 Hello, I'm Barbara Pala. I'm the consulting physician to the Health Improvement Partnership of Santa Cruz County, which most of you know as hip. And I have the pleasure of welcoming you tonight to our program. Tonight's CME is the fifth in a series of five CME events over the last two years, all of which have focused on advancing medical homes in our communities. Before we start, I'd like you to join me in acknowledging those who have made tonight possible. First, I'd like to acknowledge the Central California Alliance for Health, who has generously sponsored all five CME events, as well as their ongoing innovative leadership focused on improving health care for people in our community. Second, I'd like to thank Blue Shield of California Foundation, who has sponsored the broader Patient-Centered Medical Home Initiative, of which these five CME events have been a part. And finally, I'd like to thank the Community Health Partnership of Santa Clara County, who has done all the nitty-gritty paperwork behind the scenes paperwork to provide CME for our programs. So please join me in thanking those who made this evening possible for us to enjoy the ambience of Shalmanad and learn something new. So thank you. Now I'd like to hand the mic to Richard Helmer, the Chief Medical Officer of the Central California Alliance for Health. Thank you, Barb. Just one additional thanks to the staff, all the people at HIP, that with their vision and hard work that really put all of this together, that coordinated this, they've really done a great job. So it's been really great working with you all to see you put this together. You've probably seen a lot in the press these days about the additional 20 to 20,000 physicians, primary care physicians that are going to be needed to meet the needs of the health care, the coverage expansion due to the Affordable Care Act. And it's pretty donning. I mean, it could be looked at as a overwhelming, just a challenge that overwhelms us. But it could also be an opportunity, an opportunity for us to really promote primary care and the value of it. In my career, I've seen a couple of times in the past where it's happened, where it seems like we were gaining traction and maybe we slipped back. But I think we're really going to see a difference this time. But to really meet those needs, we're going to need the tools, the processes, the ways of how can we provide good, effective primary care to our patients. And what I like to think of as a population-based person centered care. And we're really fortunate to have with us tonight, I think, one of the leaders in bringing those resources to us as clinicians, to taking care of our patients. You can read on the bio with Dr. Thomas Bodenheimer as many accomplishments and many writings. But when I was talking with Tom before the meeting, I asked him, is there anything that you really want people to know? The one thing he said is, I want people to know about my 32 years of clinical practice. And actually, I really wasn't surprised to hear that. Because if you've read much of his works, you can see that it's very pragmatic, very insightful, really based in the real world. But he brings it out and really gives us very specific advice of how we can be more effective clinicians. So I think we're very fortunate to have Dr. Bodenheimer with us. And to help us meet the challenges that we're going to be seeing in the next couple of years, I'd like to welcome Tom Bodenheimer. Hi, everybody. Can you hear me? Please enjoy your dinner. If you'd rather just eat in quiet, you can just try to drown me out and don't worry about me. I'm going to be up here. You're going to be eating. We're going to all try to have a good time. But I want to warn you that the first part of what we're going to talk about is fairly depressing. But then the second part is less depressing. So I don't know how many of you follow patients with depression with PHQ-9 scores. Your PHQ-9 score is going to go up, and then hopefully it'll go back down as the evening progresses. So I just wanted to ask, first, how many people here are nurse practitioners? How many PAs? How many docs? How many people who are kind of administrative leaders of health care? How many people have I left out? Students. Sorry about the people I left out. And how many people work in a private practice setting? How many people work in a federally qualified health center or a community clinic setting or county setting? OK. How many of you are in a practice with three clinicians? By clinicians, I mean nurse practitioner PA or NB. Nurse practitioner NB PA. How many are in a practice with three or fewer clinicians? OK. Some of the things that I say are going to be tough for people in really small practices. I have one more question. How many of you are overworked and underpaid? Now, if people have questions for me while I'm talking, just if you raise your hand, I probably won't see you, so just yell Tom. Because I don't want to necessarily wait if you have questions. Or if you have grave disagreements or wanted to say something that is the opposite of what I say, please go ahead. So there is a way that most developed countries organize their health care systems. And it's got a lot of primary care, a little bit of specialty care, and a rare hospital. That's not our way. We have a lot of hospitals, a lot of specialists, and a few primary care practices. So this is already, we have a difficult task, just the way that the big system is organized and the resources how they're arranged. You all know about the primary care crisis. So fewer people entering primary care, declining access, burnout of practitioners, quality is spotty, sometimes it's good, sometimes it's not. So you've heard of the patients that are in medical home? This is the way it looks in many places. OK, I have a question for you. What percent of US medical students enter adult primary care? Now, I'm not including pediatrics, but most of the studies suggest that pediatrics doesn't have a major workforce crisis. So I'm talking about adult, which is basically general internal medicine and family medicine. So how many people think 5% of US medical students go into adult primary care? How many people think it's 10%? 