Podcast interview with Dr. Paul Grundy (Part I): transcript

This is a transcript of Part I of my podcast interview with Dr. Paul Grundy.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Paul Grundy.  He is Director of Healthcare Transformation at IBM and is also President of the Patient-Centered Primary Care Collaborative.  Dr. Grundy, thanks for being with me today.

Dr. Paul Grundy: It’s a pleasure David.

Williams: Paul, what is the Patient-Centered Primary Care Collaborative?

Grundy: The Patient-Centered Primary Care Collaborative is a big tent umbrella that is driving transformation of the covenant between the buyer of care and the providers of care.  At least that’s how it started.  It’s evolved now into a movement with consumers very actively engaged as well.  It started off a few years ago when 47 large buyers led by IBM met in Washington and had a discussion around trying to transform what we wanted to buy.

We were buying stuff.  We were buying episodes of care or, as we said at the time, we’re able to buy a darn good amputation for our diabetics, but we weren’t able to buy the kinds of care that prevented our patients from needing the amputation. That’s really what we wanted to get at.  So we began a conversation around about how we could change this covenant; the covenant now being we pay you for doing care and you do stuff, but we don’t pay you to provide coordinated, integrated care.  We pay you for an episode of care.  So that’s kind of how it started.

It’s evolved into an organization with over 600 supporters.  That includes all of organized primary care, most of the other physician organizations, many of the Fortune 500 companies, and the organizations that traditionally surround Fortune 500’s.  The National Business Coalition on Health and others are engaged and are at the table. Probably the single most important thing we did when we first started is we reached out to primary care, to the four physician organizations that provide most of the physician care in the United States, with this concept.  They came back and they said: “Well gee, this is what we really want to do.  We also want to change the covenant and –by the way– the Academy of Family Physicians said we’ve got this thing called: ‘The Future of Family Medicine’ that we’ve been working on that reached the same conclusions that you did.”

The internists said: “We’ve been working on this concept of the advanced medical home, which is pretty much what you’re asking us to do.”  The pediatricians said: “We’ve been doing it for 30 years and nobody has paid attention to us.”  The osteopaths basically said the same things.  So we said: “If that’s the case, then we would like you to all agree.  We’re going to leave.  We’re going to close the door.  We would like you to agree on a set of principles. That was what was born; the joint principles of the patient centered medical home.

Williams: I hear a lot of discussion about the Patient-Centered Medical Home and it sounds good, both the patient-centered aspect of it and then the home part sounds pleasant, but what does it really mean?  You say for example that pediatricians have been at it for a long period of time, which they always volunteer whenever this topic comes up.  Then I hear some people say: “That’s how my grandfather practiced” and we’re just going back to the future in a sense.

Grundy: The first thing to understand is that it is in fact a set of principles. It’s an agreed upon set of principles, sort of like within the Declaration of Independence, it’s life, liberty and the pursuit of happiness.  It’s a set of principles that all of organized primary care has agreed upon.  Those principles outline some concepts relevant to patients and buyers.

One of the things that the patients were telling us is: “We would like better access.  We don’t think the kind of access you give us is centered on our needs.  We think the access is really centered around you doctors.  We call you up and you say you’ll see us two weeks from Tuesday and we don’t want that.  We want access now.  We want flexible scheduling.  We want the ability to have communication with you beyond that face to face encounter, which is the only way we can do it now.  So we would like flexible scheduling, extended hours, the ability to have a portal or some way of communicating with you. We would like you to answer your e-mail.  We also want a relationship.”

“We think it’s really important that there is somebody in our lives we can turn to who is our healer, who we have a relationship with that’s continuous and comprehensive.  We may not always want to go to that and we don’t want to give up the right to go to a specialist or go somewhere else.  We don’t want a gatekeeper.  We want a gateway.  We want somebody in our lives who we can reach out to when push comes to shove that’s there who knows about us and who has our records in one place. So we want that healing relationship with somebody.  We want them to have a team.  We understand that they don’t necessarily have to do it all, but if we do need to see a dermatologist, we want that dermatologist to be part of a team.  We want that ear, nose and throat specialist to be part of a team.  If we need care coordination, if we have a chronic disease and we have now some disease management company calling us out of the blue and they don’t have access to our whole record, they don’t have a clue about our record.  They don’t really know what’s going on with us.  That’s not acceptable.  We want that entity, that person who is responsible for a relationship with us to be the quarterback, to be responsible for a team of folks who actually delivers the care.  We want that disease management, that care coordinator to be looped into that team.  When somebody calls us on Saturday morning and says: ‘I want to talk to you about your diabetes,’ we want that person to be related to and part of a team approach to care.”

