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APRIL 2014

The New Primary Care Model: A Patient-Centered Approach to Care Coordination

APRIL 2014 | The New Primary Care Model: A Patient-Centered Approach to Care Coordination PAGE 2TOC

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In these days of healthcare transformation, no one bears a greater burden

for change than the primary care physician. The contemporary primary

care practice is at the crossroads of reform efforts. Patients with new

insurance coverage via the Patient Protection and Affordable Care Act are

likely to access the system through a PCP. These physicians also are being

courted by payers, government agencies, and health systems to innovate

in practice design and in accountability for outcomes and costs. On many

days, it must feel like being the canary in the coal mine.

The results of the HealthLeaders Media Primary Care Redesign Survey

certainly reinforce the revolutionary changes that healthcare leaders are

experiencing. What comes through loud and clear is that PCPs cannot

navigate these sea changes alone. Nearly two-thirds of respondents (59%)

say that the goal of their primary care redesign efforts is to improve care

coordination and care collaboration. PCPs understand that strides toward

an improved system will occur through collaborations with payers and

provider systems that support new models of care. The majority identify

greater patient engagement (59%) and coordinating care with other

providers (49%) as being critical to reform efforts.

Healthcare leaders also agree that we are likely headed to a payment

environment requiring physicians to be at greater risk for their

outcomes—61% now have some kind of performance relationship with

payers regarding primary care redesign, with 18% involved in an at-risk

partnership. PCPs have come to accept that their results will be measured

and tracked, and they are looking for ways to integrate these expectations

in their daily practices. Survey respondents indicate that they will be

investing to bring about such change over the next three years: 62% will be

investing in systems to measure and track provider performance, and 51%

expect investments in electronic health records to help support primary

care redesign efforts.

As we search for solutions to the issues facing healthcare and seek ways

to improve value, retaining the attitudes and beliefs of the primary care

physician will be important. For too long, the perspective of these front-

line doctors was overlooked as the attention in healthcare was shifted

toward specialization and advanced technology. As the focus comes back

to prevention, care of chronic illness, and population health, the primary

care physician will play a pivotal role. Surveys like this help us understand

whether we are headed down the right path.

David J. Shulkin, MDVice President, Atlantic Health System;President, Morristown Medical Center; and President, Atlantic Accountable Care OrganizationMorristown, N.J. Lead Advisor for this Intelligence Report

FOREWORD

The Primary Importance of the Primary Care Physician



Table of Contents

Foreword 2

Methodology 4

Respondent Profile 5

Analysis 6

Case Studies 12

Practice Transformation: Integrating Improvement and Payment . . . . . . . . . . 12

A Model for Colocating Primary Care and Behavioral Health Providers . . . . . . . 15

Developing a Track Record for Value-Based Reimbursement . . . . . . . . . . . . . . . . . 18

Survey Results 21

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Fig. 1 Goals for Primary Care Redesign Next Three Years. . . . . . . . . . . . . 21

Fig. 2 Clinical Challenges of Primary Care Redesign . . . . . . . . . . . . . . . . . . 22

Fig. 3 Business Challenges of Primary Care Redesign . . . . . . . . . . . . . . . . 23

Fig. 4 Addressing Physician Compensation in Primary Care Redesign . . 24

Fig. 5 Physician Compensation Measures Used or Planned. . . . . . . . . . . . 25

Fig. 6 Primary Care Redesign Investments Next Three Years . . . . . . . . . 26

Recommendations 35

Meeting Guide 37

Fig. 7 Primary Care Redesign IT Investments Next Three Years. . . . . . . 27

Fig. 8 Most Effective Efforts at Engaging Patients . . . . . . . . . . . . . . . . . . . 28

Fig. 9 Involvement With Patient-Centered Medical Home Recognition or Accreditation Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Fig. 10 Relationship With Payers Regarding Primary Care Redesign . . . . 30

Fig. 11 Outreach for Primary Care Redesign With Known Partners. . . . . 31

Fig. 12 Extending Primary Care Redesign Beyond Known Partners . . . . . 32

Fig. 13 Regular Standing Primary Care Team. . . . . . . . . . . . . . . . . . . . . . . . . 33

Fig. 14 On-Call or As-Needed Primary Care Team. . . . . . . . . . . . . . . . . . . . . 34



Methodology

The 2014 Primary Care Redesign Survey was conducted by the HealthLeaders Media Intelligence Unit, powered by the HealthLeaders Media Council. It is part of a series of monthly Thought Leadership Studies. In January 2014, an online survey was sent to the HealthLeaders Media Council and select members of the HealthLeaders Media audience. A total of 317 completed surveys are included in the analysis. The margin of error for a sample size of 317 is +/-5.5% at the 95% confidence interval.

Each figure presented in the report contains the following segmentation data: setting, number of beds (hospitals), number of sites (health systems), net patient revenue, and region. Please note cell sizes with a base size of fewer than 25 responses should be used with caution due to data instability.

ADVISORS FOR THIS INTELLIGENCE REPORTThe following healthcare leaders graciously provided guidance and insight in the creation of this report.

A. John Blair III, MD, FACSPresidentTaconic Independent Practice Association Fishkill, N.Y.

Holly Miller, MD, MBA, FHIMSSMedical DirectorTaconic Independent Practice Association Fishkill, N.Y.

John Saultz, MDProfessor and ChairmanDepartment of Family MedicineOregon Health and Science UniversityPortland, Ore.

David J. Shulkin, MDVice President, Atlantic Health System;President, Morristown Medical Center;President, Atlantic Accountable Care OrganizationMorristown, N.J.

UPCOMING INTELLIGENCE REPORT TOPICS

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Copyright ©2014 HealthLeaders Media, a division of BLR, 100 Winners Circle, Suite 300, Brentwood, TN 37027 Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

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Respondent Profile

Respondents represent titles from across the various functions at

hospitals, health systems, and physician organizations.

