Tag: patient centered medical home

Primary Cares Initiative: How eConsults Provide Support

By Chris Jaeger, advisor for ACO and health system strategy, AristaMD.

In April 2019, CMS announced the Primary Cares Initiative which is expected to reduce administrative burdens and increase patient care while decreasing healthcare costs. Learn more about the payment models of the Primary Cares Initiatives, and how eConsults directly support this new initiative.

While the healthcare landscape has never been static, rarely has it seen such radical changes as within recent decades. The United States’ population continues to age, and the prevalence of chronic conditions such as obesity, diabetes, heart disease, and anxiety/depression contribute to a substantially increased demand for care. These factors are pushing a shift from a provider-centric model toward more efficient, outcomes-based models that put the patient at the center and heavily rely on primary care as the steward of patient care.

Primary care is a vital resource in dealing with the many factors altering the healthcare landscape. A 2019 study published in JAMA Internal Medicine corroborates this, finding that for every 10 additional primary care physicians per 100,000 people, patients saw a 51.5-day increased life expectancy—more than 2.5 times the increase associated with additional nonprimary care physicians. For years, primary care delivery has shifted along with changes in the healthcare landscape. Innovations in primary care and aligned incentive models reward more continuous and comprehensive healthcare, as opposed to care delivery and reimbursement models for discrete moments or episodes of care highlighted by numerous appointments and separate visits to different providers. These innovations strive to put patients at the center of care above all else.

To promote further adoption of primary-care based models, the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payments for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in the year 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.

Primary Cares Initiative payment models aimed to PCPs

All five of the payment models described in the Primary Cares Initiative are aimed at PCPs in the hopes of improving services at these linchpins within the healthcare system. However, these models can be grouped into two distinct categories–Primary Care First and Direct Contracting–and there are variations within these groups.

Primary Care First

The models categorized under PCF are aimed squarely at relieving strained hospital resources and improving health outcomes through primary care. These models aim to more adequately reward primary care providers through performance-based payment adjustments, in the hopes that this will be an effective way to reduce the overuse of hospitals for healthcare needs. These two models are:

  1. Primary Care First (PCF): The general PCF model will test whether risk- and performance-based payments for primary care practitioners will reduce Medicare expenditures while preserving or improving quality of care. Under this option, payment will be provided to an advanced primary care site based on the size of its patient population (on top of a flat primary care visit fee), and adjusted based on performance within “easily understood, actionable outcomes,” according to CMS. The performance-based adjustment represents a potential quarterly upside of up to 50 percent of revenue as well as a potential small downside (10 percent of revenue).
  2. Primary Care First – High Need Populations: In addition to the general PCF model, the Primary Cares Initiative includes a payment model specifically geared toward practices specializing in care for high-need patient populations. This includes patients with chronic care needs and a group the model refers to as seriously ill populations (SIP). This payment model creates an option for high-need patients without a primary care physician to receive care from a participating practice if the patient indicates interest.

Direct Contracting

The direct contracting path includes a pair of risk-sharing payment models, both voluntary, along with a third payment model for which CMS is seeking public input. Like the PCF models, these models aim to reward those providing more efficient, high-quality care. However, these models are geared toward organizations with experience serving broader patient populations rather than individual primary care practices. The three models are:

  1. Direct Contracting – Global Population-Based Payment (PBP): Participants in the Global model will take on the full share of risk, but also be eligible for 100 percent of any savings achieved on the total cost of care for aligned beneficiaries.
  2. Direct Contracting – Professional PBP: Under the Professional model, participants will retain both savings and losses accrued on the total cost of care for aligned beneficiaries, but at a rate of 50 percent.
  3. Direct Contracting – Geographic PBP: The Geographic model is similar to the Global model, but with an important caveat: Participants would accrue 100 percent of savings or losses on the total cost of care, but only for aligned beneficiaries within a target region. The stated aim for this model is to drive accountability to a local level so that communities can develop strategies tailored to more individualized needs. CMS is still seeking input on this model, however.

Additional healthcare initiatives strengthening primary care

As mentioned above, primary care is a crucial avenue for fostering improved health outcomes for a wide range of patients and populations. In addition to increased life expectancy, some motivations for focusing on improved primary care include the following:

For many, primary care serves as the entry point to the healthcare system, as individuals and families alike head first to their primary care physician for treatment. Primary care emphasizes population health and managing chronic illness. As such, primary care is an ideal means for improving our healthcare system on many fronts including access, cost of care, and quality of healthcare services.

