The Perfect Time for 30 Million New Patients

1. The Perfect Time for 30 Million New Patients Coverage Expansion Creates Immediate Access Challenge Source: Congressional Budget Office. “CBO‘s February 2013 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage.”February 5, 2013.http://cbo.gov/sites/default/files/cbofiles/attachments/43900_ACAInsuranceCoverageEffects.pdf(accessed March 19, 2013); Medical Group Strategy Council interviews and analysis. Percentage of Insured Non-elderly Americans n=267,000,000 (2010), 282,000,000 (2019) Health Care Utilization, Massachusetts Adults Change Based on Self-Reported Data, 2006-2008 79% 39% of exchange enrollees previously lacked usual source of care 66% 2014 brings 12 million newly insured, largest increase in expansion over a single year

2. Inching Towards Population Management Rising Volumes, Price Pressures Call for Expanded Care Services Source: Medical Group Strategy Council interviews and analysis. Advisory Board Company Population Health Leaders survey, fall 2012; n=30. New Responsibilities of the Integrated Medical Group Bolstering Ambulatory Services Reducing Downstream Care Costs Expand Chronic Care Access Standardize Chronic Care Pathways Identify, Manage High-Risk Patients Maximize Procedural Efficiency Facilitate Care Plan Compliance Create Streamlined, Effective Discharge Process

3. Doing More with Less Physician Shortage Creates Urgency to Become More Resourceful Insufficient Physician Supply… … Opens Our Eyes to Other Providers Projected 2005-2025 ” Narrowing the Skill Gap Demand “We’ve found that 98% or 99% of all patients, with our systems and pathways, can be managed by the physician assistants and nurse practitioners.” Supply Douglas Kelling, MD Internist Source: Dill, Michael J., and Edward S. Salsberg. AAMC Center for Workforce Studies, "The Complexities of Physician Supply and Demand: Projections Through 2025." Last modified November2008. Accessed March 21, 2013. https://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf; Okie, Susan. “The Evolving Primary Care Physician.” New England Journal of Medicine. 366. (2012): 1849-1853. http://www.nejm.org/doi/full/10.1056/NEJMp1201526 (accessed March 20, 2013); Medical Group Strategy Council interviews and analysis.

4. There’s no “I” in “Team” New Models Expand Physician’s Reach Source: Naylor MD, Coburn KD, Kurtzman ET, et al. “Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care.” Health Affairs. (May 2012). http://healthaffairs.org/blog/2012/05/04/a-social-compact-for-advancing-team-based-high-value-health-care/ (accessed January 14, 2014); Green, Linda V, Sergei Savin, and Yina Lu. "Primary Care Physician Shortages Could Be Eliminated Through Use of Teams, Nonphysicians, and Electronic Communication." Health Affairs. 32. no. 1 (January 2013): 11-19. http://content.healthaffairs.org/content/32/1/11.full.pdf+html (accessed March 19, 2013); Medical Group Strategy Council interviews and analysis. Estimated Average Panel Size per PCP Team-based Care in Brief Assuming 20 Appointment Slots per Day, 50% Same-Day Access “The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.” Three PCPs at single practice site available to see each other’s patients Naylor MD, Coburn KD, Kurtzman ET, et al.

5. Re-envisioning Team-based Care Source: Medical Group Strategy Council interviews and analysis. Key Imperatives Increasing Traditional Practice Efficiency Engage Patients Encourage Collaboration Maximize Team Skills Support coordination, communication within the care team Reorient decision-making, care planning around patients and caregivers Ensure care team members work at top-of-license Realizing Patient-Centered Care

6. Maximize Performance Level of All Practice Staff Bringing All Practice Team Members to Highest Level of License1 Source: Health Care Advisory Board nterviewsand analysis. Maximize Team Skills State law and institutional risk must be taken into consideration. Such as foot screening; • In Typical Primary Care Office • In Medical Home • Spends most of visit treating acute conditions • Refers patients to specialists with minimal follow-up • Little care standardization across patients • Provides standardized chronic, preventive care • Manages and leads multi-level care team • Coordinates with specialists, hospital to provide cross-continuum care continuity PCP • Not always found in primary care practices • Spends majority of time on acute care • Might not see patients independently • Actively owns patient management • Leveraged for same-day and after-hours access • Sees patients with minimal supervision How tAP • Triages incoming patient calls • Spends majority of time on acute patient ailments • Prioritizes time for patient follow-up • Reaches out to encourage patient self-management • Conducts one-on-one patient education RN • Functions similarly to an MA • Assists with patient education • Co-leads group visits • Triages patient phone calls using protocols LPN • Rooms patients, takes vital signs, assesses reason for visit • Has down time on slower days • Thoroughly screens patient needs and reviews chart, labs, self-management goals in pre-visit chart review • Performs pre-physician services2, records in chart MA • Triages incoming patient calls • Provides reminder calls to patients before scheduled appointments • Liaises with clinic nurse before appointment to check for outstanding patient needs before reminder calls • Discusses pre-visit testing with patient Front Desk Staff

7. Foster Collaboration Among Providers Physician Resistance a Common Theme, but Not Insurmountable Source: Medical Group Strategy Council interviews and analysis. Encourage Collaboration Not Ready to Let Go Overcoming Physician Barriers Common Physician Trait Performance Lever “Physicians too often just don’t want to delegate patient care to other staff—they don’t understand what they can contribute, and they don’t want to let go of the patient relationships they have built.” ” ” Skeptical Communication Unconvinced of care team abilities Educate physicians on team model, other team members’ roles Medical director Employed medical group Unprepared Training Source of Frustration for PCPs Lack team-based management, delegation skills Train physicians on team leadership “Having an AP and PCP both working at the top of their licenses creates some competition and leaves the physician seeing the “harder,” sicker patients. Without incentives, the PCP is not especially motivated to participate in that arrangement.” Compensation Risk Averse Wary of change, particularly when own income at risk Use compensation as a motivational tool, taking steps to carefully manage change Donna Littlepage CFO, Carilion Clinic

8. Breaking the Fourth Wall Source: Medical Group Strategy Council interviews and analysis. Meet Your Newest Team Member: The Patient Engage Patients Matthew K. Wynia, MD, Isabelle Von Kohorn, MD, Pamela H. Mitchel, RN Putting the Patient at the Center of Care Key Considerations ” • What is the role of the patient? How does this vary and change across settings and teams? • What processes are in place to incorporate patients? What rules and expectations do we need to formally and informally put in place? • How can we communicate more effectively? Are we transparent with patients? Do we use plain language? “In high-functioning health care teams, patients are members of the team; not simply objects of the team’s attention; they are the reason the team exists and the drivers of all that happens.... Having patients as members of teams is more than a shift in framing.” Institute of Medicine Working Group1