Senior leaders | CEO, Administrator, Chief Operations Officer, Chief Medical Officer, Chief Financial Officer, Executive Dir., Partner, Board Member, Principal Owner, President, Chief of Staff, Chief Information Officer

Clinical leaders | Chief of Orthopedics, Chief of Radiology, Chief Nursing Officer, Dir. of Ambulatory Services, Dir. of Clinical Services, Dir. of Emergency Services, Dir. of Nursing, Dir. of Rehabilitation Services, Service Line Director, Dir. of Surgical/Perioperative Services, Medical Director, VP Clinical Informatics, VP Clinical Quality, VP Clinical Services, VP Medical Affairs (Physician Mgmt/MD)

Operations leaders | Chief Compliance Officer, Asst. Administrator, Dir. of Patient Safety, Dir. of Quality, Dir. of Safety, VP/Dir. Compliance, VP/Dir. Human Resources, VP/Dir. Operations/Administration, Other VP

Finance leaders | VP/Dir. Finance, HIM Director, Director of Case Management, Director of Revenue Cycle

Marketing leaders | VP/Dir. Marketing/Sales, VP/Dir. Media Relations

Information leaders | Chief Medical Information Officer, Chief Technology Officer, VP/Dir. Technology/MIS/IT

Base = 317 Base = 138 (Hospitals)

Type of organization

Hospital 44%

Health system 35%

Physician org. 21%

Number of beds

1–199 49%

200–499 33%

500+ 17%

Number of physicians

Base = 68 (Physician orgs)

1–9 26%

10–49 31%

50+ 43%

Region

WEST: Washington, Oregon, California,

Alaska, Hawaii, Arizona, Colorado, Idaho,

Montana, Nevada, New Mexico, Utah, Wyoming

MIDWEST: North Dakota, South Dakota,

Nebraska, Kansas, Missouri, Iowa, Minnesota,

Illinois, Indiana, Michigan, Ohio, Wisconsin

SOUTH: Texas, Oklahoma, Arkansas,

Louisiana, Mississippi, Alabama, Tennessee,

Kentucky, Florida, Georgia, South Carolina,

North Carolina, Virginia, West Virginia, DC,

Maryland, Delaware

NORTHEAST: Pennsylvania, New York,

New Jersey, Connecticut, Vermont, Rhode

Island, Massachusetts, New Hampshire, Maine

Title

Base = 317

47%Senior leaders

3% Marketing

leaders

0

10

20

30

40

50

19% Clinical leaders

23% Operations

leaders

6% Finance leaders

31%

30%

23%

16%

2% Information

leaders

Number of sites

Base = 111 (Health systems)

1–5 14%

6–20 34%

21+ 52%



Transforming primary care is a complex set of interrelated tasks with

a wide range of choices. It is important to remember that we have

many primary care practice types and no shortage of approaches to

transformation. As we try to sort out what to pursue and with how much

vigor, we should never lose sight of the objectives of primary care redesign.

The broadest objective is to improve patient health, of course. The

patient-health objective has two manifestations: First, we are fostering

relationships with patient populations so that patients use a combination

of self-awareness and visits to primary care practitioners to monitor

and maintain their health. Second, we are establishing relationships

throughout the care continuum so that patients have a ready path when

they have conditions that require skills or facilities their primary care team

cannot provide.

Both factors are fundamental to healthcare reform because, for instance,

closer contact between patients and the primary care team supports

efficient utilization of acute care facilities and EDs as well. Further, more

engagement by the population at large in their own healthcare will result

in a healthier population, a population that will use all healthcare services

in a more efficient way.

ANALYSIS

Staying Focused on the Objectives of Transformative Change MICHAEL ZEIS

Here are selected comments from leaders regarding the effect of their

organization’s primary care redesign in other initiatives.

“Awareness has increased regarding patient-centeredness, but clinical and

patient experience outcomes haven’t yet budged.”

—Chief medical information officer for a large health system

“Things are very fragmented within the organization, which is moving to

an institute model. We are unclear at this point how that will integrate

with population health management, which is presently a small pilot.”

—Vice president of compliance for a large health system

“We are rolling out clinically integrated networks in multiple markets as

a key alignment strategy with our large base of independent physicians.

We are cognizant that a robust base of PCPs is critical relative to patient

attribution, risk stratification, and care management necessary for

effective population health management and risk contracting.”

—Vice president of finance for a large health system

“We are trying to integrate the major practices in our community into

a patient-centered medical neighborhood that includes primary care,

specialists, and ancillary help such as home nursing, PT/OT, pharmacy, etc.”

—Chief medical officer for a medium hospital

“We are working with the population at large and the models/outcomes

that resulted are applicable to other ‘at-risk populations,’ with some

adjustments, such as working with the integration of the mentally ill with

serious behavioral health issues into a medical treatment environment.”

—CEO for a small hospital

WHAT HEALTHCARE LEADERS ARE SAYING



Analysis (continued)

The need to collaborate is understood. With 59% of respondents to the

HealthLeaders Media Primary Care Redesign Survey identifying improving

care coordination and collaboration as being among their top three

goals for primary care redesign, the industry appears to understand

the patient-centered mandate. Nearly three-quarters (70%) say their

collaboration is primarily with known partners. According to David

J. Shulkin, MD, vice president of Atlantic Health System, with 1,315

licensed beds across four hospitals and a children’s hospital in northern

New Jersey, “Primary care doctors understand the importance of

being part of a bigger system of care and having a relationship with an

integrated system.” Shulkin also serves as president of the Atlantic ACO

and president of Morristown (N.J.) Medical Center.

Coordination is important, and it’s not necessarily easy. Nearly half of

respondents (49%) include coordinating care with other providers among

their top primary care redesign challenges. Shulkin cautions, “This is

not a solo effort of a primary care doctor. Respondents clearly recognize

that in order to accomplish the redesign goals and the transformation of

healthcare, it can’t be done by them alone.”

John Saultz, MD, professor and chairman of the Department of Family

Medicine at Oregon Health & Science University—which between the

OHSU Hospital and the Doernbecher Children’s Hospital is licensed for

572 beds and operates four clinics in the Portland area—notes that care

coordination is more important now because primary care practices are

seeing fewer patients with minor

health issues and more patients

with chronic conditions.