20%, 30%, the 5% and 10% are the closest. It's actually 9% right now. 3% of US medical students go into general internal medicine and 6% go into family medicine. That was back in 2010, and we had a great upswing in 2012. Went from 9% to 9.6%. That's not going to do it. That is not going to do it. The reasons are mostly money, work life, and the culture in medical school that kind of denigrates primary care. There's one study that tried to compare which one was more important and basically suggested that work life was the most important of all. That medical students go into primary care practices during their third year. They see how difficult it is. They see that the docs aren't necessarily the happiest people on the planet. And they decide to go into radiology. So part of it's our own fault in the sense that we're not showing medical students how amazing primary care is. The stressful work life is very, very real. This was a survey of general internists and family docs. 27% said they were burning out. Now, this satisfaction is one thing. But burning out means that you want to leave the practice at the end of the day and never come back. That's what burning out is. I know because I felt that when I was in private practice. This is a huge problem. So another study showed about 30% to 40% of US physicians experience burnout. And burnout is not just bad for us. It's bad for patients. Anyone depressed yet? It will get better, I promise you. OK, I got another question. What percent of people with high blood pressure in the United States have poorly controlled blood pressure? How many people think it's 25%? 50%. 75%. It actually was 75% a number a few years ago. It's actually gotten quite a bit better. Right now, about 50% of people with high blood pressure in this country have their blood pressure controlled and about 50% don't. Now, that's not anywhere near good enough because we know how to do it. How about diabetes? How many people think 25% have poorly controlled diabetes? 50%? 75%? It's actually about 50% now. And it's gotten a lot better also. We are improving in spite of all the problems that we have. We are improving. Cholesterol is very interesting because you think high cholesterol is very easy to take care of. Just take a statin and you can go ahead and eat your ice cream in your state. But only 20% of people with high cholesterol are at their cholesterol goal. I think a lot of it is medication adherence. People don't like to take medications for the rest of their life. Access. Access is a huge problem. So let me ask you another question. In the place where you work, can most of the patients get an appointment either the same day or the next day? Anyone? Congratulations. Some people. So there's been a huge movement around the country to try to improve access to care. It's very, very difficult. I've worked with a number of clinics and practices to try to improve their access. As we'll talk about later on, it's really hard to do if you don't do some fundamental change in your practice first. 73% of adults in the United States who have a primary care physician have trouble getting to see that physician, talking to them on the phone, or getting care at nights or weekends. So access is really about a balance between capacity and demand. So demand is, to make it very simple, let's just talk about physician or nurse practitioner or PA appointments. So demand is how many appointments your panel of patients wants to have in a year. So if you have a panel of 2,000 patients, the average patient has about three visits a year. So that means your demand is about 3,000 visits. Your capacity is the number of visits per day times the number of days you work in a year. And most practices, the demand is significantly greater than the capacity. And if the demand is greater than the capacity, you're never going to achieve same-day access on a long-term basis. And nationally, with the shortage of primary care physicians, demand is way greater than capacity. So this is the latest national sort of projection about primary care physician shortage, which is the demand is the adult population is getting older, it's growing, there's more diabetes, there's more obesity. And then the Affordable Care Act is going to make more people be able to get primary care. So that's the demand. The supply is the number of family docs of general internists, which is going to be going down. So this is a shortage of 40,000 doctors by 2020. 2020 is only seven or eight years away. So at 9% of US medical students going into adult primary care, and this being the projection of the shortage, this is not achievable. We will not have 40,000 new adult primary care doctors by 2020. So we have to think about something else. It doesn't mean we shouldn't try as hard as we can to increase the number of medical students going into primary care. And I firmly believe that it is increasing slowly. But by itself, that will not deal with the problem. Will nurse practitioners and PAs save us? They sure help. They help an enormous amount. I don't know what we'd do without them. But it's not enough. So about 2 thirds of nurse practitioners go into primary care, and about a third of PAs go into primary care. But if you add new general internists, family docs, nurse practitioners, and PAs going into primary care, there's still the ratio of primary care commission to populations going to fall by 9% in 2005 to 2020. That's the situation we're facing. And of course, this is either national figures, but each clinic in each practice feels it with the difficulty of finding