Ambulatory Care

New Models Redefine Primary Care

February 20, 2017 9:50 am

Imagine a world in which patient visits with primary care providers consistently last more than 10 minutes, patients are engaged in their care, and clinical staff believe they are making a sustainable difference in their patients’ health.

For some practices, this world has become a reality under new models designed to significantly change how primary care is delivered.

Essentially focused on population health management, these models place primary care at the center of efforts to improve quality and reduce costs. Reductions in utilization, admissions, and specialist and emergency department (ED) visits are targeted through approaches such as team-based care, chronic care management, and transitional care.

This year, the Centers for Medicare & Medicaid Services (CMS) implemented its latest model: Comprehensive Primary Care Plus (CPC+), the successor to the Comprehensive Primary Care (CPC) initiative, which ran from October 2012 through December 2016.

CPC+ charges participating practices with five key functions: care access and continuity, care management, care comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health. Like its CPC predecessor, CPC+ includes both government and commercial payers who, in addition to traditional payments, pay a monthly care management fee to support the additional care services. Unlike CPC, which used a shared-savings approach, the new model includes incentive payments linked to quality and utilization and, under a second track, a hybrid of fee-for-service and CPC payments, the latter of which apply to in-office and out-of-office evaluation and management services.

As is true for other models seeking to advance care delivery, CPC+ is challenging. Such models rely heavily on staffing, data, and collaboration among clinicians. But when these models work, their benefits can be substantial for both patients and providers.

No Turning Back

Lynn Barr, CEO of Kansas City, Mo.-based Caravan Health, a provider of population health management services to mainly rural practices, says new care delivery models have had such a dramatic effect on providers that many of her clients have said they would never return to their “old” way of delivering patient care.

“Their patients are healthier and happier and more engaged,” she says. “The patients are using less services overall, but they’re using local services more, which has been a real boon to our rural hospitals. It makes sense. They make money on mammograms and colonoscopies. Having a robust wellness program generates lots of population health revenue.”

Many of Caravan’s client practices are in the Medicare Shared Savings Program (MSSP), with the majority in the Accountable Care Organization Investment Model, in which practices receive loans from the Center for Medicare & Medicaid Innovation (CMMI) to fund population health management programs. The loans are recovered from savings generated by participation in the model.

Although Caravan did not work specifically with practices in the CPC initiative, Barr says, the firm did assist about 250 practices through the application process for CPC+.

Barr says providers believed their practices had become more like urgent care centers—focused on treating conditions rather than preventing them. Population health management is “reenergizing them as community health systems,” she says.

Feedback on CPC from physicians and care managers has been extremely positive, says Richard Shonk, MD, chief medical officer of The Health Collaborative, a Cincinnati-based nonprofit organization that contracted with CMS to help participants coordinate efforts and reach required milestones.

Shonk says one care manager reported that the CPC model enabled clinicians to focus more on patients, which has had several benefits. “The patients felt better cared for, and that made them feel more engaged in their care,” he says. “That created a sense of satisfaction and gratification within the staff that helped their morale.”

Gaining Physician Buy-In

Perhaps the most significant obstacle in achieving success in any clinical transformation is gaining the buy-in of physicians. Primary care providers and specialists must work in conjunction to reduce utilization and coordinate the care of their patients.

National insurer Anthem, Inc., which has initiated its own value-based payment models, participated in the CPC model and is participating in CPC+. Gaining the trust of physicians has been an issue for some practices. “Some have really committed to it, and the physician leadership in place truly believe in it and are championing it among their peer physicians, while others may have less experience or just less buy-in,” says Veeneta Lakhani, vice president of provider enablement for Anthem.

Anthem addresses the trust issue through data, education, and physician engagement, delivered through vehicles such as webinars and practice group get-togethers, to help practices better understand the benefit of value-based payment models and to demonstrate how some practices have succeeded.