“Today the majority of the people

we see no longer have acute care

problems, they have chronic

problems, for which a 15-minute

office visit is badly designed,”

Saultz says. “Seeing a diabetic

who’s depressed and has chest

pain is a much more complicated

visit. It’s going to require not

just the ability to assess that problem in the office, but to empower the

patient to engage in checking their blood sugars, eating differently,

losing weight, and doing a bunch of other things.”

Patient engagement. The patient is a bit of a wild card in primary care

redesign. Nearly two-thirds of healthcare leaders (59%) acknowledge

that fostering patient engagement in their own care is a top challenge.

To that end, 78% include nurse phone calls among the most effective

tactics to address patient engagement in their own healthcare (making

it the only response to exceed the 40% threshold). While only 25% of

respondents include email or text messages among their most effective

tools in patient engagement, Shulkin, lead advisor for this Intelligence

“Primary care doctors understand the importance of being part of a bigger system of care and having a relationship with an integrated system.”

—David Shulkin, MD




Report, acknowledges the potential that alternatives to direct one-on-

one contact can offer. “As the economic pressures continue to mount

in healthcare, we’re going to be looking for technology as a way to make

the process more efficient,” he says. “Many of today’s patients, a group

that’s relatively older, prefer having face-to-face or phone contact. As

the younger generation that grew up with electronic communication

enters the healthcare system in larger numbers, we’re going to see more

electronic outreach.”

Technology and new staff assignments can support the mechanics of

patient engagement, but the concept has to be accepted and supported

by the physician as leader of the care team. Report advisor Saultz says,

“Now that we’re trying to get good at caring for people who aren’t in the

office, that requires outreach methods and a whole set of behaviors not

only on the part of the physician, but also on the part of the whole team,

really, in order to get it to work.”

Who is paying for this? The financial underpinnings of primary care

redesign are being established. Nearly two-thirds (61%) are in payer

relationships that reward performance related to aspects of primary

care redesign. An additional one-quarter (25%) are in discussions with

payers to set up such relationships. Many of the funding mechanisms

are not new because primary care transformation activity is decades old,

at least. Many practices are moving forward with primary care redesign

because they participate in the Centers for Medicare & Medicaid Services’

relatively new Medicare Shared

Savings Program for ACOs, which

went into effect January 1, 2012.

The program links shared savings

or losses to quality performance

and the delivery of coordinated

and patient-centered care. Among

other things, CMS expects

participants to invest in the

workforce and the provision of

team-based care.

In an academic environment,

much of OHSU’s primary care practice transformation work has been

funded by grants and participation in pilot programs with payers. Now

OHSU’s Saultz is trying to institute sustainable business models instead.

“It requires more than just grants to study practice transformation,” he

says. “You actually have to have a business model. If the health system

invests $1 million in my practice, what am I going to produce in return

that will make their investment worthwhile? That depends on what the

ongoing business model is. Otherwise, it’s just going to be a question of

how much are we willing to lose in order to do primary care well.”

Although many are strengthening their relationships with payers and

working successfully toward primary care transformation, Saultz has

“Today the majority of the people we see no longer have acute care problems, they have chronic problems, for which a 15-minute office visit is badly designed.”

—John Saultz, MD




experienced difficulty as he pursues revenue streams other than grants.

“Payers have been shockingly unwilling to be helpful,” he says. “They

are perfectly happy to encourage us, they are excellent cheerleaders, but

they are of little use to the collaborative process.” (Saultz concedes that

virtually his entire base of experience is in Oregon, and that those in

other regions may have different experiences.)

One survey respondent reports that her multi-specialty medical practice

is collaborating with its local hospital on population health through an

occupational health program, “working with industry, rather than the

insurance companies.” Despite such provider-payer friction, Shulkin

is optimistic when he sees that 61% have some form of performance-

related practice redesign relationships with payers, but admits that there

is progress still to be made. “Relationships and collaborations with the

payers are paramount to success here, but there’s still a way to go in

developing these relationships,” he says. “But without a mechanism for

paying for quality, progress toward primary care redesign is going to be

much slower.”

Physician compensation. Care metrics (85%) and financial metrics (57%)

lead the list of measures taken to address physician compensation. “What

these two have in common is being paid for performance and paid based

upon value,” Shulkin says. Incentives based on care metrics and financial

parameters are common today. Compensation actions such as reduction

of RVU requirements (15%) and removal of volume incentives in favor of

salary (also 15%) are selected less

frequently, which is an indication

that, as with the industry overall,

finances in primary care still

are steeped in fee-for-service

payments. According to A. John

Blair III, MD, FACS, president of

Taconic Independent Physician

Association in Fishkill, N.Y.,

which has 5,000 physicians,

including 1,600 primary care

physicians, “we’re living with a

structure that came into place in

the 1960s, has evolved from that,

and everybody has built to that. They’re not going to let go of that piece

of it easily.”

Redesign investments. Two-thirds of respondents (67%) say that they

expect to invest in coordinated care across the continuum over the

next three years. With half (49%) identifying care coordination as a top

primary care redesign challenge, a substantial portion recognizes that

delivering coordinated care takes some effort. More than half (57%)

expect to invest in programs to improve patient access to care. Tracking

provider performance (62%) and tracking patients via EHRs (51%) are top

“We’re living with a structure that came into place in the 1960s, has evolved from that, and everybody has built to that. They’re not going to let go of that piece of it easily.”

—A. John Blair III, MD, FACS




IT investments related to primary care.

Considering that equal percentages of respondents identify clinical

quality and patient volume as primary care redesign goals (39% each),

Shulkin suggests that the industry has a “dual strategy of maintaining

life in the current system while preparing for the future system.” To move

primary care practices forward on both fronts concurrently will require

IT support.

“In order to be successful in clinical and economic accountability,”

Shulkin continues, “you’re going to need information systems that are

able to measure and track provider performance. While it may not always

be comfortable to be tracked and accountable for your performance, this

is where our investments need to be. If you’re going to have a payment

system, you need to have the ability to measure it and know where you’re

going to be able to improve.”

