Group Health’s Medical Home JourneyInvestments and Returns for ExcellenceAlicia Eng, Interim Vice President, Primary Care Services

The National Medical Home Summit WestSeptember 21, 2011

Who we are

•Integrated health delivery system•Founded in 1946•Consumer governed, non-profit•Membership: 661,500 Staff: 9,365•Revenues (2009): $3 billion

•Group Health Research Institute•34 investigators•235 active grants, $39 million (2009)

•Multispecialty Group Practice• 26 primary care medical centers• 6 specialty units, 1 maternity hospital• 985 physicians

•Contracted network• > 9,000 practitioners, 39 hospitals

Group Health

Medical Home Design Principles

✔✔✔✔

✔ The relationship between the clinician & patient is at our core. The entire delivery system will reorient to promote & sustain.

The primary care clinician will be a leader of the clinical team, responsible for coordination of services, and together with patients will create collaborative care plans.

Care will be proactive and comprehensive. Patients will be actively informed and encouraged to participate.

Access will be centered on patients needs, be available by various modes, and maximize the use of technology.

Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective experiences.

Medical Home Investments

Panel size

1,8002,300PCMH design:

Clinical teams Desktop time E-technology

Appointments

20 min.

30 min.

Medical Home 1 & 2 Year Pilot Outcomes

Group Health Research Institute

Year 1

Year 2

QUALITY (HEDIS)Year 1: Rate of rise, 2x that of control clinics

Year 2: Rate of rise continued to be 20 – 30% greater in 3 of 4 composites

PATIENT/STAFF SATISFACTIONYear 1: Patient satisfaction – 5% increase in patient activation/goal setting;

Practitioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalization

Year 2: Scores continued to improve at Medical Home; controls were slightly worse

ED/UC UTILIZATIONYear 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but

longer in-person visits

Year 2: Significant changes persisted

COST Year 1: Cost is neutral

Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)

Source: Health Affairs 29:5 May 2010

Reid RJ et al, Health Affairs 2010;29(5):835-43Larson EB et al, JAMA 2010; 306(16):1644-45 Reid RJ et al, Am J Manag Care 2009;15(9):e71-87

Mapping the Value Stream

OutreachWorkcell

Includes:1. ED/UC outreach2. Hospital/SNF discharge outreach3. Complex Case Management outreach4. Disease Management outreach5. Chronic Care outreach (Doc & Coding)6. HEDIS outreach7. Lipid Mgmt outreach8. TRIP outreach, Pharmacy outreach

OutreachCell Development- Who/Roles- Work Rules- Virtual or Physical - Standard Work for Outreach- Outreach Prioritization Criteria

Primary Care Future State Map August 19 – 21, 2008Medical Home Model

Other Demand

Other Demand

Other Demand

Appoint Patient

Provide Care Follow Up

(Increase Use of) Virtual

Medicine(Call Management & Secure Messaging)

Patient

Strategies & Tools for

Increasing Use of Virtual Medicine

PREREQPanel Size =

1800 rawStandard Work for Moving Panel

- Includes Strategies for Hard to Recruit

clinics

Define M-F Template Variation

Consistent pre-visit prep work (MD and flowstaff)