Given the benefits listed above, it’s no surprise that so much attention has been paid to improve primary care, and the Primary Cares Initiative is not the first such effort. Programs such as the Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and Medicare Advantage Value-based Insurance Design (VBID)  test model give healthcare stakeholders the means to promote triple and quadruple goals of allocating resources more efficiently, improving health outcomes, and improving the experience of all individuals involved–including both physicians and patients.

As its name implies, the PCMH is focused on putting patients at the center of healthcare. It recognizes the value of team-based primary care, and five core attributes are included in this model:

  1. Patient-centered
  2. Comprehensive
  3. Coordinated
  4. Accessible
  5. Committed to quality and safety

Beyond PCMH is the CPC+ program, an initiative aimed squarely at care sites that have demonstrated significant improvement and transformation in pursuit of value-based goals. Payers are invited by CMS to participate in the program if they provide, or aim to provide, care practices that go beyond fee-for-service payments based solely on visits and episodic appointments. Through this program, CMS aims to work with payers representing 5 to 7 markets and accounting for roughly 525 practices (around 75 practices in each market). Some 330,750 patients would be reached by this initiative, which focuses on several functions for practices to achieve greater healthcare successes including:

  1. Access and continuity
  2. Care management
  3. Comprehensiveness and coordination
  4. Patient and caregiver engagement
  5. Planned care and population health

By their nature, Medicare Advantage (MA) plans seek to optimize the delivery of healthcare for their members. Receiving capitated payments to provide all Medicare-covered services to plan participants, plan objectives are the perfect setting to test models of care delivery that may reduce cost while being able to offer beneficiaries improved access, options, and quality of care–versus traditional Medicare plans. MA plans have proven to be more efficient in reducing expenditures than both Accountable Care Organizations (ACOs) and traditional Medicare. The Medicare Advantage Value-Based Insurance Design (VBID) model was introduced in 2017 by CMS to allow MA plans the opportunity to offer supplemental benefits or reduced cost-sharing for enrollees with certain chronic conditions who engage with services/providers that are of highest clinical value to them. CMS released major changes to the VBID model in January 2019, and plans to test new additions 2020 to 2024. The updates are intended to lower costs while increasing the quality and coverage of care for Medicare beneficiaries and include:

Thus, the Primary Cares Initiative represents not just a single push to improve the healthcare system as a whole through primary care, but an overarching drive to do so via many initiatives and programs. Bringing more practices on board with initiatives such as the PCMH, CPC+, innovation within Medicare Advantage, and the Primary Cares Initiative will undoubtedly solidify the success of these and future programs, as stakeholders and policymakers come to a greater understanding of how to incentivize and create a path toward improved healthcare outcomes.

eConsults directly support Primary Cares Initiatives by maximizing primary care’s value in healthcare delivery

A continuing challenge in maximizing the efficiency and effectiveness of primary care is that of managing specialist referrals. Electronic consultations (eConsults) have gained favor in meeting this challenge. eConsults help in reducing variations in referrals, increasing access to specialist care and consultations among broader populations, and reducing wait times for specialist visits. 

With the new CMS Primary Cares Initiative targeting advanced primary care practices for these payment models, eConsults are becoming increasingly valuable. Advanced primary care practices are defined as those that demonstrate an aim toward implementing fundamental strategies that focus on patient needs, with primary care as the foundation for maximizing value in healthcare delivery. These practices focus squarely on improving primary care in terms of health outcomes and lower costs. A key component of such advanced primary care practices is shepherding resources to improve efficiency and effectiveness in order to achieve their goals.

eConsults — which directly support improved health outcomes, reduced costs, and increased provider and patient satisfaction — are one such resource. As more health systems look toward creating PCMH models and consider adopting new value-based payment models under the Primary Cares Initiative to better manage the health of their patient population, eConsult systems will be instrumental in improving team-based care coordination and communication. 

Patient-Centered Care Needs Engaged Communication through Shared Data

Guest post by Jennifer Holmes, chief executive officer, Central Logic.

Jennifer Holmes
Jennifer Holmes

Healthcare systems gather a lot of patient data as care providers, but a surprising lack of coordination too often puts patients at risk.

Tragically, that is exactly what happened to my father nine years ago.  A week before his 70th birthday, he passed away due to the lack of care coordination.  His risk factors were high and his care provider had all his health records and history documented in his chart. Over the course of 15 years, my father had been admitted and treated six times at the same hospital. He was an open heart surgery patient, had multiple coronary artery stents placed 10 years post surgery, and he was diagnosed with cancer eight years before his death.