Redesign goals. As mentioned above, improving care coordination

was mentioned most frequently as a top primary care goal. After care

coordination, five items fall within a few percentage points of each other

as top goals: healthcare leaders want to increase patient volume (39%),

improve clinical quality (39%), improve access to care (35%), increase

market share (34%), and improve utilization of resources (33%). That’s

a daunting task list, which, Shulkin observes, “demonstrates how

much is being asked of primary care doctors. It’s not as if we’re asking

them to do one thing, like lower

costs. They must take a multi-

faceted approach to change and

redesign.”

We can see that practice

transformation places demands

on primary care physicians. They

have to drive the transformation

of primary care, but nearly half of respondents (45%) say that they lack

the time to do so. And new skills are needed, as well. More than one-

third (37%) include the lack of change management skills among the top

primary care challenges.

“We can’t train family doctors the way in which we used to train family

doctors and expect them to be facile in this new system,” Saultz says.

“They have to be more capable of using data to improve their practices,

and have to be ready to participate in and lead interdisciplinary teams.

On top of that, there is the complexity of taking responsibility for the

care of a population of patients. Traditionally, our training has been

about the patient that’s in front of us. We did not think that it was the

doctor’s problem if a sick person didn’t come to the doctor.”

What about motivation? Nearly half (47%) say that motivation to change

represents a top challenge. Shulkin says motivation has three facets. “Are

“It’s going to take years to see results in terms of healthcare value.”

—Holly Miller, MD, MBA, FHIMSS



the financial incentives in place today to cause me to change?” he asks.

“Are there personal dissatisfiers in my current practice that [drive] me to

change? Finally, what’s my life situation? If I’m close to retirement, do I

really want to change?”

Holly Miller, MD, MBA, FHIMSS, medical director at Taconic IPA and a

report advisor, says that early results from primary care redesign efforts

will lay the groundwork for future progress. “It’s going to take years to

see results in terms of healthcare value,” she says. “We need to improve

quality and control costs so that we’re delivering better value. If the

programs that are underway now succeed—programs where payers have

contributed and have partnered—then more will follow. I am optimistic

that these programs will prove that with practice transformation, patient

engagement, and all of the other things that are involved, we will start to

see great improvements in healthcare value.”

The steps toward providing a robust primary care foundation that

fosters healthcare reform are difficult because at virtually every turn,

one finds that the old way of delivering primary care needs enhancement

or overhaul. Generally speaking, primary care redesign means moving

toward a more collaborative environment, working as a member of a care

team, and supporting patients as they become more aware and more

responsible for their own health status.

Because primary care practices

must move toward delivering

value-based care while the

industry’s business models are

still largely based on performing

procedures for a fee, funding

mechanisms still are uncertain.

That means that investments

must be made in an environment

of uncertainty. But uncertainty

should not be used as an excuse

to delay, because practices that

are not involved in activities

such as establishing strong working relationships throughout the care

continuum, developing a system of team-based care, and supporting

their patients in their efforts to become more aware of their own health

status may find that the industry moves forward without them.

Michael Zeis is research analyst for HealthLeaders Media.

He may be contacted at [email protected].


“As the economic pressures continue to mount in healthcare, we’re going to be looking for technology as a way to make the process more efficient.”

—John Saultz, MD



CASE STUDY 1

Practice Transformation: Integrating Improvement and Payment

The current effort to

redesign the primary care

delivery system to improve

patient access and outcomes

depends in large part on

aligning payment and

clinical improvement to

engage physicians in practice

transformation, including the

use of EHRs, collecting quality

metrics, and coordinating care.

And to effectively engage

physicians in that

transformation, making

the connection between

improvement and payment

needs to be direct and timely,

says David J. Shulkin, MD,

vice president of Atlantic

Health System, president of

Morristown Medical Center, and president of Atlantic Accountable

Care Organization.

That’s why the Atlantic ACO has a program to correct what Shulkin

calls “an imperfection in the design of the ACO payments portion”

in the Centers for Medicare & Medicaid Services’ Medicare Shared

Savings Program. In April 2012, Atlantic ACO was among the first

ACOs selected to participate in the MSSP, which seeks to bring about

practice transformation by tying provider reimbursements to quality

metrics and patient outcomes. Shulkin explains that the way the

MSSP is designed, physicians are expected to meet certain quality

metrics and patient outcomes each year but under MSSP rules CMS

makes no distribution of shared savings payments for at least 21

months.

He likens the rule to offering your child an allowance for keeping his

room clean today and promising to pay the allowance when he turns

16. “Let’s say we’re successful and we’re going to get $2 million in

MSSP payments down the road. Asking doctors to wait 21 months to

see a penny of that money is not a great strategy for getting doctors

engaged and involved” in practice transformation.

ATLANTIC ACCOUNTABLE CARE ORGANIZATIONAtlantic Accountable Care Organization is a joint venture of Atlantic Health System (a Morristown, N.J.–based system with 1,315 licensed beds across four hospitals and a children’s hospital) and Valley Health System (a Ridgewood, N.J.–based system with a 451-licensed-bed hospital, a medical group with nearly 200 physicians, and a homecare unit). The ACO comprises 1,500 physicians who provide care for 100,000 patients in Bergen, Morris, Somerset, Sussex, and Union counties in northern New Jersey.



Case Study 1 (continued)

Instead, Atlantic ACO offers its primary care physicians an advance

payment on future MSSP awards. The incentives that are the basis for

the quarterly advance payments more or less track MSSP requirements,

but also target the physician behaviors critical to changing the way

they deliver patient care within the Atlantic ACO, including the use of

technology, participating in disease registries, and practicing preventive

and coordinated care.

For example, Atlantic ACO wants its primary care physicians to use its

physician portal. Last year as part of the advance payment program it

began to require the physicians to simply get a password, sign on, and

get familiar with the portal. Now that the organization knows how many

doctors are using the portal and how often they’re using it, Shulkin says

the ACO has refined the requirement to include using the portal as a

patient management tool.

