The Annals of Family Medicine Special Edition Reports the findings of the 2 year National Demonstration Project (NDP) facilitated by TransforMED that involved 2 Arizona practices.  Click here to read the full article and talking points

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CMS will announce  (10/20/09) that it is putting on hold the Medicare Medical Home demonstration project authorized in the 2006 Tax Relief and Health Care Act (TRHCA).

The legislation called for a budget neutral implementation of the demonstration project in eight states. The plan to implement the demo has been stalled in the OMB for nearly a year. Additionally, health care reform legislation, specifically section 1302 of HR 3200 calls for repeal of the TRHCA demo and replacement with an “improved” medical home demo along with authorization of funding which addresses some concerns about budget neutrality.

CMS has decided it would be prudent to await the outcome of health care reform legislation before proceeding with the current demonstration.

This decision does not however affect the state-based multi-payer medical home demonstration project announced recently by Secretary Sebelius. We are currently awaiting direction from the Secretary’s Office concerning an implementation plan which is intended to plug into existing state-based medical home projects involving private payers.

The AAFP will continue to monitor these developments and keep you apprized as additional information is available.

Q&A With Paul Grundy, M.D., M.P.H.

IBM Director Lays out Goals, Vision For Health Care System

Business Leader Calls for Robust Foundation of Patient-Centered Primary Care

By James Arvantes
9/16/2009

In the battle to recognize the importance of a primary care-based health care system to health care reform, computer giant IBM has been a vocal proponent of the patient-centered medical home, or PCMH. Led by its global director of health care transformation, Paul Grundy, M.D., M.P.H., the company has been immersed in encouraging other large employers to recognize that a PCMH model can lead to lower costs, as well as to improved access, quality and health care outcomes.

Grundy also currently serves as the president of the Patient-Centered Primary Care Collaborative, or PCPCC, a coalition that IBM and the AAFP helped to create that advocates adoption of the PCMH as a way of transforming the nation’s health care system. Before joining IBM, Grundy worked as a senior diplomat in the U.S. State Department, where he supported the intersection of health and diplomacy. He also was medical director for the International SOS, the world’s largest medical assistance company, and for Adventist Health Systems, the second largest not-for-profit medical system in the world.

AAFP News Now recently sat down to talk with Grundy about the status of the U.S. health care system, current health care reform efforts, and the prospects for primary care and family physicians in the coming years.

Q. Why are you such a strong proponent of primary care and the PCMH?

A. That is a simple question to answer. Primary care — done right and paid for in the right way — works. Comprehensive care with the patient at the center works. When you look around the United States and around the world at places with a robust system of primary care and prevention, it adds value. Places that have experimented with systems of care without a strong primary care base — like we have done in many parts of this country during the past 20 years — do not work. They are broken, big time — so broken that we are in trouble as a nation. We have got to get back to a system of care with a robust foundation of patient-centered, relationship-based primary care and prevention.

Q. Why are you convinced that the U.S. health care system is at a crossroad?

A. Everybody who understands health care has pretty much come to the conclusion that we really can’t survive economically with the model that we have, which is a focus on high-end partialist care that is uncoordinated and not integrated, and which causes such human desperation and pain and suffering, as well as cost. It has really been made clear by many folks who have looked at this that we have a nonsustainable (health care) system that has to change.

Q. Is health care reform required for these changes to occur?

A. Transformation of the health care system will occur, with or without health care reform. There are components of health care reform that have already passed. We have the State Children’s Health Insurance Program and the American Recovery and Reinvestment Act. I would consider those measures health care transformation and reform.

There is reformation and transformation. The transformation within family medicine was clear to AAFP leaders when the AAFP did the Future of Family Medicine project. The AAFP looked down the road and saw a future in which care had to be coordinated, and it basically said, “We see the future, we understand the future. We need to get in front of this and on top of this.”

The AAFP started to do something about it. The Academy created TransforMED and collaborated with other primary care organizations to create the Joint Principles of the Patient-Centered Medical Home (3-page PDF; About PDFs).

