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

This is a transcript of Part II of my podcast interview with Dr. Paul Grundy. You may want to read Part I first.David Williams: Have you seen patient-centered medical home principles being translated into practice in this country?Dr. Paul Grundy: We see examples that are working all over the country and they're working really well.  Just two days ago the group out in Seattle, the Seattle Group Cooperative released their study after one year. What they showed is that better upstream care, i.e. better care coordination, better care integration, better prevention, better communication results in lower downstream costs, i.e. if you have access for your patients to e-mail you, to call you, to see you after hours, to have some sort of flexibility built into your schedule so that you're actually centered on your patients needs, they don't show up in the emergency room as often.  In fact, the data out of Seattle and I think I sent you these exact numbers so you could use those, but the data we sent out of Seattle I think resulted in about a 20% reduction in ER visits.  I think it's about an 11% reduction in hospitalization.  People will say that's true in Seattle and that's a big group, but we have examples of others who have done that all over the country in small practices.  I have visited over 110 now that show very consistent and similar results.  A pediatrician in Florida has about 40% Medicaid and uninsured patients, so it’s a relatively less affluent community.  He has a pretty high rate of asthma statistically in his population as a pediatrician.  He used to average about one patient a week that was hospitalized with asthma; pretty normal when I talk to pediatricians who take care of this population.  He has gone 20 months now in which he's had only one single patient hospitalized.  That's it.Williams: That's great.Grundy: Why?  He empowers his patients and his patients are watched.  I've been in his office.  They e-mail him and he says: “Well just double your dose on that.”  He begins to empower them on their responsibility for their disease.  He begins to give them a sense of control of management, of coordination.  His staff works really closely with him, so he's got care coordinators that are engaged in doing this.  Surprise, surprise!  You pay a little attention to details and you help your patients manage their own condition better and they don't wind of up in the hospital as often.  So carry that ten years down the road, which is how Denmark now looks.  They've gone from having 155 acute care hospitals to a little less than 50 today and they're probably going to flatten out at about 25.  Asthma is an extremely rare event to result in a hospitalization.Williams: Right.Grundy: It's a condition that's now taken care of by and large with better communication in the outpatient environment and in the home.  No different then when you come back to the United States and you look at places like Geisinger.  We've seen a 48% reduction in rehospitalization, a 20% reduction in hospitalization for chronic diseases.  Same thing.  Better upstream care, better care coordination, not giving the patient drugs that are contraindicated with each other and surprise, surprise they don't end up back in the hospital.  It's simple really.Williams: So you mentioned before there's kind of these two choices, the Danish model or the English model. You seem to favor the Danish model, bu if it carries all the way through to having the number of hospitals go down by a factor of six, that seems unlikely to be the path we're going to take here.Grundy: I mean it is what it is.  We have coming online the kind of transformation that occurred when Dodge was designing the transcontinental railroad in transportation or the livery men were standing around New York in 1906 and talking about whether they should get this new fangled thing.  They had horses and there were no roads.  We can look out not only externally, but even places within the United States and see places where the future is now.  That future is going to happen.  It's going to happen.  It's going to happen because the demand for efficiencies is going to drive that.Williams: Tell me a little bit more about the role of the patient.  You talked about this pediatrician example where the patients are empowered.  Are patients basically ready for this kind of transformation?Grundy: The patients love it.  Patient satisfaction in those 110 places I've gone, there is nothing more empowering to me than sitting in the doctors office, most of them don't even have waiting rooms any more, but sitting in the office and talking to the patients as they come through, they love it.  A doctor in Portland started this process six or eight years ago.  He went from one doctor to eleven.  He has a little fee he charges because the insurance companies don't pay for the e-mail yet, to kind of cover that sort of cost.  They vote with their feet.  He has grown from himself to eleven doctors by delivering this level of care and patients love it.  Patient satisfaction in Peter Anderson's practice in Virginia when he moved to this model went from 63% to well over 90%.  What's not to love?  You have a doctor that cares about you that makes his time more available to you and it helps to educate you around your disease.  You watch.  