Shulkin notes that the physicians must demonstrate the behaviors before

qualifying for an advance payment. The advance isn’t based on financial

results. He says physicians understand that the quarterly payments are

an advance on the shared savings and there will be a future accounting

for the physicians based on the payment advances and the actual shared

savings payments received from CMS.

The advance is a per-member per-month calculation based on

attributed Medicare beneficiaries as well as physician performance

on several measures, including quality and outcomes improvement,

and participation in educational sessions on practice transformation.

Performance is reassessed each quarter, and the advance payments may

shift up or down.

Part of the 2013 program included having depression and active falls

screening tools in place, as well as patient satisfaction surveys. Shulkin

says at the start only a minority of practices had those items in place,

so the total of all quarterly advance payments for the program was less

than $100,000 at the beginning of the year. As doctors began to learn

from one another and share tools and information, the total quarterly

payments for the program increased to several hundred thousand dollars

by the end of the year. About 400 primary care physicians with attributed

patients participate, although not all of them have qualified for advance

payments.

As noted, the physicians are expected to meet the requirements of the

MSSP, including lowering the cost of care. Shulkin says there isn’t

enough information available now to fully assess how well physicians

are performing on MSSP targets. He says on the quality side the ACO

did meet the year one requirement of being able to measure and collect

quality metrics, and is now in the second year of data collection. On the

cost savings side, the ACO still doesn’t have data that is complete enough

to make an assessment of where it stands on shared savings.




LESSONS LEARNED:

• Approach the board. The Atlantic ACO’s board was receptive to

the idea of funding the payment advance in part because its initial

approval of participation in an ACO had already demonstrated

commitment to healthcare reform and practice transformation.

Shulkin says that recommendations for payment advances on

future MSSP rewards may receive a better reception if a practice-

transformation rationale is presented instead of a financial

rationalization.

• Physician governance. Shulkin says Atlantic ACO developed the

advance payment program to “make sure our physicians were fully

engaged and participating in the transformation of healthcare.”

He notes that the process has been “physician-led and physician-

developed” from the beginning. It was the physicians who identified

the most important behaviors to change to transform a physician

practice. He says it takes hours and hours of dialogue and debate to

identify the most meaningful changes. It’s a process that couldn’t

be dictated by administrators. It must be endorsed by the physician

structure of the ACO.

• Embrace refinement. Shulkin says the primary care practices moved

quickly in the first year to collect quality data. Rather than continue

to incentivize simply collecting the data, the ACO added outcome

improvement the next year in three specific areas—congestive heart

failure, diabetes, and renal care.

• Name a practice leader. Atlantic ACO requires each primary care

practice to designate a lead for office transformation. The ACO

works with the lead to facilitate the behavioral changes, including

proactively reaching out to patients instead of waiting for them to

call the office and using claims data to identify care coordination

opportunities. Depending on the practice, that role may be filled by a

physician or a nonphysician.

Shulkin says Atlantic ACO’s advance payment program is important

because it is identifying successful ways to accelerate practice

transformation. “In many ways this is trial and error. If something

doesn’t work, we’ll drop it. If it is successful, then we’ll give it more

of a focus. It’s primary care redesign on steroids—a constant learning

experiment that we’re fine tuning as we go.”

—Margaret Dick Tocknell



The redesign of primary care

presents an opportunity to co-

ordinate care between primary

care and behavioral health pro-

fessionals. While the healthcare

delivery system has long main-

tained a separation between the

two disciplines, the result has

meant that the family physician

has been left to deliver care for

sophisticated behavioral and

mental health issues, such as at-

tention deficit disorders in chil-

dren and depression in adults.

But delivering behavioral healthcare in the primary care setting has

proven to be a “challenging time drain on the primary care delivery

system,” says John Saultz, MD, a family physician, professor, and chair

of family medicine at Oregon Health & Science University in Portland.

“It takes longer to see a patient with behavioral health issues, and

there are times when a patient’s poorly controlled mental health prob-

lems are huge drivers of the inability to manage physical illness.”

Saultz offers this scenario: He walks into a typical 15-minute patient

appointment expecting to treat the headaches of a patient with high

blood pressure and instead encounters a patient experiencing an acute

life crisis that can’t be addressed in a quarter-hour appointment. He

performs a crisis intervention assessment that could include anything

from medication and follow-up visits to an immediate referral to an

emergency department or to a psychiatric inpatient facility. It might

include an immediate consultation with a mental health provider,

“but I would be arranging a plan and talking to the patient about it.”

About five years ago, OHSU began to study colocating behavioral and

physical health services at its family medicine clinic in the Richmond

area of Portland. The Richmond clinic is a federally qualified health

center where, Saultz says, 70% of the patient visits are either Medicaid

or uninsured, and another 20% are Medicare. “We got consistent and

generous support from our local Medicaid HMO, which has a pool of

dollars for innovation grants.” The project also received federal grants

to cover alcohol and drug screening.

OREGON HEALTH & SCIENCE UNIVERSITYPortland-based Oregon Health & Science University is an academic health center. It includes the 544-bed OHSU Hospital, Doernbecher Children’s Hospital, more than 200 community outreach programs, and four community medical practices.

CASE STUDY 2

A Model for Colocating Primary Care and Behavioral Health Providers




Warm handoff. Today at the Richmond clinic, instead of devoting primary

care time to a patient who is in the midst of a life crisis, the physician is

able to walk down the hall to immediately call in a mental health profes-

sional to take the visit over. To ensure such availability, there are walk-in

slots built into the appointment schedules of the mental health provider,

just as they are in the primary care schedules.

“Then I go to the next exam room and see my next patient,” says Saultz.

“I’m able to move through my day without hour-long delays for everybody

else in the middle of my schedule. The patient in this model actually gets

better care. I’m not risking sending them to another provider in another

building where, with these types of referrals, there’s a high likelihood the

patient won’t show up. Here the teams work together.”

Follow-up visits for both behavioral health and primary care also take

place at the clinic. Saultz says “it’s transformative to the primary care sys-

tem to practice this way. We’re identifying people in crisis before it leads to

really big expenses.” Still, he freely admits that sustaining the colocation

of primary and behavioral healthcare requires more than just grants. “You

have to have a business model to support it.”