“We had to walk the talk—continue to bring data, continue to bring resources,” says Julie Schilz, Anthem’s staff vice president for care delivery transformation, who spearheaded the health plan’s CPC efforts.

Webinars have featured national speakers who are well-respected in primary care, such as Pauline Lapin from CMMI. Physician practice representatives have offered best practices, such as for reducing ED utilization.

In addition to accepting value-based models, physicians must also become adjusted to the concept of team-based care. For physicians who are accustomed to one style of care practice, working with a care manager is very different, says David Cho, MD, FACP, co-chair of the division of primary care at Health Quest Medical Practice, a LaGrangeville, N.Y.-based health system that includes four hospitals, 13 primary care clinics, and multiple specialty clinics. Five of Health Quest’s primary care practices participated in the CPC model and 10 are enrolled in CPC+.

Even more challenging has been getting specialists onboard with a coordinated, team-based care management model, Cho says.

“We realized that as primary care providers, we could control the cost of certain services in terms of utilization as well as decreased visits to the ED and hospital,” Cho says. At the same time, the imaging and other tests that specialists often order affect the total cost of caring for a patient, which is used to evaluate the performance of primary care practices in the model. “Our utilization we found out is very dependent on the specialists’ costs,” Cho says.

Cho says two approaches can help win buy-in from specialists. A specialist champion can persuade colleagues to recognize the need to coordinate care and to comply with new care practices as they are instituted. “The issue really is about trying to identify a leader from the specialty side and having them understand that the overall health of the patient depends on active integration with the patient and with the patient’s primary care provider,” he says.

There should also be a direct line of communication between the primary care physician and specialist to ensure the specialist knows who to contact for questions about prior care. The primary care physician and specialist should also establish a clear set of expectations, which can be established in a document outlining what services are expected from the specialist and what follow-up the primary care physician should provide. Once a patient’s issue with chest pain has been resolved, for example, the next step may include follow-up primary care visits for ongoing treatment of related conditions, such as hypertension. “Even something as simple as that can really be enlightening,” Cho says.

The primary care physician and specialist should also have secure forms of communication, such as texting or messaging, to transmit documentation and images in real time, Cho says.

Data Presents Challenges

Another challenge that turned up in the CPC model was data aggregation from disparate systems of non-CMS payers.

Along with 75 practices that included 250 physicians, CMS and nine commercial health plans participated in the CPC model in southwestern Ohio and northern Kentucky in which The Health Collaborative was involved, Shonk says.

Physicians quickly realized that receiving data sets from multiple commercial insurers and CMS would be overwhelming. The physicians wanted to know how process improvement could be possible when their performance—measured through utilization rates, quality outcomes, and cost data—varied by payer, Shonk says. Consequently, the physicians wanted the data to be managed, analyzed, and presented in a transparent and actionable format.

Fortunately, the health plans also recognized the need for high-quality, usable data “and were willing to go down this route with us to do that,” he says.

Participating physician practices and health plans agreed to split the cost of developing a tool that would generate and aggregate the data into an actionable form. “That created a somewhat unanticipated large benefit in that it made the practices co-owners of the data process,” Shonk says. “They were involved in what we called our data work group, where they had input into risk adjustment and other methodologies,” Shonk says. “So when the data actually came out, they were less likely to question it and argue over it and were much more willing to accept and work on the results.”

The reports took about 18 months to develop, including establishing agreements to satisfy data security requirements and comply with the legal policies of each health plan, Shonk says. “That was a major accomplishment of this approach.”

Results Are Mixed

The CPC model included a shared-savings component designed to split cost savings from improved care practices between payers and practices. Four of the seven participating regions shared in CMS savings, which were calculated at the regional level; three had net losses.

In terms of overall performance, the indicators show practices are progressing.

“We’re certainly seeing that the needle is being moved,” Anthem’s Lakhani says. “Across our value-based programs, we have seen consistent improvement in inpatient utilization as well as gaps-in-care closure and year-over-year improvement in quality measures.”