Q. What is your opinion of the health care reform legislation now pending in the House and Senate?

A. I think, by and large, a lot of the major issues have been looked at and tackled, and there is not a lot of debate about most of it. I think most of the debate is really around whose pocket is going to pay for it — is it public or is it private? Those are ideological points of view. When you look around the world, you see systems in which government and private sector models work. It is just a matter of how they are structured.

Q. The House health care reform bill includes a primary care medical home pilot expansion that includes two different types of medical homes. But both are geared toward high-needs beneficiaries. Is this a problem?

A. I think it is a problem. We know from some of the results of the pilots that we have seen that you really have to fundamentally transform a way a (physician’s) practice practices. Physicians who are now only delivering episodes of care have got to understand and agree to the principles that the primary care societies have laid down around this transformation that moves them from where they are to a process of continuous improvement.

My concern is if you only focus on a few patients who happen to be on Medicare or Medicaid who are high need — let’s say it is 5 percent of your practice. I just think it is too easy for physicians to continue to do what they are doing now, which is episodic-based care, focusing on a small percentage of their practice and not really changing the way they practice. This is going to be tough for the doctors. The experience from TransforMED shows that to transform from episode-based care to a system of care in which physicians are the quarterbacks is not easy. They are responsible for coordinating care and integrating care for their whole practice.

Q. You participated in the White House stakeholders meeting on advanced systems of primary care in August, which was moderated by Nancy Ann DeParle, director of the White House Office on Health Reform, and other White House officials. What do you think their sense is about primary care and the PCMH?

A. I am absolutely convinced in the conversations I have had with the Obama administration and the leadership on both sides of the aisle in the House and Senate that they understand the importance of primary care. They all understand that we are in real trouble because there is not a system in this country in which there is a very robust system of primary care.

Q. Five to 10 years from now, where do you think the health care system will be?

A. I think in five years or in 10 years, we will be well down the road toward a much more integrated system. I think society is going to demand that. The advent of technology in terms of data analysis, data flow — which we are already starting to see — will demand that.

Q. What will this mean for family physicians?

A. I think family physicians are in an extremely powerful position. There is not a newspaper that you pick up now that doesn’t talk about the concern around there not being enough family physicians — that family physicians are valued. That wasn’t true three years ago. Three years ago, there were an enlightened few who would have realized (the value of family physicians). There is not a day that goes by now when people are not screaming about that.

Q. If our political leaders and policymakers truly understand the value of primary care and family physicians, why don’t we have a system based on primary care? Why are we still in the discussion stages of moving toward a primary care system?

A. I think it is a historical series of events that has brought us to where we are now. We tried the HMO model, in which we used a gate-keeper, rather than a relationship-based model. We ended up in a dead end.

Q. There are concerns that health care payers and policymakers, in an attempt to save money, will turn to physician assistants and nurse practitioners to do the things that primary care physicians do now. How do you feel about that?

A. Our patients tell us they want a healing relationship. They want a healing relationship from a figure in society who is trusted. The level of training and the kind of training a family physician has are extremely valued and will continue to be valued by our patients. The physician as a healer in society is an image that is extremely powerful, and that element of trust is extremely powerful. Given a choice, many patients will want someone who has a medical degree, someone who has the years of training a family physician has.

Q. You are president of the PCPCC. What impact has that collaboration had on the ongoing health care reform debate?

A. I think it has had a significant impact and influence because it was companies like IBM (within the collaborative) that began to wake up and understand the value of primary care at a time when primary care was evaluating itself and in trouble. There are not enough medical students going into primary care. It had been undervalued for years. The PCPCC started calling in the alarm on that. That is probably a significant role we played.

The PCPCC also asked all the primary care physician groups to accept a set of principles that they could agree on, not just one organization. This evolved into the Joint Principles of the Patient-Centered Medical Home, which laid down a foundation for this movement to take place.

Q. How has IBM embraced primary care and the PCMH?

A. I think we were one of the leaders of the whole PCPCC. We certainly recognized the value of primary care and started a conversation with other large employers. We continue to play a role in that from the standpoint of leadership in the conversation around this journey of transformation with other employers and with national and state governments. Companies like IBM need to be engaged so that it is more than just primary care talking about itself. It was important for someone else to wake up to the value of primary care.

Texas AFP provides information on PCMH