ALTERNATIVE PAYMENT MODELS IN DEPARTMENTS OF FAMILY MEDICINE: OUR JOURNEY TOWARD THE QUADRUPLE AIM

A combination of escalating costs of health care and an aging population with increased longevity and complexity is changing the environment of the patient office visit and how physicians are reimbursed for their services.

In 2008, Berwick et al presented the Triple Aim¹—improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. Since that time, the Affordable Care Act was passed and new models of health care delivery have evolved to redesign the delivery of health care to meet these goals.

Various alternative payment models include payment rewards to providers for delivering high-quality and cost-efficient care. A payment model founded on value-based care, the Accountable Care Organization (ACO), targets total population spending and was designed to provide incentives for physician groups or delivery systems to reduce per-capita spending and improve quality with the savings generally shared with the organization that employs the primary care physician. Medicare created the Medicare Shared Savings Program and the Advanced APMs, a subset, to allow practices to earn more rewards in exchange for taking on risk related to patient outcomes. Many practices have adopted the patient-centered medical home (PCMH) model with levels of recognition by NCQA and other review organizations. The PCMH model strives to establish long-term relations between patients and their primary care team from a population health standpoint. These models developed shared plans of care; coordination of care to include subspecialists and hospitals; and offer innovative access to services through improved scheduling and integration with community resources.

Recently, the Association of Departments of Family Medicine (ADFM) surveyed its membership to determine how academic family medicine departments are navigating through the changing environment. A large majority (87.6% of respondents) reported that their departments are involved in an alternative payment model. Among those with any alternative payment model involvement, Medicaid or Medicare ACOs are very common, with 67.4% and 56.5% respondents involved, respectively; though a significant number of departments (66.3%) are using the PCMH model with enhanced payment for either monthly care coordination or population-based payments in addition to fee-for-service payment received.

The survey results reported a shift within a majority of the family medicine departments from a fee-for-service or capitated arrangement to a value-based plan with only 2.2% of our surveyed members participating in a direct primary care model that consisted of fully capitated/per-member, per-month payment paid directly to the primary care practice by patients or their sponsors.

Utilizing a population health management approach is an imperative focus in order to decrease the overall cost of care while improving the quality of care delivered. A potential association of the additional work required to achieve the Triple Aim goals has been the increase in frequency of reported physician and staff burnout. Bodenheimer and Sinsky identified a fourth aim, The Quadruple Aim,² to address this concern. The Quadruple Aim focuses on areas to adjust the work life of the clinician and their staff and accentuates its importance in order to succeed in improving population health in any model. Since 2015, ADFM has provided continuous programming to assist its members to identify, address, and manage burnout in their departments and rekindle the joy of practice with their faculty and staff.

Other identified challenges encountered in implementing and sustaining these new practice models have included: (1) the ongoing investment in time, staff, providers, and multiple other personnel required to implement further change; (2) the increasing financial risk in order to be eligible for or to attain an incentive that is not guaranteed; (3) the variations between payer contracts around attribution, metric definition, and various logistics (data capture and integration of other supplemental data); (4) the continued rise in general operational expenses such as the costs for supplies, labor market, pharmaceuticals, information technology, etc, while working within a defined budget; and (5) the increasing out-of-pocket expenses for our patients to meet the recommended follow-up and quality gap metrics the model is required to fulfill.

As part of the strategic plan over the next 2 years, the membership of ADFM has expressed interest in opportunities to share best practices in health care delivery that advance the Quadruple Aim and to identify ways to implement population health strategies in patient care, research, and education that benefit their departments. ADFM has an ongoing webinar series to address some of these content areas (more at: http://www.adfm.org/MembersArea/Webinarsresources).

We invite all in the “family of family medicine” to join our upcoming webinar on Alternative Payment Models, featuring a panel of those who have been involved in the various models. This webinar will take place on December 13, 2018 at 12:00PM Eastern. Please register here: https://goo.gl/forms/DCkyxbmnmAxN4SCe2.

• © 2018 Annals of Family Medicine, Inc.