:11:07
maybe changing direction professionally
00:11:10
working for a pharmaceutical company or
00:11:12
something like that instead if they can
00:11:15
go into this retainer base models it
00:11:17
buys them a couple of more years where
00:11:19
they can work in this field in a
00:11:22
different pace the second issue is that
00:11:26
retainer based models tend to make
00:11:29
primary care more attractive to young
00:11:31
doctors who are choosing which field of
00:11:34
medicine they want to go into and if we
00:11:36
want to solve the shortage of primary
00:11:37
care in the long run we have to make
00:11:40
primary care more attractive and and
00:11:42
when we see that happening on the ground
00:11:44
and the last point is that there's many
00:11:47
models of retainer based medicine that
00:11:50
do not rely on major reductions in the
00:11:52
panel size those models typically called
00:11:56
hybrid models have a huge potential
00:12:00
because they're both scalable and also
00:12:04
because they tend to segment patients
00:12:06
into those who value access to their
00:12:09
physicians from those who see their
00:12:11
physicians you just for routine checkups
00:12:13
and very basic here
00:12:19
I think in spirit Obamacare fits very
00:12:23
well with this trend of innovation in
00:12:25
primary care this innovation when we
00:12:28
look at patient-centered medical homes
00:12:30
places the patients in the center and in
00:12:33
in a way it transitioned us from a world
00:12:37
in which physicians were paid based on
00:12:40
volume to a world in which we're trying
00:12:43
to shift and pay physician based on
00:12:44
value that they create for their
00:12:46
patients that's very much in the spirit
00:12:47
what else is in the spirit is the
00:12:50
reliance on information technology on
00:12:52
cost containment on finding ways to have
00:12:55
other non physicians in the clinic part
00:12:58
of this medical home that will work at
00:13:01
the top of their license will engage in
00:13:03
population management will reach out to
00:13:05
patients with chronic conditions and
00:13:07
will follow up and will try to improve
00:13:10
care to reduce the burden of kind of
00:13:13
downstream utilization that can happen
00:13:16
when those are breaks in continua t of
00:13:19
characters
00:13:24
there's a couple of research projects
00:13:26
already underway the first stream deals
00:13:30
with this heavily understudied returner
00:13:33
base medicine models this is coming
00:13:37
through a partnership with one of the
00:13:39
leading companies in the industry to
00:13:42
study the real effects of patients who
00:13:45
stay within a retainer based framework
00:13:47
and those who find themselves outside of
00:13:50
that framework what happens when you
00:13:53
spend half an hour the physician instead
00:13:54
of 8 or 12 minutes what happens to
00:13:57
referrals what happens to outcomes what
00:14:00
happens to your health and what happens
00:14:02
on the financial side in terms of health
00:14:04
costs on the other venue the
00:14:07
patient-centered medical homes our
00:14:09
partners at independence Blue Cross and
00:14:12
I have received a very unique data from
00:14:16
NCQA allowing us to look at all the
00:14:19
individual scores on all standards
00:14:21
elements and factors for those practices
00:14:25
that we've studied in the research I've
00:14:27
described today this will allow us to
00:14:30
look under the hood well at the very
00:14:33
granular level of what is driving change
00:14:37
and innovation in primary care and allow
00:14:39
us for the first time to understand the
00:14:41
elements that are driving this the
00:14:44
various improvements in care both in
00:14:47
terms of outcomes and costs
00:15:03
you