His primary care physician admitted him to the Emergency Room after finding a lump on his leg. Later that evening, we learned he had Stage 4 non-Hodgkin’s Lymphoma. The coordination care breakdown started with his oncologist who, although armed with most of my father’s health information, he missed one critical piece to the puzzle. Our family later learned the physician never reached out to my father’s interventional cardiologist to better understand his percent of heart function. If he had, they would have learned his left ventricular function was only 45-percent. Due to this lack of care coordination, the wrong drug cocktail was prescribed to treat his cancer, ultimately resulting in heart failure.  He was gone in six weeks.

Finding the Good in the Bad

The good news is that EHR technology adoption and compliance certifications around Meaningful Use is driving improvement for quality, safety, efficiency, and reduced health disparities. I believe these efforts to enhance care coordination will result in improved population and public health so that fewer and fewer families will experience what mine did.

According to the Health and Human Service’s Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine identifies patient centeredness as “a core component of quality health care.”  The agency tracks and analyzes the number of incidences of avoidable hospital-acquired conditions along with adverse events.  While progress has been made over the years, more work is necessary to improve care coordination.

To be fair, enormous demands have been placed on healthcare systems for profitability, efficiency, compliance, safety and overall excellence. However, excellent quality healthcare is inextricably connected to a patient care centered strategy. Our current systems must get back to that root focus through improved communication and sharing data transparently across all facets of the patient’s health spectrum. The key is finding user-friendly solutions to collect and analyze the right data, and warehouse and share all this data in a compliant way.

How to Engage – Transparently

Sharing all of that data sounds like a tall order and the technicalities of exactly how it gets accomplished seem daunting. We must follow patients from their first office visit to hospitalization, to discharge, to outpatient care, to patient-centered medical home (PCMH) care, and even at-home care. Lives can depend on it. The rub for patients and providers comes when collecting information becomes cumbersome, time-consuming and inefficient.

Recent tech and software solution advances portend smoother sailing ahead. Powerful tools are now available to collect, connect, communicate and share data from inside and outside a hospital’s four walls, directing real-time, actionable health decisions to improve patient-centered care. Providers realize efficiencies of scale when they use systems and software solutions that aggregate a patient’s total record. Optimal tools collect data from the patient’s complete health history and the best solutions can synthesize that data across all platforms and providers. This connected data roadmap then acts as a support and monitoring tool, as well as a yardstick to measure business intelligence goals.

What to Engage – Complete Data for Excellence

Patient-centeredness must then be a partnership among systems, practitioners, patients, and their families (when appropriate) to ensure that decisions respect the wants, needs, and preferences of patients.  Such partnerships ensure patients have the education and support they need to make decisions and participate in their own care.

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Can the Pioneer ACOs Survive without the PCMH Model?

Guest post by Timothy “Dutch” Dwight, vice president of business development, Medullan, Inc.

Timothy “Dutch” Dwight

Will today’s pioneer ACOs share the same demise as the HMOs of the 80s and 90s? It’s certainly starting to look that way.

Like HMOs, ACOs (Accountable Care Organizations) were created to reign in excessive fee-for-service arrangements and provide an incentive for capitating costs. The premise was that under the umbrella of an ACO, providers and payers would share in the responsibility for quality, cost and coordinated care for a defined population of patients.

If an ACO saved money for the payer without compromising quality, providers — defined as physician practices, hospitals, group practices, physician-hospital alliances and networks -–would share in the savings. And the savings were projected to be significant. Early forecasts from the Congressional Budget Office estimated that the 32 pioneer ACOs could save more than $1.1 billion in the first five years. On the other hand, if the ACO failed to meet capitation limits while providing care, the group shared in the losses.

To offset the risk and encourage membership, the early ACOs were supposed to receive multi-year compensation. However, that financial support disappeared after the first year and most provider groups did not have the business margins to carry them through a long-term investment approach. In addition, the ACO model requires a draw on scant resources from all parties to create another layer of program oversight – further cutting in to margin.

So where does the ACO model stand today? Nineteen of the 32 pioneer ACOs have left the program over the last two years, resulting in considerable wasted taxpayer dollars. As CMS moves towards the Next Generation program, can it succeed?

What will it take to save the ACO?

I believe ACOs can be saved, but significant changes must be enacted.

The fundamental problem with the pioneer ACO is that it manages the care of an unhealthy population without having sufficient oversight of that population. This leads a risk-adverse industry to hold their cash and cling to old processes.

Two years ago, Clayton Christensen rightly pointed out that the provider community must make major process and procedural changes in order for the ACO model to work. “No dent in costs is possible until the structure of healthcare is fundamentally changed.” I couldn’t agree more.

