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:
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).
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
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:
– 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.
– 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.
– 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
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:
Adults in the U.S. who have a primary care provider have 19 percent lower odds of premature death than those who only see specialists for their care.
People who have a primary care provider save 33 percent on healthcare over their peers who only see specialists.
A study in a North Carolina ER found that nearly 60 percent of the patients’ problems could have been addressed in a primary care clinic for a savings of 320 percent to 720 percent — that’s a value of a three to seven times reduction in healthcare spend.
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:
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:
Planned care and
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:
Allowing customization of cost-sharing based on chronic condition, socioeconomic status, or both, including some non-health related benefits, such as transportation.
Expanding eligibility to include chronic condition special needs plans (SNPs), dual eligible SNPs, institutional SNPs, and regional preferred provider organizations.
Bolstering the rewards and incentives programs that plans can offer beneficiaries to take steps to improving their health.
Increasing access to telehealth services.
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.
Guest post by Jennifer Holmes, chief executive officer, Central Logic.
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.
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.
The Hill Country Health and Wellness Center is a small clinic located in the rural community of Round Mountain in Northern 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.
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.
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.
Big data. Along with big data, you need to make sure you’re making a move to structured data collection. In its most simple terms, you need to make sure that all of the data being collected in the practice is being collected in the same fashion, and that all of the same data is being collected. Once your data gets “bigger,” you’ll be better able to work with and analyze it. According to Gartner, “This may take time to implement, but it will have a “transformational” benefit and organizations that implement all facets of big data by 2015 can expect to start to outperform their competitors by as much as 20 percent.”
E-visits. “This facet of telemedicine is catching on now that EHR systems and patient portals include secure messaging. Success comes with setting expectations and enforcing policies,” Gartner says.
Wireless health asset management. Putting RFID chips on anything that moves—equipment as well as patient wristbands—is an “increasingly routine component of cost and patient care quality management.” Since there’s a lot to monitor, CIOs must collaboration with clinical engineering or biomedical device departments.
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?
Patient decision aids and personal health management tools. These appear largely in the form of interactive apps that educate patients or help them make care decisions, such as seeking treatment or undergoing surgery for a particular ailment. Though, Gartner says their effectiveness is questionable and adoption remains low, I’m not sure I’m convinced that they should be avoided. There is some value to these programs, especially if they help with patient engagement and education.
Personal health records. “The concept is attractive, as it gives patients ownership of their data, but poor usability and vendor disinterest have hindered adoption. Only with a government mandate, as is the case in Australia, does PHR adoption seem to catch on, Gartner says. Patient portals, which connect patients directly to their caregivers, are more popular.” Not only are they more popular, they are required through meaningful use and, if leveraged properly, can be quite effective in helping drive engagement and education.
The patient-centered medical home. “There’s been much discussion of making this a reality, especially in light of the accountable care organization model, but information exchange challenges and a reimbursement model unfavorable to insurers hinder adoption.” Again, not sure if I agree with Gartner. I don’t have any hard reasons why except that for some, they actually have proven successful. Check out this piece for more about a practice that clearly has leveraged the PCMH successfully.
Patient self-serve kiosks. “While these can streamline patient registration and payment collection, the ROI isn’t there, Gartner says. Most organizations are better off focusing on meaningful use or the conversion to the ICD-10 code set, which must be done by Oct. 1, 2014.” Again, for some organizations, these are simply good tools help streamline the patient intake process. They may not improve ROI, but they can get people into the practice more easily and to their physician without the cumbersome paper and pen approach.
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.”