A Conversation with Paul Grundy, MD, MPH

I was fortunate to speak recently with Paul Grundy, MD, MPH, the director of healthcare technology and strategic initiatives at IBM, about the work he is driving as the chair of the Patient Centered Primary Care Collaborative. Through the magic of Web2.0, I first picked up word of Paul’s work via this post on the IBM HealthNext blog, and since then have participated (in one meeting last summer) and watched as the movement has gained traction.

I chose Patient centered health information technology as manageable scope for a sabbatical; the ultimate goal for a career is patient centered care that respects patients, their communities, and those who serve them.

Paul sent along his thoughts on patient-centered primary care, and I am reposting them here, for others to read. As I have listened to Paul and his colleagues and compared it to my own experience studying Informatics and process improvement methodology, I have become acutely aware of not just the value stream within health care. I am aware of the value stream for a person in society, which is to achieve their life goals through optimal health.

When I wrote about my visits to work sites, like Genie Industries in Washington (see: “Overwhelmed with Possibility,” DailyKaizen Blog, July, 2006) and the NUMMI Plant in California (see: “NUMMI, Fremont California,” DailyKaizen Blog, August, 2007 ), it has become clear that our role is as the support system for these individuals, who are providing for themselves and their families, and finding fulfillment in their lives, through optimal health. The medical center is just a stop on the journey, not the destination. Employers add this perspective to our work and can assist in having our health system reflect this ideal design.

Paul’s words are below. As usual, your comments are welcome.

First and foremost — Patient Centered Primary Care is an effort to address the high cost/low value situation we find ourselves in as large employer buyers of care. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Let’s call that a Patient Centered Primary Care (PCPC) or Patient Centered Medical Home (PCMH).

But we the buyers have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change.

When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care and 2) the way primary care is financed. Our premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.

As large employers our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care as a work around of the core problem and not face the real issue head on. If stand alone disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, with the right tools is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Stand alone disease management programs which are not delivered at the point of care present a Band-Aid approach to problem solving. These kinds of work a rounds instead of addressing those problems directly, have in fact created additional, expensive, fragmented responses to the primary problem.

For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to “pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.

Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let’s seize this opportunity and make the fundamental changes we have been asking for as large employers.

While I would not argue that primary care should be all things to all people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.

For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.

So how do we as large employers join the ranks of other systems like the VA and Denmark that have driven as much as 60% of the inefficiencies out of the system.

In step lock with our partners, the primary care providers, lets make it clear to the healthcare benefit companies that we deal with that as an employer buyer it is no longer business as usual. Let also be counted on as employers to send the same message to the other large healthcare buyers Health and Human Services, CMS, Medicaid, Federal Employees, DOD TRICARE, the White House, Congress, State and local government and others.

Demand of ourselves and our Healthcare benefit companies:

Comprehensive, continuous, patient centered, personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.–Paul Grundy, MD, MPH