Paul Grundy on Alternative Payment Model Success: Culture, Data and Team Transformation

Paul Grundy, MD, MPH, FACOEM, Global Director of Transformation, HealthTeamWorks

Paul Grundy is known as the “godfather” of the patient-centered medical home movement. A member of the Institute of Medicine, he also serves as a director of the ACGME, the body responsible for accrediting graduate medical training programs. He is the founding president of the Patient-Centered Primary Care Collaborative, an organization dedicated to advancing the medical home. He previously served as IBM’s chief medical officer for its Healthcare and Life Sciences Industry. 

Question: When you talk about human factor engineering in the context of health care transformation, what are you getting at? Why is it important?

Grundy: Practices need to transform from the mindset of managing an episode of care to proactively managing a population and developing  a healing relationship of trust. It’s a change in covenant between what purchasers have bought in the past and what practices now need to provide. The role of the primary care physician becomes that of a comprehensivist working with a medical home team.

For that change in covenant, there must be a tremendous amount of learning about reengineering primary care. In the book The Familiar Physician, Peter Anderson walks through his experience making this transition, and what he had to learn in order for him to efficiently, effectively and proactively manage a population, using data. He found that it takes about three years for a physician out of residency training to come into an integrated, team-based model, like Kaiser Permanente, and really be able to deliver the kind of care they should be delivering.

That’s because what we were taught in medical school is that all the data we need to practice is stored in our brains. It takes a cultural shift to learn how to manage care with a team of folks. It means giving up stuff. There’s no need for a doctor to do all the typing, or all the medication management, or to keep up with all the data. For this to work, you have to make the mental shift from master builder—that person building the cathedral who has all the information for the job stored in his head—to learning how to function at the top of your license with a plan and a team of people delivering on the plan. That’s not easy.

The experience of HealthTeamWorks in helping systems and practices transform to this new mindset—that’s what I refer to as the human factor engineering side of this work. If you’re going to manage a population with data—and you need data—that’s the technology side. But the harder part is almost always the cultural part, the shift in human factor engineering.

Question: What are two things primary care practices need to know about alternative payment models?

Grundy: Physicians tend to have their eyes set at a future state of health care payment, but they really should be able to capture APM funding that exists today.

Using population health tools now to identify gaps in care, and caring for patients today in a way that, someday, doctors are going to be reimbursed for—all that is worth doing now. It can also be economically rewarding now. There are sweet spots providers can be paid to manage now.

Second, how much money you take home in your practice is a result of how much you’re paid, plus how efficient you are. In the medical home demonstration pilots, where there was no change in payment model, the practices earned an additional 12 to 14 percent in terms of take-home pay because they were more efficient. Peter Anderson, in his book, The Familiar Physician, said he just woke up one day and asked himself, why am I turning money away? Why don’t I redesign my practice so it allows me to get patients in and seen today instead of in two weeks? And why not do that effectively by having everyone practice at the top of their license—so I can practice at the top of my license? It’s about efficiency and effectiveness.

Question: How will the use of data factor into alternative payment models?

Grundy: Data will do for your mind what lenses will do for your vision: It will make clear what you’re seeing. We’re reaching a point where technology solutions coming on line can automate some tasks and really make us work more efficiently.

How can I automate some of what can be done to manage a population? Well, my cat gets notified that it needs immunizations. My vet has a system of notifying me, which results in my vet getting paid and my cat getting appropriate care. Thinking as a provider, why wouldn’t that kind of registry happen with everyone in my medical practice?

I was coming home two weeks ago from a meeting in London, and I Googled Heathrow Airport traffic conditions. What I got was an AI solution in which millions of data inputs from millions of travelers have created a shared understanding about distance, specific times of the day traffic flows one way or another, and what was happening right in the moment. The AI solution also knew I had a Delta flight at a certain time during the day. It looped that data in and told me that, if you need to be there two hours ahead of that flight, this is what the traffic will be like at that time.

Let’s say you’re a mom with three kids, and you’re doing all kinds of things to manage the family, and you have a doctor’s appointment coming up. An AI solution can look through your records and notify you before the visit occurs to remind you and tell you that these are the things you should focus on during this appointment.

Every patient needs a plan for their health. AI can support that.

When we started this journey for the medical home, I took this cat visit notification to my general practitioner and asked my him, how many women are in your practice over age 55 who haven’t had a mammogram?  They should be getting a reminder like this to have an annual mammogram. He didn’t know how many women he had in his practice, much less how many were over age 55. But he does now.

That’s the covenant kind of change we’re asking for.