To survive, ACOs need to align with the Patient Centered Medical Home (PCMH) model, which is continuing to thrive and grow. PCMH is designed to align more holistic care management with a consumer incentive to prevent high-spend patients from seeking services from the more costly care centers such as emergency rooms. The payer, or insurance company, rewards the consumer for making smart choices by reducing deductibles and other fees if they use lower cost service centers such as primary care physicians, nurse practitioners, and urgent care centers. PCMH models use a combination of fee-for-service, value based payments to providers and align consumer incentives to reduce the cost of care. Comparatively, the ACOs capitated, “value based” payment model, intends only to lower the cost of care without having the proper procedures, tools and feedback loops in place to account how that care is provided. In other words, a visit to a PCP or ER makes no difference in the ACO model. On their own, ACOs do not have enough process control(s) and sufficient incentives to change patient behavior.

However, in combining the ACOs and PCMH model, the healthcare industry stands a much greater likelihood of meeting its goals — to improve the quality of care while containing or lowering the costs.

What needs to happen?

It starts with patient education – consumers need to be educated about their options and when and how to best use them. The next step is employing financial incentives. In short, money talks and will be key in changing old habits. When there is financial reward for going to one’s PCP or an urgent care center instead of an ER, consumers will make smarter choices. And ACOs will have an easier time capitating costs.

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How Rural Health Center in Northern California Successfully Made the Journey to MU Attestation

The Hill Country Health and Wellness Center is a small clinic located in the rural community of Round Mountain in Northern California. California is home to Hollywood and startups that enjoy incentives to start an LLC in California. The Center, which opened in a trailer in the 1980s, continues to reflect its founder’s passion for helping the area’s rural, largely underserved population. From that humble beginning, with one doctor and one nurse working without pay, the clinic today is housed in a modern building, with 90 employees.

The Center’s provider staff, consisting of two MDs, three mid-levels and three dentists sees about 3,700 patients per year — most of whom drive 30 miles or more for care.

All of the Center’s providers are in different stages of earning meaningful use incentive payments. The physician and nurse practitioners have each attested to Medi-Cal’s Adopt, Implement, Upgrade (AIU) incentive program.

The Center, which has been live on its EHR since June 2012, uses GE Centricity.

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How Patient-centered, Value-based Care Will Drive Innovation in Healthcare

Fauzia Khan, MD

Guest post by Fauzia Khan, MD, FCAP, is chief medical officer and co-founder of Alere Analytics.

This has been a very interesting year for the healthcare industry, which appears to be on the brink of a real sea change. Government mandates are driving transformative discussions in the C-suite circles on topics such as meeting meaningful use Stage 2 and Stage 3 requirements, satisfying Accountable Care Organization (ACO) standards, care delivery models in the patient-centered medical home and much, much more.

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Is Gartner Right in Recommending that Healthcare Embrace or Avoid these IT Trends?

Though there no longer necessarily a “season” for trend and projection pieces, but given our place in the calendar year, it’s appropriate that analyst firm Gartner recently released its latest piece, “Healthcare IT Trends to Embrace/Health IT Trends to Avoid,” published recently on CIO.

The following tips are part of a larger article about big data that, other than being a bit of a clumsy read, is worth a look. One of Gartner’s top healthcare analysts, Vi Shaffer, opines about the current state of healthcare and how those in it can begin to embrace the changes ahead.

So, without further ado, here’s some of the things you should definitely do (according to Gartner, that is), if you’re seeking ROI. I’ve made some edits to the list in points not relevant to this blog.

According to Gartner, the following are four healthcare IT trends to avoid. For various reasons, I don’t agree with any of these reasons, do you?

White Rose Family Practice, a Patient Centered Medical Home, on the Benefits of Adopting an Electronic Health Record

White Rose Family Practice
White Rose Family Practice

Serving patients is a fundamental value of White Rose Family Practice and so is maintaining a work/life balance for the practice’s physicians and physician assistants. To make this combination of values work, Cathy Carpenter, MD, founder of the York, PA, practice, was naturally drawn to using new technology to improve patient care while finding efficiencies in delivering that care.

From its founding in the 1990s, White Rose has been ahead of the curve: adopting electronic prescribing before pharmacies had ever heard of the technology, assigning one of the earliest-available tablet computers to its physicians, and hiring part-time physicians long before that was considered acceptable.

According to Whitney Almquist, Business Manager, even in the transition from a paper record to the clinical module, White Rose went against the grain.

In converting some 14,000 charts from paper to electronic encounter notes, White Rose decided to scan entire charts, not just recent visits. It took about four years for a crew of several part-time college students using high-speed scanners to complete the task.