I sat in this practice and watched the exchange between this mom with acute asthma and the doc and you see, you just see, the appreciation of somebody who will communicate in either real time or close to real time and make that kind of commitment to keep your kid out of the hospital.  They love it.  The patient satisfaction just goes through the roof.Williams: Now we talked before about the federal role, in particular the stimulus for meaningful use of electronic health records.  I'm wondering about generally on the payment side.  I've heard some complaints from health plans in this market in Massachusetts for example that have tried to do innovative things and they said: you know what, Medicare and Medicaid are the biggest payers and so anything I try to do isn't going to have much of an impact.  Now I understand pediatrics could be a little bit different. But what has to happen on the payment system for this vision that you're describing to be realized and what's the federal role?Grundy: That is is probably one of the big bottlenecks in this.  I would say there are a couple other bottlenecks, but one of the biggest bottlenecks is aligning payment for adding value.  Right? I do think that the folks that I talk to across the political spectrum and at the federal government and at the state level, etc. get this by and large because we've seen 370 some laws passed at the state level and we've seen a number of bills in which they're addressing this with some of the language.  So I think that they get it, but the insurance companies are absolutely right.  That's our frustration in that when I go to Massachusetts to buy health care for my employees, I'm pretty much stuck with the way Medicare buys its care and it buys its care as an episode of care.  Again, I'm empowered to buy that amputation, but I'm not empowered to buy the kind of care that really rewards the physician for not allowing it.  The doctors now make a bundle on doing the amputation.  That's the dilemma.  We have absolutely misaligned money in to value out.  That's the reason we're twice as expensive.Williams: Right.  That makes sense.Grundy: 40% of the care that's delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it's $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.Williams: That makes sense.  Well it doesn't makes sense, but certainly when you see that it shows you what the opportunity is.Grundy: And when you start to think about this and you see it actually rolled out in some of these pilots, not only are the primary care doctors happier with this, the comprehensivists are seeing that their patients are more satisfied and feeling more rewarded about what they do.Williams: Can you tell me more about your roles?  You wear two hats with the Patient-Centered Primary care and also your IBM role.  How do those two go together?  You've spoken to it somewhat, talking about how IBM is obviously a big purchaser of health care, but does it go beyond that?Grundy: Yes.  It goes beyond that in the sense that from the perspective of a company that does quite a bit of health care technology, health care services, the whole migration from paper to the flow of data and data being analyzed is something that we would like to help provide a bit of structure around so that it's not wasted effort.  We happen to be involved in the technology under the Danish system.  So we see how this flows out in a system that works and we understand how the structure of heath care is organized empowers the health care information technology to actually work.  So we see it in our interest as a company who is an American based company with some sense of social responsibility to help provide a bit of structure and flow to this so that it makes sense.  We spend a huge amount of money on health care for over 450,000 people, so from that standpoint we are very interested.  We are a global company so we see this from a global perspective. We really want to sell knowledge based information technology into a structure that is going in the right direction and is making sense.  We are kind of like Dodge when he was building the transcontinental railroad. I would love for there to be a design in which the two parts of the railroads actually connect.Williams: That would be something.Grundy: It makes sense. What we see now is that there are a whole bunch of folks laying rail, but not necessarily any that are ever going to connect or any of the gages are going to work together.Williams: We've been talking a little bit about the future and also the past in terms of the railroad, but let me change the subject and ask you one historical question that I'm curious about.  Is it true that during the war of 1812 that the Federalists who were against it blamed “Madison, Grundy, and the devil” and that they were actually referring to one of your ancestors?Grundy: Yes. One of the antecedents in our family is a guy named Felix Grundy and he was Attorney General at about that time frame.  Most of my ancestors were Quakers and he was quite “unQuakerly” in that he was one of the big pushers for the War of 1812. There are a number of counties that were named after him.  He died at the time that places like Iowa and Illinois were being settled and so in Iowa there is a Grundy County and I think there's one in Illinois.  Felix Grundy.Williams: I've been speaking today with Dr. Paul Grundy.  He is Director of Health Care Transformation at IBM and in addition, he is President of the Patient-Centered Primary Care Collaborative.  Paul thanks so much.Grundy: Thank you very much David.  It's only a pleasure.