people. And it varies by where you are in the country. If you're in a rural area, it's really, really tough. If you're in an inner city, it's really, really tough. FQHCs have a very difficult time. But this is the situation nationally, and you feel it in each primary care practice. So panel size. Average panel size in the United States is over 2,000 patients. If you provide perfect preventive services, so 2,500 patients, it would take you 7.4 hours every single day. And if you add chronic care, that's another 10.6 hours a day. That's only 18 hours. There are 24 in a day. Plenty of time for acute care, care coordination, having lunch, a little bit of sleep. So I think what this says is that if with panel sizes this big, primary care as a doctor basically done by doctors without much of a team is not a possible job to do. It's impossible. So this is sort of the low point here. Panel sizes are too large for the average physician to manage. But we can't reduce the panel sizes because of the shortage. So the shortage means that the panel is going to have to go up if people are going to get primary care. That means access is going to go down, quality is going to go down, and burnout's going to go up. And if burnout goes up, then the medical students seeing primary care, even fewer of them are going to want to go into primary care. So this is kind of what one might want to call a death spiral. There could be a death spiral for primary care if we don't do something about it. Luckily, we are. And there's enormous hope going on. So five years ago, I would have stopped the talk right here. I was really, really depressed about the future of primary care. I'm feeling so much more hopeful now. And a lot of it is because just the things that so many people are doing all over the country to make primary care work better. And just seeing the UCSF, the excitement of med students, there's a whole organization called Primary Care Progress, which was started by a bunch of Harvard medical students, which is pretty amazing because Harvard and primary care is sort of two words that don't go together. Having gone to Harvard, I know that. But a bunch of them started this organization called Primary Care Progress, which now has chapters in 30 medical schools around the country. And it's really helping medical students to embrace primary care as a career. So there's a lot of good stuff happening. But we do have to think very differently about what we're doing. And one of the things is we talk about the primary care workforce shortage as a physician shortage, or one could say a physician, nurse practitioner, and PA shortage. I think we have to change how we think about it. And I'd like to think about it as an imbalance between demand and capacity. The demand for care is greater than the capacity provided. But who can provide, who can increase the capacity of a practice? It doesn't have to be a clinician. Nurses, pharmacists, medical assistants as health coaches and panel managers, there are many other people who can increase our capacity. So even though we need more doctors, nurse practitioners, and PA is going into primary care, I believe that we can solve the demand capacity imbalance in primary care partly by having other people on our teams add capacity and help us take care of the patients. That's what we're going to talk about quite a bit. So this is the new chart. So demand and capacity, as you can see, the red line, which is the capacity, which in this chart is going down. In this one, because we're adding capacity not just with doctors, but with other people on our team, we can imagine the capacity for primary care going up and meeting the demand. But it requires us to share the care with other people on our teams. So how can teams add capacity without adding clinicians? Basically, this was the question that was kind of burning in our brain, in our group of the Center for Excellence of Primary Care at San Francisco General and UCSF. So we decided, well, let's go to some high-performing practices and see what they're doing. And one of the things that's the most wonderful about having left practice and being in academia and having the chance and the time to go see other practices is one learns so much and it can be so rewarding to see what other people are doing. So a number of these practices, and some of them are private practices, some are hospital-owned practices, some are integrated delivery systems like Group Health in Seattle and some are federally qualified health centers. The interesting thing is that a lot of them have really good access for their patients, but they still have big panel sizes. They've figured out a way to add capacity without adding clinicians. So it can be done. Is it easy? It's not easy. But other people have done it. This is the 23 practices that we visited all over the country. And what we decided about all these practices was, you know what, these practices actually look kind of like each other. They have certain characteristics that are common to each other. So we took the practices and we looked at these characteristics and from these characteristics we decided that there were 10 building blocks of high-performing primary care. And these are not building blocks that come out of our brain. They're building blocks that come out of our observations of these practices. And to go over all these building blocks takes quite a long time. So we're going to mostly focus on the four fundamental bottom building blocks that are required to get the other building blocks. So the first building block is leadership and leadership having a shared mission and concrete goals. And the most important part is the concrete goals. A lot of us have mission statements. And the mission statements are very nice. And we should have them. But a concrete goal is something like we're going to reduce the percent of patients with diabetes with