[Extra-special treat today! This clinician guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, just opened its doors this month in Chicago.]
Nationwide seniors are up against a wall when it comes to primary care, and this is particularly true in Chicago, home of our new approach to integrated geriatrics care called Oak Street Health. We recognized the need and are now on a journey to fix it.
In 2012, I (an emergency medicine resident) and two colleagues (an attorney and a financial engineer) launched what we believe is a truly innovative approach to caring for seniors. Your blog host, Dr. Leslie Kernisan, has been an email-mentor to me through this process and has now invited me to be a guest blogger on GeriTech. Over the coming weeks and months, I have the honor of blogging to you about what we’ve built, how, why, and what’s coming next for us in our mission to build the right kind of care model for seniors. I hope you enjoy the posts, and please: feedback and suggestions are welcome. We’re a humble bunch, and we hope to learn from these conversations as well.
Chicago is a city of over 1 million seniors. The primary care infrastructure is anecdotally thin: patients tell us appointments require weeks of notice, wait times are long, and many doctors aren’t taking new patients. Furthermore, most primary care providers are either (a) employed by a large hospital system or (b) a part of a large multi-specialty practice; from an economic standpoint, this means primary care exists not for its own sake but instead to serve as an aggregator for referrals to more highly reimbursed specialty services.
The typical Medical patient in Chicago has an unfortunate burden of disease:
- 24% have diabetes
- 17% have CHF
- 12% with depression
- 11% with COPD
- 9% with CKD
- 6% with cancer
Beyond the disease burden, the complexity of the care ecosystem is onerous; the typical Medicare patient in Chicago must manage the following:
- He/she takes 11 medications a day, from 5 drug classes, prescribed by 2-3 providers, dispensed from 1-2 pharmacies.
- He/she sees 7 physicians in a year, which includes 2 primary care providers, all across 4 different practice locations.
Furthermore, that same patient is not well equipped to manage his/her disease:
- 73 years-old
- 56% with high school diploma or less
- 45% below twice the poverty level
- 30% with a functional limitation
And it’s not just patients who face challenges; primary care providers have a daunting task as well:
- Too much to know: there were roughly 900,000 medical journal articles published last year.
- Too much to do: following recognized society guidelines would require 21.7 hours/day for a practicing primary care provider, excluding documentation (and eating, sleeping, etc.).
- Too much to manage: there are 87 different categories of United States Preventive Services Task Force recommendations for management of preventive/maintenance care.
- Too much to coordinate: a typical primary care provider in Chicago has a panel of 2,000-2,500 patients and must work with 299 other physicians across 117 practices over the course of the year to manage that care.
In our population in Chicago, a typical hospital admission costs $10,000. The reimbursement for CPT 99212, a medium complexity visit with an establish patiented, is $43.89. That means you can buy 228 clinic appointments if you avoid one hospitalization. (Just for comparison, there are around 250 business days in a year.)
How does all this add up for us? We’ve tried to build two things: (1) a primary care model that creates downstream savings in acute care and (2) an economic model that lets us capture the savings we create and reinvest them in even better primary care. One of the many tools we’re considered in developing the Oak Street Health model was the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report contains 10 recommendations in 3 broad categories for how to achieve “best care:”
Foundational Elements
Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
Care Improvement Targets
Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.
Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.
Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
Recommendation 6: Care continuity. Improve coordination and communication within and across organizations.
Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
Supportive Policy Environment
Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
Recommendation 9: Performance transparency. Increase transparency on health care system performance.
Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.
Easier said than done, but over the coming posts, I’ll use this framework to explain our philosophy and our approach to what we think matters in achieving “best care.” Up first? Recommendations 1-2.
Until then, take a look at WGN’s coverage of the opening of our first center in Chicago’s Edgewater neighborhood, and please post any questions or suggestions for us in the comments!
Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health. He is currently in his final year as an emergency medicine resident in Boston. You can contact him at griffin (at) oakstreethealth (dot) com.
Disclosures: Dr. Myers wishes to disclose a financial interest in the primary care model discussed above. Furthermore, he is a trainee in a postgraduate clinical training program, and neither the program nor the affiliating university endorses, owns, or has any formal or informal relationship with the primary care model.
References & Links
– U.S. Census Bureau
Centers for Medicare and Medicaid Services.
Lee TH, Mongan JM. Chaos and Organization inHealth Care, MIT Press, 2009.
U.S. Preventive Services Task Force Recommendations for Adults
Oak Street Health analysis