The payoff is two-fold: 1) no more paper charts in the building, and 2) all the data White Rose physicians need to determine how their patients are doing – and how the physicians are doing in treating them – is as close as the nearest computer, thanks to the reporting capabilities of the electronic record.

“Now there is so much clinical data that we can mine and report on,” Almquist says.

White Rose had a yen for reporting well before the purchase of its system. Using a practice management system in the years leading up to the EHR purchase in 2003, Almquist admits she was entranced by the practice management system’s power to easily produce custom reports based on claims data, patient visits and other practice management data.

Reporting is essential for the White Rose physicians. It’s also been key to the practice’s successful participation in a statewide Chronic Care Initiative led by the Pennsylvania Governor’s Office of Health Care Reform. Taking part in the program and its intensive training has paid off in the form of new insights into the care of diabetic and other patients with chronic conditions, as well as experience in quality reporting.

Since beginning participation with the program, the practice has created and used clinical reports to monitor its patients. For example, with diabetes patients, the practice’s care manager uses reports to track those patients’ blood pressure, cholesterol, and A1C levels, among other measures.

Almquist can quickly determine what percentage of the practice’s diabetic patients have had an annual flu shot or recently received an eye exam. She and the staff then can run reports showing the names of those who have not had the exams and contact those who need to come in – something not practical to do without an electronic health record.

Almquist also can quickly run a report to show providers exactly where each one stands compared to others in the practice care results and, importantly, how they match up to the goals the practice has set for chronic care.

If there was any doubt as to the usefulness of an electronic record, that was all expunged when White Rose applied to participate in the Governor’s Chronic Care Initiative, which was built on a model developed by Dr. Ed Wagner of Seattle, Washington.

From the beginning, White Rose did a good job of getting its diabetes patients back into the office for regular follow-up exams, Almquist says.

“What we did not realize, until we looked at the data as a whole, was that some of our patients had high A1Cs, high LDL cholesterol [and] blood pressure that needed better control,” she admits. “There has been improvement and I credit the reporting capacity of our EHR in helping us fight against clinical inertia – not taking more aggressive action. It’s helping us continue to push our patients to make changes in their behavior.”

Some practices have struggled to get on board with chronic care initiatives, like Pennsylvania’s, because their EHR was simply not designed to do population management or patient registries, says Colleen M. Schwartz, RN, Quality Improvement Coach for Improving Performance In Practice (IPIP). The national program, which trains chronic care providers in team-oriented approaches to treating patients with asthma and diabetes, is sponsored in part by the Robert Wood Johnson Foundation and the American Board of Medical Specialties.

“I’m not sure you can be a highly successful medical home without an EHR,” Schwartz says. “White Rose has been able to do incredible things and leapfrogged to the head of the group of practices we’re training.” Schwartz concludes: “White Rose Family Practice has been an incredible beacon and leader for the South Central Pennsylvania Region collaborative teams.”

Almquist says the increased focus on reporting has some unexpected side benefits, too. It has helped the practice to solidify its own care team by spreading around more of the duties to staff who haven’t always had a direct role to play in patient care. In the front office at White Rose, for example, a receptionist runs a weekly report that shows which diabetic patients, who are scheduled for near-term a follow-up appointment, have not yet had lab work done. She calls those patients, which allows her to get involved in care management, a key part of the chronic care model, as well as expands the variety of work roles she experiences.

“What is the purpose of collecting the data if you’re not going to use it to improve patient care?” asks Almquist. Good question.

White Rose Family Practice plans to begin tracking its success in scheduling colorectal screenings for patients. The plan is to have one of the practice’s nurses to follow up on patients who were scheduled for colonoscopy but didn’t get one.

Additional areas where the practice is doing more intensive follow up are immunizations and medication reconciliation for patients discharged from the hospital or seen in the emergency department within the past 24 hours. That reporting is helping improve staff productivity, too. Almquist says nurses use the reports to hone in on patients who most need the counseling.

Schwartz agrees with the utility of an EHR and adds that it also extends to improve patient care and education: “People are visual. When you have a report card from the EHR, people can see their blood pressure is trending down, their A1C going down. They can see that they have met most of the measures and are doing a good job of self management.”

Cathy Carpenter, MD, founder of White Rose, sums up the practice’s experience in using the EHR to manage and involve the practice’s providers and chronic disease patients in working as a team.

“We use the clinical data that we have created to provide better patient care. With an EHR, we are in position to cut down on healthcare costs, and to make people’s lives better.”