A1Cs greater than 9 from 20% that it is now to 12% by the end of this year. Or we're going to have an access goal. And these goals are measurable. And having a measurable goal and saying, for this year, we're going to concentrate on these three goals really focuses people on improvement. Because you can't do all the improvement at once. You have to do it step by step. So having these concrete goals and having everyone in the practice know what the goals are and think, one of my jobs is to get to those goals. And that relates very much to data-driven improvements. How do you know what percent of your patients with diabetes have A1Cs greater than 9 unless you have a really good data system? But the interesting thing, most of us have data systems now. That's a big change when I was in private practice. The interesting thing about these high-performing practices was that their data systems were shared by everyone in the practice. They had data walls like every team had a data wall. Every place that had a nursing station or a co-located team had the data on the wall. It was usually changed every month or so. And people would discuss it at their team meeting. So the data was shared among everyone in the practice. Impanelment. Impanelment is a fundamental building law. You cannot do most of the other things you need to do without impanelment. And impanelment is basically linking patients with a primary care clinician or team. And it sounds so simple. Well, you know, I'm Dr. Bodenheimer, and I have 1,000 patients. This is the list of them, and they're impaneled to me. It's actually not simple at all. How many of you have either impaneled or in the process of impaneling your clinic or your practice? How many of you think it's really easy? It's not easy, because what you have to do is you have to say, OK, who are the patients they're seeing me now, seeing each of the clinicians in the practice now, make a list of them, and you have to make sure the patients think that that clinician is their clinician, and you have to make sure the clinician thinks that those patients are his or her patients. Then after you've done that, then you'll find out that one of the clinicians has a panel of 500 patients, and another clinician has a panel of 1,500 patients. Well, that's not fair. They're both working the same number of hours and getting paid the same amount of money. Well, then you have to figure out how you equalize the panel. But equalizing the panel means taking a patient from one clinician to another clinician the patient might not want to do that. Really hard. Really, really hard. And then you find out that you have two clinicians that both have a panel of 1,000 patients. Wow, isn't that great. But one of them has a panel of young, healthy people, and the other has a panel of people who are over 75 years old. So you have to risk adjusting your panels. And paneling is difficult, but it's really critical. Number one, you want to have a situation where there's continuity of care. We know the continuity of care associated with everything good associated with provider satisfaction, patient satisfaction, better preventive care, better chronic care, and lower costs. So we want continuity of care. You have to be in panel to know who your patients are so you can make sure that those patients see you as much as possible. Patients really care about knowing their clinician or their team. And you care about knowing your patient. I mean, how many of you really enjoy seeing the patients of another person? I used to hate it. You like it, huh? Can you tell me why? Seeing the patients? Seeing the patients of another clinician? I sure. I think most patients want to see their clinician and most clinicians want to see their patients. It's most of the ones I know. Maybe Santa Cruz is different. I doubt it. If you have in panel, you can measure continuity of care. Continuity of care is the percent of visits done by people in your panel that are to you over the total number of primary care visits that they've made. So if that's only 50%, that means half the time they're seeing someone else, which is not that good. Most of these high-performing practices had 75% to 80% continuity of care, and they measured it, and they kept measuring it, and everyone knew about it, and they tried to improve it. Impanelment is necessary to calculate panel size, and panel size is crucial for access, because panel size determines your demand. If you have an average panel, it's 2,000, and the patients come in three times a year, so your demand is 6,000 visits a year. Now, this is not talking about e-visits and phone visits and group visits and everything else. To make it simple, I'm just going to talk about one-to-one visits. So you can tell whether your capacity and your demand are in sync or not. And we know from risk-adjusting panel sizes how many visits the average child from zero to one has a lot of visits, and the average elderly person has a lot of visits, and so forth. The average young teenager has very few visits, et cetera. And then finally, if you want to deal with quality, if you want to know what percent of my patients have hemoglobin, my diabetes patients have hemoglobin A1c greater than nine, if you don't know who my diabetes patients are, you don't have a denominator for that figure. So impanelment's necessary for doing quality work. Very, very crucial. Hard work needs to be done. We're going to spend the rest of the time talking about team-based care, and that's very closely related to population management. This is where we're going to talk about sharing the care. So to do team-based care, everyone talks about teams. Teams are supposed to be health care, there's teams, sport, all that kind of stuff. Most teams don't work very well. The high-performing practices we saw, the amazing thing was how their teams worked. And the first thing is that they believed in sharing