Health care reform: Possibilities &amp; opportunities for primary care

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Applied Evidence

Health care reform: Possibilities & opportunities for primary care

J Fam Pract. 2014 June;63(6):298-304

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References

1. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicaid Innovation should test accountable care organizations. Health Aff. 2010;29:1293-1298.

2. Medicare’s delivery system reform initiatives achieve significant savings and quality improvements - off to a strong start [press release]. Washington, DC: US Department of Health & Human Services; January 30, 2014. Available at: http://www.hhs.gov/news/press/2014pres/01/20140130a.html. Accessed March 28, 2014.

3. The family physician’s ACO blueprint for success: Preparing family medicine for the approaching accountable care era. Texas Academy of Family Physicians Web site. Available at: http://www.tafp.org/Media/Default/Downloads/practice%20resources/acoguide.pdf. Accessed March 28, 2014.

4. Mechanic RE. Opportunities and challenges for episode-based payment. N Engl J Med. 2011;365:777-779.

5. Medicare prospective payment systems (PPS): A summary. American Speech-Language-Hearing Association Web site. Available at: http://www.asha.org/practice/reimbursement/medicare/pps_sum.htm. Accessed March 28, 2014.

6. Pay for performance (P4P): AHRQ resources. Agency for Healthcare Research and Quality Web site. Available at: http://www.ahrq.gov/legacy/qual/pay4per.htm. Accessed March 29, 2014.

7. Komisar H, Feder J, Ginsburg PB. “Bundling” payment for episodes of hospital care: Issues and recommendations for the new pilot program in Medicare. Available at: http://www.americanprogress.org/issues/2011/07/pdf/medicare_bundling.pdf. Accessed May 20, 2014.

8. McAlearney AS. Population health management: Strategies to improve outcomes. Chicago, IL: Health Administration Press; 2003.

9. Centers for Medicare and Medicaid Services Web site. Comprehensive primary care initiative. Available at: http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/. Accessed March 29, 2014.

10. Robertson DC, Lerner JC. Top technology issues for ambulatory care facilities this year and beyond. J Ambul Care Manag. 2009;32:303-319.

11. Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the united states. Arch Intern Med. 2007;167:1400-1405.

12. Vest JR. Health information exchange and healthcare utilization. J Med Syst. 2009;33:223-231.

13. Parente ST, McCullough JS. Health information technology and patient safety: evidence from panel data. Health Affairs (Millwood). 2009;28:357-360.

14. FAQ on Accountable Care Organizations. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/practice-management/payment/acos/faq.html. Accessed March 29, 2014.

15. Torrieri M. CMS appeals to rural practices with another ACO participation perk. Physicians Practice blog. June 1, 2011. Available at: http://www.physicianspractice.com/blog/cms-appealsrural-practices-another-aco-participation-perk. Accessed March 29, 2014.

16. Crabtree BF, Nutting PA, Miller WL, et al. Summary of the national demonstration project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8 suppl 1:S80-S92.

17. Friedberg MW, Schneider EC, Rosenthal MB, et al. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311:815-825.

18. Nielsen M, Olayiwola JN, Grundy P, et al. The patient-centered medical home’s impact on cost & quality: An annual update of the evidence, 2012-2013. Available at: http://www.pcpcc.org/resource/medical-homes-impact-cost-quality. Accessed May 20, 2014.

19. Laine C. Welcome to the patient-centered medical neighborhood. Ann Intern Med. 2011;154:60.

20. Pham HH. Good neighbors: how will the patient-centered medical home relate to the rest of the health-care delivery system? J Gen Intern Med. 2010;25:630-634.

21. Taylor EF, Lake T, Nysenbaum J, et al; Mathematica Policy Research. Coordinating care in the medical neighborhood: critical components and available mechanisms: White paper. Available at: http://pcmh.ahrq.gov/sites/default/files/attachments/Coordinating%20Care%20in%20the%20Medical%20Neighborhood.pdf. Accessed May 20, 2014.

22. Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.

23. Collins C, Hewson DL, Munger R, et al. Evolving models of behavioral health integration in primary care. Available at: http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf. Accessed April 10, 2014.

24. The cornerstones of accountable care. Health Leaders Media Web site. Available at: http://www.healthleadersmedia.com/content/256694.pdf. Accessed March 29, 2014.

25. AAFP statement: AAFP commends CMS for improving Medicare ACO final rule, announcing the advance payment model [press release]. Leawood, Kansas: American Academy of Family Physicians; October 21, 2011. Available at: http://www.aafp.org/media-center/releases-statements/all/2011/aco-final-rule.html. Accessed March 29, 2014.

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29. Developing a community-based patient safety advisory council. Agency for Healthcare Research and Quality Web site. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/patient-safety-advisorycouncil/. Accessed March 31, 2014.