Funding. One of the ways OHSU has avoided substantial salary costs is by

using doctoral students to provide the mental health services in much the

same way that family medicine residents are used for primary care in the

clinic. A partnering agreement with the psychology department at a local

university provides postdoctoral interns and doctoral students for the

program. Social workers were also included in the program.

About a year ago, the decision was made to forgo grants and instead

negotiate with Medicaid to shift from fee-for-service to a per-member-per-

month payment model for providing the integrated services to the Med-

icaid population at the Richmond clinic. It was a rancorous process—in-

cluding at one point a threat by Saultz to shut down the behavioral health

portion of the program—but by October 1, 2013, a deal was in place for

capitated monthly payments.

It’s a “ballpark calculation,” says Saultz, and is based in part on salaries,

the relative value units of services provided, the number of patients, and

the number of patient visits. “Now we need to right-size the service for

what we’re being paid. At some point you have to make adjustments, and

we’ve tried to be kind of hard-nosed about this.”

Beyond the Richmond clinic. Saultz says OHSU wants to expand the co-

location model into its other clinics, which will involve negotiating a pay-

ment model with commercial payers. While there are some mental health

patients at other clinics, “it’s nothing on the scale of” the mostly Medicaid

and uninsured group at the Richmond clinic.




In the meantime, OHSU has created a primary care presence in an existing

mental health clinic run by Cascadia Behavioral Health Services, a non-

profit provider of mental health services. The walk-in clinic is located a few

blocks from the Richmond clinic. Saultz says the patients there have rather

severe chronic mental illness, and many lacked access to good primary

care. The clinic can enroll patients in the Richmond clinic for continuity of

primary care.

Saultz is cautious but hopeful for the colocation of primary care and be-

havioral health outside of the academic medical center model. His advice

for private practices interested in colocation is to approach a local mental

health facility and propose a joint hire, bringing in a mental or behavioral

health professional who would work part-time for the mental health clinic

and part-time for the physician practice. “That way there could be warm

handoffs at least half the time and the [primary care physician] can have

the follow-up visits happening down the road. But it’s risky because if a

practice can’t recoup the money, they are essentially paying for this out of

their own pocket.”

Saultz indicates that payers have yet to be convinced of the value, but he

says “now that I’ve piloted it, I’ve showed that it works and I’ve showed

what it costs. It ought to be something that can be replicated if we can get

the payers to want to export it.”

He says most primary care and mental health professionals believe that if

they increase by 30% or 40% the funding they’re putting into primary care,

including care coordination and mental health competencies, that the

lowering emergency department visits and hospitalizations would save the

health plan more money than it spends on reimbursements.

Although Saultz has no data to share, he indicates that the clinic’s pa-

tients have experienced lower hospitalization rates and the clinic has had

improved throughput. “The family doctors are more productive because

they’re not having their clinic blown up by the extra time that behavioral

health patients need,” he says. “The family doctors, the staff of the clinic,

and the mental health providers are happy. The satisfaction of our delivery

team is better.”




CASE STUDY 3

Taconic IPA, a 5,000-mem-

ber independent physician

association in Fishkill, N.Y.,

was an early adopter of the

patient-centered medical

home model. The effort was

successful in terms of deliver-

ing office-based medical care,

but within the IPA there was

a sense that a more proactive

approach was necessary to

help patients manage their

healthcare in terms of following doctors’ orders. Data indicated

that some practices were not performing well on some of the

markers of a PCMH, such as immunization rates, breast cancer

screenings, and colonoscopies.

The IPA began to examine what actions it would need to take to posi-

tion its PCMHs to produce results similar to those coming from the

successful PCMHs at Geisinger Health System.

Of course, as an IPA—with 5,000 independent physicians at 1,537

sites in New York’s greater Hudson Valley—Taconic is far from

Geisinger’s integrated health system structure. Another challenge:

The disparate EHR systems used by its physician practices compli-

cates the exchange of data.

The idea that “we are an open community is something we struggled

with,” says A. John Blair III, MD, FACS, the president of Taconic IPA.

While some foundational work was in place, how could the IPA con-

tinue to innovate—to move the needle—for patient care without the

advantages of system integration?

In July 2011, Taconic launched a pilot project to test that very ques-

tion. Case managers were embedded in seven physician offices that

had already achieved NCQA level 3 PCMH status. The two-year pilot,

modeled after a program at Geisinger, provided training and sup-

port, and focused on providing embedded case managers to coordi-

nate care for adults with chronic, complex medical conditions.

Registered nurses were designated as case managers primarily be-

cause of the job responsibilities, including conducting comprehen-

sive patient assessments and patient education, developing individu-

alized care plans, and coordinating patient care across care settings.

TACONIC IPATaconic Independent Practice Association is an independent physician association based in Fishkill, N.Y. It has 5,000 physicians, including about 1,600 primary care physicians, at 1,537 sites in New York’s greater Hudson Valley.

Developing a Track Record for Value-Based Reimbursement




Each case manager was assigned 125 complex patients, with a target ratio

of one case manager for 10 primary care physicians.

Taconic looked for experienced, certified case managers—typically with

five years at a health plan and 10 years of clinical experience in a practice

setting. Blair says “the real lift” was taking good case managers who did

standard case management for a health plan, often working remotely,

and making sure they were compatible in the ambulatory setting. The

participating physician practices were selected based on having achieved

NCQA level 3 PCMH recognition.

Taconic also had to make the financial pieces fit together. It helped that

the IPA had a 10-year history of working with commercial payers in the

area on a number of other incentive programs, including developing and

providing incentives for electronic prescribing and EHR usage, as well as

for physician practices that achieved NCQA level 3 PCMH recognition.

Payers were interested in the embedded case manager pilot because they

wanted to see if case managers could add additional value for the physi-

cian practices that achieved that NCQA recognition.