the care. And sharing the care really means that other people on the team that are not the doctor, nurse practitioner, or the PA really did meaningful things to help the health of the patient's panel. In order to do that, the clinician has to be willing to give those things up. So for example, mammograms. So women between 50 and 75, according to the US Preventive Services Task Force, they have a mammogram every two years. Do you need a medical degree to make sure that every woman between 50 and 75 years age has a mammogram every two years? You don't. You could teach a high school student to do that in about a day. You get your registry for your patients. You find out who's overdue for mammograms, you contact them. We teach the person how to discuss the value of mammograms, they get the mammogram to happen. And then if the mammogram's normal, they can inform the patient the mammogram's normal. If it's abnormal, then the clinician is involved. So sharing the care, now sharing the care requires a bunch of things. Requires number one, someone you share the care with. So you have to have enough staff to share the care. It means they have to be well trained and it means you have to trust them. To trust, for example, a medical assistant, because right now in most primary care practices, the only other people in the practice are medical assistants. There's some nurses, there's some pharmacists, there's social workers. But in every primary care practice in the United States, there are clinicians and medical assistants. So we believe that teams should have a certain structure and the reason we believe that is that almost every single one of these high-performing practices had a structure of a larger team around smaller teamlets. And the teamlets were basically the clinician and the medical assistant. Some of the practices actually had the clinician and two medical assistants, which is great because they could do a lot more things. Why is a teamlet important? Number one, if you move from doctor care to team care, how does that affect the patients? Do patients want a team? Most patients want a doctor. So our feeling is if you have a team of two people who both know the patient, who know each other, who work together every day, then you can take the relationship, which is critically important between the patient and the physician or the nurse practitioner, and you can extend it to the medical assistant. So if the patient really gets to know the medical assistant, the medical assistant knows the whole panel of patients and everyone trusts each other all the way around. It's basically a throwback to the old days. You'd have a solo GP, the solo GP would have a nurse, they'd work together for like 30 years. The patients knew them both, trusted them both, sometimes trusted the nurse more. They trusted each other and knew how to work together. That was the original teamlet model and what we're trying to do is suggest the teamlet model. We should reintroduce into our much more complicated healthcare system. So in a number of our clinics, we've taken what used to be different MAs working with different clinicians all the time and we've created stable teamlets and so far people have much preferred them. We've actually done some studies of clinician satisfaction. People who work with the same MA every day, 70% of them were satisfied. People who didn't work with different MAs all the time, only 11% were satisfied. It seems it works much better. Is it easy to do, not necessarily, but we think it's a really key part of team-based care. So sharing the care again is non-clinicians assuming responsibility for care that doesn't require MD nurse practitioner or PA level of training. And that gets us into population management because population management is a very powerful way to share the care. So if you say, this is your panel of patients right here. For preventive care, every single person on your panel needs it. Preventive care is for everybody. So we've trained a lot of, especially medical assistants, in some cases RNs, to be panel managers. And a panel manager's job, and this is a critically important job, to make sure that everyone on your panel of patients, like should be on our panel of patients, it's an MA and a clinician, it's best that the panel manager be part of that team with the clinician. That every single person on that panel of patients has all the preventive services and all the chronic care services that they need, which are basic algorithmic sort of regular things. People with diabetes, they're out of control, they need a hemoglobin A1C every three months if they're in control every six months. They need a microalbumin every year. They need eye exam, they need foot exam, they need LDL cholesterol and so forth. Making sure those things happen does not require an MD degree. The panel managers can make that happen if they're empowered by standing orders, which we as the clinicians write. Standing orders is a key glue that's needed to make a team work correctly and to enable the care to be shared with other people. So panel management, remember the 7.4 hours per day it takes to do all the preventive care? We've estimated that about 50% of that could be done by a medical assistant panel manager if that medical assistant has time to do it. If you look at the studies on places where preventive care has been shared with the non-clinicians, usually a medical assistant, what you find is that the quality of the care improves. More people get their mammograms, more people get their colorectal cancer screening, more people with diabetes get their A1Cs on time, et cetera. So panel management improves care, takes some of the work off of the clinician and allows the medical assistant as panel manager to feel like, wow, I am really helping to take care of a panel of patients. So let's say that the medical assistant and there are absolutely examples