Prep for Visit

Determine Medical Home Applicability to

Pediatrics- Panel, Visit levels, Peds RNs

Standard Work for

Managers/Leaders

PREREQDefine Facility Assessment

Needs/Strategy

Standard Work for Huddles & Pre-visit Prep

- Team Huddles (everyone attends)- Dyad Huddles

PREREQVisit Length =

30 minutes

-More holistic care/opportunistic care

PREREQ1:1 MD/Flow Staffing (consistent each day

if possible)PREREQ

Co-Location of Team Members

Standard Work for Chronic

Disease Mgmt- Meet regulatory requirements, build reporting

Consistent AVS usage

Select Standard

Tools/AVS Content

Design Heijunka

Format & RulesHeijunka Box to Level Work

XOXOConsistent

Use of Visual Systems

LEGEND PREREQ Prerequisite for individual clinic before going live

Improvement work

Medical Home element to be

spread

Spreading the medical home

Virtual Medicine

Disease Management

Visit Preparation

Patient Outreach

1. Staged spread of practice change modules

Team Huddles Standard Mgmt Practices

Enhanced Staffing Model Value-based MD Payment Model

2. Supported by management & staffing changes

Standardization & Spread using LEAN methods

Acute and Planned Visit Access

Medical Home 1 & 2 Year Pilot Outcomes

Group Health Research Institute

Year 1

Year 2

QUALITY (HEDIS)Year 1: Rate of rise, 2x that of control clinicsYear 2: Rate of rise continued to be 20 – 30% greater in 3 of 4 composites

PATIENT/STAFF SATISFACTIONYear 1: Patient satisfaction – 5% increase in patient activation/goal setting; Practitioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalizationYear 2: Scores continued to improve at Medical Home; controls were slightly worse

ED/UC UTILIZATIONYear 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visitsYear 2: Significant changes persisted

COST Year 1: Cost is neutral Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)

Source: Health Affairs 29:5 May 2010

2010 performance continues to hold for:

•Quality

•Patient/Staff Satisfaction

•ED/UC and Hospital Utilization

•Cost

•Building on the Foundation

-The Patient Centered Medical Home

•Accountable Care

- Provider Partnerships

Opportunities for Further Investments

Building on the Foundation

• The Patient Centered Medical Home

– Full Capitation

– Integrated group practice – Primary Care and Specialty

– Manage a full continuum of care in an integrated, local delivery system

Value Created from Integration

Entry

Scale‐up • Add wrap‐around services: e.g. Hospitalists

• Add specialties that scale warrants (e.g. Pulm, Oncology, Occ

Med)

Observation • Add observation unit: 24/7 urgent care coverage

• Enter with Primary Care Medical Home minimum scale

‐

2 – 4 provider is minimum scale 

‐

Waived testing, “Rx‐lite”

(e.g., sampling, mail order, ADM)

Efficient scale• Add remaining specialties as scale warrants,

e.g. Allergy, neurosurgery, infectious disease

• Add additional ancillary (Rx & Lab) & after hrs urgent care 

• Add specialties as scale permits:

‐

Smaller scale: e.g. OB‐GYN, Pediatrics

‐

Mid‐scale: e.g. Anesthesiology, General Surgery

‐

Larger scale: e.g. GI, Neurology

MinimumEnrollm

ent

120K+ enrollees

Cumulative PM

PM value

$50M ‐

$200M PMPM value 

(depending on LOB)

Accountable Care

• Provider Partnerships

– Groups of practices come together around a population

– Focus on the patient and care models to improve care and lower costs

– Establish specific spending levels and shared savings under fee-for-service or increasing degrees of capitation

– Select partners with shared values and principles

• Increase PC presence in the market through partnerships and acquisition

– 1% annual impact on Hospital Inpatient Utilization over 5 years

– 0.5% annual impact on Hospital Outpatient Utilization over 5 years

• Build a Specialty Group

– Incremental 25-40 Specialty FTEs across target service lines

– Shift $20-30M ongoing operating external delivery system spending to internal

• Joint clinical programs and integration utilizing care management and other features of patient support:

– 2% annual impact on Hospital Inpatient utilization over 5 years

– 1% annual impact on Hospital Outpatient utilization over 5 years

• $20 million in savings across Integrated system by year 5

– Lower premium and costs of care

– Distribution in shared savings to partner provider groups and hospital to account for decrease in claims revenue

Network Design & Clinical Integration in Spokane

Keys to Success

Contact Information

Alicia Eng, Interim Vice President of Primary Care Services

Group Health Cooperative, Seattle WA

(206) 448-7323

eng.at@ghc.org