New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS

Richard J. Baron

doi:10.1370/afm.1366

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Re: New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS
Simone R. de Bruin

Published on: 12 April 2012
How would you spend $200K for better care?
Christine Sinsky

Published on: 12 April 2012
** Comprehensive ** Primary Care
Charles M. Kilo

Published on: 16 March 2012

Published on: (12 April 2012)
Page navigation anchor for Re: New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS
Re: New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS
Simone R. de Bruin, Researcher
Other Contributors:
Thanks to Dr. Baron for providing an interesting description of innovative US payment and service delivery models in primary care. Also in the Netherlands, new payment (e.g. bundled payment) and care delivery models (e.g. disease management programs) are employed to improve quality and continuity of (chronic) care in an effort to improve value and control growth in health care costs.
An example of a nationwide i...
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Thanks to Dr. Baron for providing an interesting description of innovative US payment and service delivery models in primary care. Also in the Netherlands, new payment (e.g. bundled payment) and care delivery models (e.g. disease management programs) are employed to improve quality and continuity of (chronic) care in an effort to improve value and control growth in health care costs.
An example of a nationwide implemented payment and delivery reform within primary care is a bundled payment system for integrated chronic care. In 2007, the Dutch minister of health approved this system, initially on an experimental basis with a focus on diabetes. Under this system, health insurers pay a single fee per patient to a principal contracting entity, the so-called "care group", to cover a full range of chronic disease services. Care groups assume both clinical and financial responsibility for all assigned patients. Care groups either deliver the various components of care itself or subcontract other healthcare providers. Under this model, the care group becomes responsible for the coordination and collaboration between care providers. The price for the bundle of services is freely negotiated and the fees for subcontracted care providers are similarly freely negotiated by the care group and providers. A detailed description of the basic premises of bundled payment can be found elsewhere [1, 2]. In 2010, the bundled payment concept was approved for nationwide implementation for diabetes, chronic obstructive pulmonary disease, and vascular risk management.
After 4 years of experience with bundled payments in the Netherlands it is, however, yet too early to draw firm conclusions regarding its effects on the quality of care and overall costs of care. This also holds for other innovative payment reforms (e.g. pay-for-performance) and care delivery models (e.g. disease management) in primary care that have worldwide been introduced [3-8]. Even more than a decade after their introduction, evidence for the effectiveness of these payment and care delivery models is still scarce or inconclusive. We therefore fully endorse the efforts of the Center for Medicare and Medicaid Innovation (Innovation Center) to rigorously evaluate new payment and delivery models before upscaling them. We would specifically like to encourage the Innovation Center to contribute to the development of methods to evaluate these complex models within the real life setting. Most models are multifaceted which makes it difficult to disentangle the single effects of payment reforms and care delivery reforms, and to determine to which specific components potential benefits can be attributed. Drawing conclusions regarding the effect of these models is further complicated by the interaction with contextual factors such as the characteristics of the health care system in which they are implemented. Only when these methodological issues are addressed in evaluations of models such as those tested in pilots of the Centers for Medicare and Medicaid Services, the US 'lessons learned' can be translated to and will be relevant for the rest of the world. In addition, the implementation process should be taken into account to gain insight into the barriers and facilitators for the implementation of these new models.
As Dr. Baron concludes, the rest of the world will be watching indeed. However, in the first place (at least in the Netherlands) to see how these pilots are being evaluated and which methodologies are being used since these insights are necessary to interpret the findings. Neglecting these methodological, contextual, and implementation issues will therefore be a missed opportunity.
[1]De Bakker DH, Struijs JN, Baan CA, Raams J, De Wildt JE, Vrijhoef HJM, Schut FT. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Affairs (Millwood) 2012 (doi: 10.1377/hlthaff.2011.0912).
[2]Struijs JN, Baan CA. Integrating care through bundled payments - Lessons from the Netherlands. New England Journal of Medicine 2011; 364:990-1.
[3]De Bruin SR, Baan CA, Struijs JN. Pay-for-performance in disease management: a systematic review of the literature. BMC Health Services Research 2011; 11:doi:10.1186/472-6963-11-272.
[4]De Bruin SR, Heijink R, Lemmens L, Struijs JN, Baan CA. Impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: a systematic review of the literature. Health Policy 2011; 101:105-21.
[5]Mattke S, Seid M, Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? American Journal of Managed Care 2007; 13:670-6.
[6]Ofman JJ, Badamgarav E, Henning JM, Knight K, Gano AD, Jr., Levan RK, Gur-Arie S, Richards MS, Hasselblad V, Weingarten SR. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. American Journal of Medicine 2004; 117:182- 92.
[7]Christianson JB, Leatherman S, Sutherland K. Lessons from evaluations of purchaser pay-for-performance programs: a review of the evidence. Medical Care Research and Review 2008; 65:5S-35S.