of this. The medical assistant really works hard on colorectal cancer screening, which in many places is one of the more difficult metrics to get up as high as you want to get it. And finds an early colon cancer, which may not have been found if we didn't have panel management happening. That medical assistant has saved some of life. So everybody in the panel needs preventive care. Not everyone needs chronic care, but some people do, people with diabetes, hypertension, cholesterol, asthma, et cetera, et cetera. So this is a different function, but it also is a good opportunity to share the care and sharing the care through health coaching. So what is health coaching? We've done a lot of work with health coaching. So if you take someone with diabetes, the medications are pretty easy. The hard part is the behavior change, making sure that people understand their disease, working with them on lifestyle changes which are extremely difficult and most importantly, medication adherence. We know that a third of people take all their meds, a third of people take some of their meds, and a third of people don't take any of their meds. That's probably one of the main reasons why we have poor statistics on the percent of people who are in control, because these meds are very powerful and they work really well. So our coaches spend a lot of time, they know the meds well, they spend a lot of time with patients on trying to deal with the barriers to medication adherence. There are a number of studies that show that medical assistants trained as health coaches can improve the care of people with chronic disease. So we've talked about what health coaching is. We've estimated that about 25 to 30% of chronic care work could be done by a health coach, because that's the really time consuming part of taking care of these patients. Now we're not talking about really complex patients with five or six different chronic diseases and 12 different medications and mental health comorbidities and all that. That's not a health coach issue. We're talking about people with maybe one or two chronic diseases that are not that complicated. Health coaching can work. We actually have trained a lot of patients, low income patients, to be health coaches for other patients. The patients who are health coaches, we call them peer coaches, because they have diabetes just like the patients that they coach. We did a randomized control trial and the patients who had peer coaches improved the hemoglobin A1Cs, whereas the patients that didn't have health coaches didn't improve. There was a significant difference between the two groups. Coaching can work. So sharing the care, again, means that the clinician doesn't do everything. But remember how important in primary care is the relationship between the patient and the clinician. And what we're talking about is spreading that relationship out to another person. And that's why we like team lists, because if you say, okay, to the patient, we've changed our system now, and rather than me, the doc, taking care of you, we have a team of eight people who's gonna take care of you. Well, patients don't wanna deal with eight people. But if you say, you know the medical system I've been working with for the past two years, of course, I know her really well. In fact, you know, I like her better than I like you. So both of us are gonna be taking care of you. For most patients, that's fine. Now I don't have research to back that up and hopefully we'll do that research at some point. But we think that patients are gonna be okay with sharing the care with a small team that and then occasionally other people will be needed to help with certain patients. So team list is a key part of team formation. This is a resident in family medicine working with a health coach talking to a patient with diabetes. They work together as a team list. I think I mentioned peer health coaches. This is just a lot of data that shows that peer health coaches can improve the care of people with diabetes. And these peer health coaches, they're other patients. That's what they are. So one can even consider, you don't only, there's an opportunity not only to share the care with a team, but there's an opportunity to share the care with patients if you train them to be able to help other patients. And a lot of elderly people are really interested in helping other people. People will be tired and maybe have some time. We had one elderly African-American man who used to work for Apple Computer. He had a stroke. He had an aphasia, especially aphasia, but he could still communicate fairly well. We trained him as a peer coach and after he had been a peer coach for a while, he came to us and said, you changed my life. I thought my life was over after I had the stroke, but now I have a new life. I can be a peer coach and I can help other people. These are some of our peer coaches and more about training sessions. We can also share the care with patients in another way, which is self-care. So we know that people who have home blood pressure monitors, there have been a number of studies that show that people have home blood pressure monitors and are in communication with someone on the healthcare team about their blood pressures, but their blood pressures are better than people who don't monitor their pressure at home. We also know that people on anticoagulation, on warfarin, who learn how to do the INRs and to use the algorithm to self-manage and self-titrate their warfarin doses, they do better in terms of being in the right warfarin range than if a physician does it. Now again, the reason that we don't do it well is often we don't have time to many other things, but the patient who has atrial fibrillation, they care about it. They make sure that it happens right. So patients can do a lot of these things themselves. You can share the care with patients. Technology is also