As health IT continues to evolve, additional means of interacting with patients and improving patient care will be developed. Physicians and organizations that are ready to take advantage of these advances in technology will be well positioned to address the goals of health reform. (See “Health care reform: Recommendations for family physicians” below.^3-7,14,15)

How the patient-centered medical home fits into the picture

The implementation of ACOs and other new models of care has promising implications for the establishment of PCMHs. Consistent with the goals of health reform, the PCMH movement focuses on a coordinated teamwork approach, anchored within a general practice or family medicine setting.

An evaluation of the PCMH National Demonstration Project funded by the American Academy of Family Physicians found that the adoption of more components of the PCMH at the practice level was associated with improvement in patient outcomes, as measured by the Ambulatory Care Quality Alliance starter set16 (a compilation of clinical performance measures developed by a broad coalition of providers, payers, consumers, and government agencies).

A recent look at the Southeastern Pennsylvania Chronic Care Initiative¹⁷ found less promising results. “A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA [National Committee for Quality Assurance] certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years,” Friedberg et al¹⁷ concluded. The authors did note, however, that NCQA recognition was what the practices involved in this initiative were rewarded for—not PCMH activity.

Coordinated delivery models that integrate primary care and mental health services have been shown to be cost-effective.It is also important to keep in mind that PCMH activity has been shown to improve care and reduce costs—not NCQA recognition in and of itself. In fact, a large body of evidence clearly demonstrates the positive patient care outcomes and reductions in overall cost associated with the PCMH. These findings were compiled by the Patient-Centered Primary Care Collaborative—which issues annual reports on the progress of the PCMH—in a January 2014 update.¹⁸

In a PCMH model, the focus shifts away from the procedure(s) or treatment to the whole person. However, all components of care (eg, primary and specialty care, hospital, ancillary services, laboratory, and radiology) are vital and need to be connected to increase efficiency and reduce cost—creating what is sometimes referred to as a “medical neighborhood.”^19-21

What’s in the neighborhood?

In a medical neighborhood, such as an ACO, each patient is cared for by a team of providers at multiple locations. The PCMH serves as the base, ensuring that all providers work together toward a common goal. In addition to providing primary care, the PCMH coordinates each patient’s specialty and support services and communicates the care plan to all involved.

Successful implementation of a medical neighborhood requires a close working relationship among providers, payers, and community resources. For example, payers can provide real-time information about patients who have been admitted to the hospital or discharged from the emergency department, which enables close follow-up and coordination across multiple systems.

Health care reform: Recommendations for family physicians

Given the emerging opportunities for new care delivery models to advance primary care, we urge family physicians to respond positively to these changes and challenges. Here’s what we recommend:

Carefully consider payment methodologies. Changes in the way physicians are paid will vary by payer source, as well as geographic market.^3-7 Regardless of the reimbursement model you’re offered, however, do not agree to it until you have the opportunity to evaluate it, along with your particular circumstances, to ensure that you have the infrastructure to support whatever changes the new model will require.

Read the fine print. Look out for your own interests by carefully reading the terms you are presented with. Consider seeking advice from those who understand the particular nuances faced by family physicians under particular reimbursement strategies. Just because a payment method benefits a particular specialty does not mean it will be favorable to family physicians.

Before you join an ACO
Before joining an accountable care organization (ACO ) or a similar entity, find out whether it supports primary care principles and the patient-centered medical home (PCMH ). Some questions to ask:
• Does the ACO have the infrastructure necessary to be successful, including the requisite health information technology, administrative support, actuarial knowledge, and experience with population health management?
• Is the ACO founded on primary care principles? Find out, for example, whether primary care physicians are represented at all levels of the organization and provide appropriate input on all important issues.

If you practice in a rural area … The growth of ACO activity is expected to be slow in both rural and underserved metropolitan markets. To address this issue, the Centers for Medicare and Medicaid Services is allowing primary care physicians in such markets to participate in more than one Medicare ACO and providing financial incentives in the form of savings exemptions to smaller, rural ACOs.^14,15 Another option for rural providers is the adoption of a “virtual ACO ”—a loosely organized group of providers, united in the effort to achieve high-quality care and reduced costs and willing to submit to computer analysis that will determine their relative contributions to efficiency and the distribution of savings.¹⁴

Get involved
It is important for all family physicians to engage in discussions about health care reform, and to represent both their patients and their specialty. Familiarity with what is happening is essential. One way to do that is to become an active member of your state or local American Academy of Family Physicians affiliate.

More information is available at:

• www.aafp.org
Practical information with regard to health reform, in addition to suggesting ways to get involved
• http://www.tafp.org/Media/Default/Downloads/practice%20resources/aco-guide.pdf
Information to consider before joining or forming an ACO
• http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx and http://www.transformed.com/
Resources for practitioners considering transformation to a PCMH
• http://innovation.cms.gov
Information, including webinars and forums, on innovative payment and service delivery models.