Williams: I understand that organized medicine is interested in this from the primary care side and it makes a lot of sense to me.  I have heard some commentary or criticism from some other quarters and I’d be interested in your thoughts about it.  One was maybe predictable because it’s from a disease management company that’s saying: “The Patient-Centered Medical Home sounds great, but physician offices really don’t have the scale to pull that off and therefore you need a disease management company.”  Then somebody else who was talking about it and saying: “It sounds good, but doctors really aren’t very good at being project managers or being the quarterback of a team.”

Grundy: Well, to the first question: do the doctors need something beyond the scope and scale of their office to deliver appropriate care coordination?  I would say: “yes.”  I would say that there is an important and powerful role for tools for all around care coordination.  I can think of many, but the one that comes to mind is a company called Phytel that minds data and delivers it to the doc.

I can think of a number of disease management companies that would add tremendous value into this whole concept of better care delivery.  But I can’t imagine any of them adding as much value as they could if they were coordinated and integrated into the person in that individual’s life who is their healer. I think that the patients are right when they say: “Yes, we want disease management.  We want coordination of care, we want care integration, but we want that somehow linked into somebody who has a meaningful relationship with us some way or another.”

It doesn’t have to be that everybody who does that sits in one office.  It’s absolutely possible to have a virtual integration and use HIT to help with the care coordination, but what has to happen is that there has got to be a better way of coordinating and integrating this so that from the standpoint of the patient, they see a team approaching their care and not a fragmented, dysfunctional effort.

It’s just damning what we do.  We tend to have four or five people handling somebody with chronic disease; doctors, specialists, disease coordinators and nobody has a clue what the other one is doing.  It’s dangerous.  It’s unethical.  So I think all we’re saying is: let’s put some structure around this and some coordination around this.  Let’s identify some tools and resources.  Some of them can be remote, absolutely.  Not a problem.  Just integrate them.  So from the standpoint of the patient, they see these individuals as part of a team with somebody in charge and that somebody that’s in charge ultimately should be them the patient with a trusting, healing relationship with team members supporting them.?

Williams: What about the doctor who told me, “Physicians aren’t really trained to be project managers or quarterbacks of a team and maybe the role isn’t very well suited for us.”  That was actually coming from a younger physician.

Grundy: We’re really at a point in time where these younger physicians and older physicians are being told by David Blumenthal and our Congress and our President that we’re going to throw at least $20 billion on you like a tsunami for this HIT, maybe as much as $60 billion, and we’re going to reward you for the first few years to do this and we’re going to punish you if you don’t.

So we have some stuff coming at these docs right now.  We’re kind of at a Y in the road.  We know that no longer will uncoordinated care be accepted.  We know that it’s wasteful.  That message is out there loud and clear.  That’s part of why HIT is being thrown at them by the federal government.  How do you structure care in a way in which the doctor-patient relationship has a meaningful component to that?

So in this road that we’re going down, we really have two choices.  We really have the choice that the Danish and many other societies and communities have made of making the paramount, the most important part of health care in that relationship based care.  And within that relationship, the key decisions are made or the patient is supported in making those key decisions.  So that’s route number one.

Route number two is a route that the English went down, but they kind of got too far.  The Minister of Health came and spoke to our Collaborative a year ago and said it was the biggest mistake that they made: the responsibility is given to an administrative body in society. I think that what the American patients are telling us is that we really want our healing relationship.  We want our clinicians to make our decisions for us, not some administrative body.

Williams: That makes sense.

Grundy: There is no other choice.  There is no other route to go.  That physician who is young who wants to abdicate that and say “I’m not going to step up to that” and “I’m not going to do that coordination” is going to have to step up to it and say: “We’re going to change the way we practice and we’re going to use the technology and tools that are going to evolve around our practice to be the quarterback.”

But not everybody is the quarterback.  Not every team is going to function the same way.  It’s clearer in other parts of the world than it is here because they have a clear relationship about this.  There is a group of providers, of clinicians who really want to be good and have an in depth understanding of a specific part of the body.  Let’s say the left knee.  They really want to be good at doing the left knee and that’s all they want to do.  They don’t want to be care coordinators.  They don’t want to be comprehensive.  They want to focus on a part of the body and be good at it and just do that.

That’s fine.   We need those people.  So the other group of people –in New Zealand and Denmark and other parts of the world, they’re called comprehensivists– who, in America, are the primary care providers by and large, who agree to and accept responsibility for the role of being the quarterback, of being somebody who is comprehensively in charge.  So if you have nobody willing to take that role in the physician community, somebody will take that role because it’s just too dangerous not to have it.  That will be some sort of administrative function that will end up evolving and accepting that role.  We know you can’t leave care uncoordinated when doing so results in the kinds of medical errors, the kinds of slippage that happens when you go from the hospital to out of the hospital and back in, etc.  We just know we can’t continue to afford the kind of waste that has resulted in us being twice as expensive as any other country in the world.

Continue to Part II.

September 10, 2009

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