[8]Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: Effects, design choices, and context of pay- for-performance in health care. BMC Health Services Research 2010; 10:247.S
Competing interests: None declared
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Competing Interests: None declared.
Published on: (12 April 2012)
Page navigation anchor for How would you spend $200K for better care?
How would you spend $200K for better care?
Christine Sinsky, physician
The CMS Innovation Center's three primary care payment pilots provide an occasion to think big, and differently, about how, with more resources, we could deliver primary care better. What would you do with more practice revenue to increase quality and lower costs for your panel of patients?
How much additional revenue is under consideration? An increase in total practice revenue of 30-50% could mean an additional $...
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The CMS Innovation Center's three primary care payment pilots provide an occasion to think big, and differently, about how, with more resources, we could deliver primary care better. What would you do with more practice revenue to increase quality and lower costs for your panel of patients?
How much additional revenue is under consideration? An increase in total practice revenue of 30-50% could mean an additional $120-200,000. Let's dream big, and go with the higher number. For the 18 adult primary care providers in my organization that could mean $3.6 million additional annual reveue. What would we do with these additional resources?
In my imaginary budget I'd dedicate 2/3 of the enhanced primary care payment to strengthen teamwork and support non-visit based care at the individual practice level: hiring an extra nurse per physician, training staff, and paying physicians for non-visit based care ($140,000/practice.)
I would use the rest ($1.1 million for our 18 physicians) to build extended care teams of social worker, health coach, data manager; improve communication with the emergency room to reduce unnecessary imaging, reduce hospital admissions, and systematize follow-up in primary care; and incent primary care physicians to provide continuity to their own patients by seeing them in both the inpatient and outpatient settings.
Other physicians' imaginary budget will be different. If one starts with less clinical support, the choice may be to spend much of the additional revenue on nurses or MAs, including an after hours nurse advice line; or if needed, an EHR. Some physicians may determine that hospital management of their own patients isn't feasible because of time or cultural factors. But I imagine that most primary care physicians could develop effective ideas to improve quality while reducing cost.
Seventy-five practices across the country will have the opportunity to develop their own strategy for using increased practice revenues to deliver better primary care. If they are successful the rest of us may be able to get in the game.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (16 March 2012)
Page navigation anchor for ** Comprehensive ** Primary Care
** Comprehensive ** Primary Care
Charles M. Kilo, Chief Medical Officer
Primary care owes Dr. Baron a great deal of thanks, not just for his work at CMS/CMMI's Innovation Center, but for his longstanding work to advance primary care. While his patients sadly lost Dr. Baron as their physician, healthcare gained Dr. Baron's expertise and passion for quality when he joined CMMI. For instance, Dr. Baron has been central to creating the Comprehensive Primary Care Initaitive (CPCI).
Thos...
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Primary care owes Dr. Baron a great deal of thanks, not just for his work at CMS/CMMI's Innovation Center, but for his longstanding work to advance primary care. While his patients sadly lost Dr. Baron as their physician, healthcare gained Dr. Baron's expertise and passion for quality when he joined CMMI. For instance, Dr. Baron has been central to creating the Comprehensive Primary Care Initaitive (CPCI).
Those fortunate to be selected for the CPCI will undoubtedly want to implement the "Patient-Centered Medical Home", but experience tells us that those changes will be insufficient to drive the magnitude of sustainable performance improvement that our patients and communities need - substantially improved outcomes with controlled costs. Appropriately designed primary care should be able to remove 10-20% of the total costs of care, while maintaining or improving outcomes. Accomplishing this requires more than the changes proscribed in the PCMH - it requires a culture of truly comprehensive primary care - a deep belief system in comprehensiveness, and the medical practice system design to match. The concept may be intimidating to some while others may not understand the full implications of comprehensiveness, which doesn't mean the provision of excess care, but the provision of thorough, evidence-based-care.
With comprehensive care, thoughtful, trust-based relationships, and rapid access to the practice supplant a substantial amount of test ordering and specialist consultations. The comprehensive practice pulls care into itself, instead of allowing care to leak to less optimal locations such as urgent care and emergency departments in non-emergent situations. Comprehensiveness requires complete review of prior records for all new patients, justification of all medications a patient is taking, returning to suturing instead of using the ED, and other activities many primary care practices have long since given up.
That many in primary care have lost this attitude and these skills and habits has put the very foundation of primary care at risk. CMMI will be giving a selective few the chance to address this head on. The choice of the word "comprehensive" was not an accident - it is a signal for culture, attitude, and system design that primary care needs to achieve. Thanks to Dr. Baron and colleagues at CMMI for creating this opportunity and shining the light on comprehensiveness.
Competing interests: Board Member, TransforMED, LLC
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Competing Interests: None declared.