Taconic structured the pilot so the case managers were IPA employees;

participating physician practices paid for the case managers. Physicians

who had relationships with several payers preferred having IPA-employed

case managers instead of payer-employed case managers, because it

enabled the practice to develop a relationship with a single case manager

instead of a revolving team of case managers.

As an extra incentive, Blair says the health plans selected the members

they wanted to participate in the pilot. It was seen as a benefit for the

health plans, which had their sickest (and costliest) patients in the pilot,

and for the physicians, who were often able to increase their reimburse-

ments by improving outcomes for their chronically ill patients. The

health plans directly paid the practices for patient services based on their

existing contracts.

Because the pilot included many small practices, statistically valid out-

comes from the completed pilot are not yet available. However, Blair says

some health plans have reported declines in 30-day readmissions that can

be attributed to the case managers.

Still, there is enough anecdotal evidence of success that Taconic has ex-

panded the program to 10 case managers; more physician practices—both

inside and outside the IPA—have signed up for embedded case managers;

and health plans continue to participate.

Taconic IPA is also among 500 primary care practices participating in

the comprehensive primary care initiative pilot offered by the Centers for

Medicare & Medicaid Services. The pilot, which involves 2,347 providers

and 315,000 Medicare beneficiaries, is expected to produce statistically

valid evidence that will support the use of case managers.

Taconic has made some changes in the original pilot program. Case

manager training, for instance, has expanded from 10 weeks to 12,




including a month of classroom and online lessons that cover regulatory

and contracting requirements among other topics, plus one month of

on-site training at a physician practice well-versed in the work of the case

managers. After the RN is assigned to a physician practice, the mentor-

ing and supervision, as well as EHR and workflow training, continue for

another month.

EHR training is critical. Blair says the embedded case managers probably

work on one or more of a half dozen different EHR systems. Taconic ar-

ranges for the RNs to receive the requisite amount of training to be certi-

fied on a practice’s system. “That’s one of the tougher things for the case

managers that work at two sites—they may have to learn two systems.”

In addition, Taconic has modified the standard intake template from

Geisinger so it can be used by the RNs at whatever physician practice they

are assigned to.

Blair says case managers really need to be placed in advanced medical

homes—whether that is the NCQA level 3 recognition or something else—

because “leadership transformation, the cultural transformation, and all

of those pieces are a big deal. You can’t underestimate the transformation

effort. Embedded case managers are supposed to be taking care of high-

cost, high-risk, complex patients. If you put them in a practice that’s not

ready, their expertise will be not utilized.”

Still, he says, the Taconic pilot does hold promise for less integrated

programs. “But it’s tough because you’ve got a technology piece to this, a

transformation piece, and you’ve got a reimbursement redesign piece. If

you’re in an integrated delivery network where a lot of care settings are all

brought together under one roof, particularly if you’ve got a health plan

there, it gets easier to do those three things. When you walk out into a

community where you’ve got ambulatory, inpatient, long-term care, and

10 plans in a region, I mean, it’s tough. I think it’s easier today than it was

10 or 15 years ago, but those are the pieces that you’ve got to figure out.”

Participating in Taconic’s pilot were practices ranging in size from solo

practitioners to 300-physician groups. Blair says that the solo practices

and smaller group practices “are making it, but they have to put in a

tremendous amount of work” in primary care transformational efforts.

However, recognizing the high selection parameters for participation in

the case manager program, Blair says, “If they were to start now doing

what they’ve been doing the last 10 years to get where they are, I don’t

think they possibly could make it.”




Click on these icons to dig deeper.

FIGURE 1 | Goals for Primary Care Redesign Next Three Years

Q | What are the top three goals for your primary care redesign efforts over the next three years?




FIGURE 2 | Clinical Challenges of Primary Care Redesign

Q | What are the top three most challenging clinical components of primary care redesign for your organization? (Among those with primary care redesign underway or expected.)




FIGURE 3 | Business Challenges of Primary Care Redesign

Q | What are the top three most challenging management or business components of primary care redesign for your organization? (Among those with primary care redesign underway or expected.)




FIGURE 4 | Addressing Physician Compensation in Primary Care Redesign

Q | Has your organization’s primary care redesign effort addressed physician compensation? (Among those with primary care redesign underway or expected.)




FIGURE 5 | Physician Compensation Measures Used or Planned

Q | Which of the following have been done or are planned to address physician compensation? (Among those with primary care redesign underway or expected and primary care redesign addresses physician compensation.)




FIGURE 6 | Primary Care Redesign Investments Next Three Years

Q | What elements of primary care redesign will your organization invest time and/or resources in over the next three years? (Among those with primary care redesign underway or expected and investing time/resources over next three years.)




FIGURE 7 | Primary Care Redesign IT Investments Next Three Years

Q | What are the top three IT investments or developments your organization expects to make over the next three years to support primary care redesign? (Among those with primary care redesign underway or expected and planning to make IT investments.)




FIGURE 8 | Most Effective Efforts at Engaging Patients

Q | What are the top three efforts you have found to be most effective at engaging patients in their own healthcare?




FIGURE 9 | Involvement With Patient-Centered Medical Home Recognition or Accreditation Programs

Q | Are you involved with any of the following patient-centered medical home recognition or accreditation programs? (Among those involved.)




FIGURE 10 | Relationship With Payers Regarding Primary Care Redesign

Q | Please describe your organization’s relationship with payers regarding primary care redesign.




FIGURE 11 | Outreach for Primary Care Redesign With Known Partners

Q | Is your organization’s outreach for primary care redesign principally with known partners such as physician hospital organiza-tions, managed care organizations, ACOs, employed physician groups, or clinics? (Among those with primary care redesign underway or expected.)




FIGURE 12 | Extending Primary Care Redesign Beyond Known Partners

Q | What is your organization’s status regarding extending primary care redesign beyond known partners such as physician hospital organizations, managed care organizations, ACOs, employed physician groups, or clinics? (Among those with primary care redesign underway or expected and participating in outreach with known partners.)




FIGURE 13 | Regular Standing Primary Care Team

Q | Which of the following are or will have an essential role as part of your regular standing primary care team?