very powerful. So for example, panel management. We talk about training medical assistants to be panel managers. You can actually train a computer to be a panel manager. Why couldn't everyone who needs a mammogram, the computer would figure out who needs them. The computer can spit out either a phone call or a letter to the patient. That doesn't mean every patient's gonna take it up, but it could be the first start and then it could be followed up for the people who don't come and get the tests that they need by a person. Computers can do a lot of this stuff. Standing orders. We think that RNs could do a lot of prescription refills for people with stable hypertension diabetes and cholesterol, as long as the patients are in reasonable control and are coming into the clinic or the practice on a regular basis. There's no reason why we have to do all of these prescription refills that can take quite a bit of time. You could also program a computer with standing orders to do these refills. The computer would know where the patient's been coming, what the hemoglobin A1-C are, their cholesterol, their blood pressure is, and could authorize medications without even any person involved. Some people may think that's going too far, but I think it's a possibility. You could even imagine with patient self-care, we know that uncomplicated urinary tract infections can be treated over the phone without a urinalysis or a urine culture, and patients do well, as long as there are no red flags. Well, you could imagine the patient going to a pharmacy, going to a kiosk, entering all of their symptoms. If there are no red flags, they could press a button and the kiosk could be like a vending machine. The antibiotics would come down and patients would just pick it up and wouldn't even be dealing with a person. Now, some of you may be outraged with this idea. I'm sort of outraged with it myself, but I think it's possible. I think there are a lot of things technology could do that we could share the care to take some of the burden off of us to try to close that primary care gap. Remember, we have a primary care gap that we can't close with doctors, nurse practitioners, and PAs, so someone else has to help us close it. It's either gonna be teams, patients themselves, or technology or a combination of all of the above. So the question was, what about physical breast exams as a precursor to mammograms, as a necessary precursor? I have a question. Okay. Just to make sure that patients don't only rely on mammograms. Okay, so it's very interesting. If the radiology department requires a clinical breast exam before a mammogram, the mammography rate drops dramatically. Not a good idea to require it. Now, the other part of it is that a lot of, in our residency program, our family medicine residents don't do clinical breast exams. They say, well, there's some, there's evidence now that they don't really help. I strongly disagree. I think that doing a clinical breast exam is part of cancer prevention for women. I don't think it should be required to do a mammogram because the mammogram rate will go way down, but I think it should be done. It's an interesting controversial topic right now. And that part is more of a clinician function as opposed to the ordering of the mammogram. The other thing is public health and the community. So we all believe in evidence-based medicine, but evidence-based medicine is great as far as it goes, but there are a couple of problems with it. And I'm almost done if you're worried about the time. Number one, we have these guidelines which are great, but the patients don't know the guidelines. And if you don't help the patients integrate the guidelines into their lives, the guidelines don't do any good. And also evidence-based medicine doesn't deal with the toxic environment in which patients live with fast food and cars and people watching TVs and kids watching TV all the time and all of that stuff. Evidence-based medicine doesn't deal with that. And that's a key important thing with chronic disease. So we really need to share the care by partnering with public health and the community in addition to teams, patients, and technology. So we have this whole concept of evidence-based health, which is different than evidence-based medicine. It's evidence-based medicine plus self-management support which is health coaching to help people understand their disease and to help them with behavior change and community health to try to address the toxic environment that really causes a lot of the disease. So if you add evidence-based medicine, self-management support, community health, you get evidence-based health. And partnering with the community can really help to share the care. Now in primary care, we don't have time to partner with public health. We have this gap between public health and primary care even though we really could work together to improve the care of our panel of patients. There are other countries where clinical preventive services are done by the public health department and not done at all by the primary care practices. So this is a gap that's been around for decades and it's really hard to close but it's something that we really could work on in addition to all the other things that we need to work on. Why isn't this all happening faster? It is happening, but it's happening slowly. It's payment. So the problem is fee-for-service in most places just pays for the MD nurse practitioner and PA. So a coach, a panel manager, a nurse, those are expenses. They're not reimbursed. We need to have a payment system that makes practices want to have these extra team members because we don't have the extra team members, we can't share the care. And then we're back in our same old situation. So I personally like global budgets or capitation, risk-adjusted capitation to allow us to have other people on the team. There are other