Still, individual performance varied significantly. “You definitely find that all providers are not made equal, and some are really doing very well, earning savings, and winning in these programs while others are struggling,” she says.

Lakhani attributes this variation to differences in readiness for value-based care in terms of mindset, resources, and data utilization. “Enablement is all about how people, process, technology, and culture come together to deliver a result, and that’s where we see the differences across providers.”

From Anthem’s perspective, the CPC model was lacking in efforts to help practices understand cost and how to achieve savings through reduced utilization, Schilz says.

“We tend in our model to look at both quality and cost as the total package on value,” she says. “CPC, in the learning curriculum, initially focused a lot on quality and a lot on care delivery organization and a little less on things like utilization, such as ED visits or inpatient utilization or perhaps cost of care related to pharmaceuticals, which we feel is a critical component to add.”

Schilz says CPC+ addresses this issue in part by replacing the shared savings approach with an incentive system that measures performance at the practice level rather than the regional level, thereby helping to foster accountability for the cost of care at each practice site.

CPC practices affiliated with The Health Collaborative saw improvements in quality and utilization for members across Medicare (including Medicare Advantage), Medicaid, and commercial payers, Shonk says.

Comparing data from the first quarter of 2013 to the first quarter of 2016, the number of specialty visits and primary care visits declined by 10 percent and 9 percent, respectively, and the number of ED visits declined by 5 to 7 percent, Shonk says. Inpatient admissions declined by about 18 percent, including a 25 percent reduction among ambulatory sensitive conditions, a group of about 15 chronic-disease diagnoses. This decrease included reductions of 28 percent in admissions for congestive heart failure and 13 percent in admissions for chronic obstructive pulmonary disease.

“The reduction in admissions for chronic conditions is probably our most significant outcome because it is exactly where you would expect to see the impact of a methodology that paid practices to manage care,” Shonk says.

Positive Outlook for CPC+

Despite the mixed results from CPC, the outlook for CPC+ is encouraging. For the first round, which began in January, CMS expanded the program from 500 to 2,983 practices. The number of payers grew from 31 to 54 and the number of regions increased from seven to 14. Round 2 of CPC+ will begin in January 2018 with as many as 2,000 additional practices and up to 10 additional regions.

Caravan’s Barr says the care management requirements for CPC+ are intimidating—roughly twice the amount of work as is required in an ACO. In addition to wellness and chronic care management, she says, CPC+ requirements include the integration of behavioral health services and the use of data for risk stratification and disease-specific panels.

 “CPC+ is basically the roadmap to how you would manage population health in a primary practice if you did it all,” Barr says.

Barr says she has high hopes for CPC+ even though she believes some practices will leave the program because of the heavy demands. “But the ones that stick with the work are going to do a great job for their patients,” she says. “It’s a great time to be in primary care.”

Health Quest’s Cho is also encouraged by CPC+, specifically noting the use of psycho-social factors to identify a patient’s barriers to effective care. He acknowledges that there are many compliance and documentation requirements—a lot of “clicking of boxes”—that may frustrate clinicians.

“I really don’t think that advances the delivery of health care, frankly,” he says. “I think that ensures compliance.” With these increased requirements, he says, CPC+ will be challenging, “but I think this is definitely the way forward.”

Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a frequent contributor to HFMA publications.

Interviewed for this article: Lynn Barr, CEO, Caravan Health, Kansas City, MO.; Richard Shonk, MD, chief medical officer, The Health Collaborative, Cincinnati; David Cho, MD, FACP, co-chair, division of primary care, Health Quest Medical Practice, LaGrangeville, N.Y.; Veeneta Lakhani, vice president, provider enablement, Anthem, Inc., Indianapolis; Julie Schilz, staff vice president,  care delivery transformation, Anthem, Inc., Indianapolis.

David Cho photo: Courtesy of Health Quest Medical Practice.

Julie Schilz photo: Courtesy of Anthem.


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