FIGURE 14 | On-Call or As-Needed Primary Care Team

Q | Which of the following are or will have a secondary role as part of your primary care team, serving in an on-call or as-needed capacity?



Primary care redesign is not one thing for one organization. Many

find that population health, integrated care delivery, and primary care

redesign are part of their work toward becoming more efficient and

more patient-focused. In addition, an organization’s efforts cannot be

done in isolation; collaboration is essential. The director of quality at

a hospital told us, “We cannot effectively achieve any of these efforts

independently.”

Outreach? Small steps may be better than big moves. Patient outreach is

important. Something to remember as we review our outreach programs

is that organizations that are really good at marketing take the approach

that they will sell to their customers using whatever methods their

customers would like to use to purchase. Being patient-centered means

keeping such a perspective in mind when establishing or enhancing

patient outreach programs. Yes, it’s marketing, and if the outreach is

headed in the right direction, at least some of it will be new to most

organizations. But because organizations might not be used to spending

their resources this way, outreach efforts should be made in a stepwise

fashion, with frequent measures of effectiveness and efficiency, followed

up with decisions about whether and in what fashion to proceed. In other

words, expect to spend time and money on patient outreach, but don’t let

difficulty calculating a return on investment keep you from developing

this important infrastructure.

Collaboration for the solo practice. There are reasons for staying in

solo practice, but those who do may find that the investments required

to be a full participant in population health initiatives and healthcare

reform threaten the practice’s viability. In addition, those who shun

collaboration will not have other collaborators to learn from, and there is

a lot to learn.

Primary care practices need collaborators. Survey results tell us that

care coordination and outreach are top primary care redesign goals.

While business models at the practice level are very much in flux

(that is, without a clear view of a revenue stream to support practice

transformation activity), hospitals and health systems are positioning

for change by acquiring practices, participating in ACOs, and creating

integrated healthcare delivery models. As a report advisor observes, those

in private practice are fully aware of the new drive toward collaboration,

Recommendations

HealthLeaders Media Research Analyst Michael Zeis draws on the data, insights, and analysis from this report:



and are forming allegiances that will help them make the transition.

Primary care practices without such relationships may find it difficult to

provide the team care that is fundamental to primary care redesign, may

struggle to make infrastructure changes such as working with EHRs and

monitoring quality and productivity, and may not have the resources

to invest in transformation activities that come with what is now an

uncertain return.

Accreditation. Know your partners, and let your partners know you. If

you are a physician in private practice, participating in an accreditation

program such as the National Committee for Quality Assurance’s PCMH

accreditation program is a way of focusing transformation efforts and a

way for potential partners to understand what you have achieved. If you

are a hospital or health system, accreditation programs offer an objective

appraisal that a potential partner has developed an infrastructure and a

degree of expertise that will likely support practice transformation.

As ever, spend on IT. Collaborating on care requires the ability to

share electronic health records, monitor utilization, measure provider

efficiency, track quality across partners, and so on. Providers who are

not at parity with the IT capabilities of their partners will hinder their

collaborators.

Revenue is mostly fee-for-service today, but prepare to change. Respondents report that the most common primary care incentives from

payers today recognize quality performance. Trailing now but important

in the future are per-member per-month compensation schemes,

gainsharing, and at-risk partnerships. New payer relationships are

coming. The more experience one has with performance measures other

than volume, the better one’s negotiating position and performance

will be.

Recommendations (continued)



QUESTIONS FOR YOUR TEAM

meeting guideTo address primary care redesign issues, consider asking your leadership team these questions:

1. In practice redesign and healthcare reform, it appears that the industry will reward those who are clinically integrated. Are we establishing a set of relationships that will ensure that we are meeting those demands?

2. As we examine alternatives for delivering care and study new reim-bursement models, are we focusing as well on what patients value in healthcare?

3. The idea that there are benefits when patients are engaged in their own healthcare is not new. What is new for some is the need to act on that knowledge, and provide an outreach system that encourages and sup-ports patients in that activity. Are we prepared to make such investments, recognizing that some portion of our patient population will resist?

4. When we examine outreach techniques, are we enhancing and optimizing the tried and true person-to-person techniques at the same time that we are taking advantage of newer technology-based methods?

5. Of course we think of care coordinators and medical specialists as members of our care team, but we have to consider payers as collabora-tors, too. Can we be open-minded and look beyond our current working relationships with payers, relationships that may be largely financial in nature? As the industry moves beyond pilots and trials, the payer commu-nity must move as well because of the role it will continue to play as a key economic entity for both old and new business models.

6. A report advisor noted that physicians in primary care practice say that the expectation of higher compensation levels leads medical students to pursue medical specialties, while medical students themselves claim that compensation level is not a factor in their choices. At least for now, striv-ing for parity between primary care practice and specialty practice does

not seem to be a top issue: survey results show only 3% include recali-brating physician compensation as a top goal. Are we ready to consider physician compensation as a secondary issue, and let the care-provision motivations that bring individuals to medicine in the first place take precedence for now?

7. As we approach primary care physician compensation and incentive is-sues, do we recognize that the inevitability of the switch to value-based compensation means we must eventually de-emphasize RVUs and other volume-based incentives in favor of incentives that are based on, for instance, clinical quality?

8. Do we fully understand the complexity and the relative importance of the physician shortage problem, which respondents place in the second tier of primary care transformation challenges? It’s more involved than merely tracking where physicians go after medical school. Increased ac-cess, team-based care, and patient engagement are just three factors that will affect utilization patterns, probably in ways that will lessen the ef-fects of primary care physician shortages. Yes, we need more primary care physicians, but healthcare reform should improve primary care provider efficiency, perhaps limiting the functional impact of the shortage.

9. We expect primary care physicians to lead their transformation efforts, but do we recognize that primary care physicians probably need the help of skilled advisors such as practice facilitators to help them with the busi-ness and logistical aspects of primary care transformation?

10. Do we recognize that primary care practices may need time and funds to develop the IT resources needed to support delivery of the patient-centered care that is to be the hallmark of transformed practices?

➔

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