ways. The patient-centered medical home concept is fee-for-service and on top of that, you have a care coordination fee and on top of that, you have a pay-for performance and maybe even shared savings with a hospital. That's another way, but we need to change our payment mechanism to allow this to happen. We also need to invest in primary care. Five to 6% of the total U.S. healthcare budget goes to primary care, ridiculously small. But in addition to investing in primary care, we have to make primary care feel the consequences of unnecessary ED visits and hospitalizations. That means that primary care should either get penalized if the too many of their patients go to the ED, or to the hospital unnecessarily, or much better, of course, should get rewarded when their patients, ED visits and hospitalizations go down. So investing in primary care so they can, primary care can really create these building blocks and then they can, primary care, somewhat accountable for the total cost of care of the patients. So sharing the care means non-quinitions assuming responsibility. Patients not only receiving, but providing care for themselves, technology, public health, and the community. To do that, we need payment reform. But if we do all those things, we can add capacity without the need for 40,000 new doctors, which is not gonna happen. I'm very hopeful that we can deal with this demand capacity gap in adult primary care by some more doctors, some more nurse practitioners and physician assistants, but also by sharing the care and adding capacity with other people in the healthcare team. I think we can do this. Thank you, and any questions are welcome. What's your hope for realistic decision? For which? I am cautiously optimistic, but quite cautious. Some of us, including myself, have been around the healthcare system for many decades. I've never heard more talk about payment reform than now. On the other hand, in the 80s, a lot of the country went to capitation. California was still doing it a lot, and then disappeared. So I don't know if the talk is just cheap talk or if it's really meaningful, but I think that the crisis in healthcare costs which could not only bring down the whole healthcare system, but the whole country, I think that crisis is gonna entail us to do something about payment, if we know that fee-for-service plus good insurance means increasing costs, because if people can get anything they want without paying much for it with good insurance, which I want, which I'm in favor of, but if doctors can charge anything they want for these patients and the patient doesn't feel the pain of paying for it, costs are gonna keep going up. So I think we have to do something about fee-for-service. Because we have community TV, we wanna have the microphone for the questions. How have these successful practices around the country, the ones that have done real well, how have they dealt with the real difficult patients, the patients that don't wanna participate? So this is a gross estimate based on no data, okay? I would say that if you tell someone for the first time they have diabetes, about 20% of people will just do everything right and take care of their diabetes without very much work on our part. About 20% of people, no matter what you do, they're just, their lives do not allow them to deal with their diabetes and they just won't do it and they can't do it no matter how hard you try. But I think there's 60% of people in between, that's just, again, number out of my hat, that if we have really good health coaching and really work with people, we don't tell them what to do, we ask them what are they willing to do. If they're not motivated, we make sure they know that, see one of the big things is diabetes, high blood pressure and cholesterol don't hurt. People with arthritis wanna do something. So people say, I feel good, I feel worse when I take my blood pressure medication. So one has to really make sure that they understand that they're not gonna feel good forever if they don't take that medication or if they don't do the lifestyle changes. So our health coaches have been fairly successful in getting some of those people who were not interested to become engaged. And as you say, if they're not engaged, it's not gonna work, it has to be a partnership. Not everyone, I mean, there's always gonna be some people who for whom their health is not a priority. It's not, nothing good's gonna happen no matter how hard we try. But I don't think it's the majority of people. I think the problem is that because we don't have time that we don't really try very hard or as hard as we need to try with the patients who could be changed. Quick follow-up would be how do you prevent people from wasting their time with people who aren't gonna change? Because if people are resources and they are, and right now our outreach team is expense, you're trying to change behavior and yet you don't wanna beat your head against a wall. I mean, is there any answer to that or just, you know, you just. Well, you know, one of our really good health coaches at San Francisco General, she's been doing coaching for about four years. She has some patients who, she just says, why am I seeing this patient? It's getting nowhere. And then all of a sudden, something happens and it's probably not anything to do with her or us. Something in their life happens. And all of a sudden their hemoglobin A1C goes from 13 down to eight, whatever it may be. And she's spent all of this time, or you've spent all of this time beating your head against the wall. And at what point do you stop beating your head against the wall? I think you have to stop beating your head against the wall after you feel like you've done what you can do and then you hope for the best that the patient may at some point decide that it is important. It's thanks to all of you guys that we're gonna succeed. Thank you.