Contribution of the Transforming Clinical Practice Initiative in Advancing the Movement to Value-Based Care

TRANSFORMING THE HEALTH CARE DELIVERY SYSTEM THROUGH ALTERNATIVE PAYMENT MODELS

The articles in this supplement address a wide variety of practice and system transformation efforts that include the Transforming Clinical Practice Initiative (TCPI).¹ This editorial provides context about the ongoing TCPI model test to help readers understand the broader effort addressed by the quality improvement articles in this supplement.

To put patients first, the Centers for Medicare & Medicaid Services (CMS) is working in concert with partners in the private, public, and nonprofit sectors to transform the nation’s health care system so that it rewards value rather than volume, more closely aligning payment with the quality of care. One way to do this is through alternative payment models (APMs), payment approaches developed in partnership with the clinician community that provide added incentives for delivering high-quality and cost-efficient care.² These models can be designed to fit the need; an APM can be developed for a specific clinical condition, a care episode, or a population, as well as for a particular innovation in care delivery.

All APMs and payment reforms that seek to deliver better care at lower cost share a common pathway for success: clinicians, payers, and others in the health care system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of health care. Making operational changes will be viable and attractive only if new APMs and payment reforms are broadly adopted by a critical mass of payers. When clinicians encounter new payment strategies for one payer but not others, the incentive to change is weak. When payers align their efforts, the incentive to change is stronger, and the obstacles to change are reduced.

TCPI: A REVOLUTIONARY STEP IN DELIVERING HIGH-VALUE PERFORMANCE

To make the transformation to value-based care easier for providers, CMS launched the TCPI in 2015.¹ TCPI is one of the largest federal investments uniquely designed to provide technical assistance to clinician practices. It created a nationwide, collaborative, and peer-based learning network that facilitates large-scale practice transformation designed to prepare practices to successfully participate in value-based payment arrangements.

TCPI was designed to support more than 140,000 clinicians (both primary care and specialty care) who were not participating in a value-based payment arrangement, over a 4-year period in sharing, adapting, and further developing their comprehensive quality improvement strategies. It is one part of a nationwide strategy to strengthen the quality of patient care and spend health care dollars more wisely.

Delivering value calls for a health care delivery system that is able to provide the right care at the right time at reasonable costs. TCPI prepares practices for success in APMs in 8 areas; the first 5 pertain to achieving outcomes to demonstrate model success, while the last 3 pertain to implementing improvements critical to practice success:

1. Attaining benchmark performance levels on health outcomes and clinical processes,

2. Avoiding unnecessary use of hospitals and emergency departments,

3. Avoiding unnecessary tests and procedures,

4. Lowering total cost of care and producing cost savings for payers,

5. Benchmarking results on patient experience,

6. Providing patient- and family-centered care, helping to engage patients in both the care process and the ongoing continuous quality improvement process within practices,

7. Using continuous, data-driven quality improvement practices, and

8. Creating sustainable business operations.

TCPI was implemented using a strategy of establishing practice and professional association networks to support transformation. The Practice Transformation Networks (PTNs) are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. This approach allows practices to become actively engaged in transformation and ensures collaboration among a broad community of practice that creates, promotes, and sustains learning and improvement across the health care system.

TCPI also established Support and Alignment Networks (SANs) to provide a system for the development of innovative quality improvement programs and workforce skills building needed to support practice transformation. SANs coordinate the efforts of national and regional professional associations and public-private partnerships that are currently working on practice transformation. Using existing and emerging assets (eg, continuing medical education, maintenance of certification, core competency development), these networks help enable transformation and ensure the sustainability of these efforts through the active engagement of professional and specialty organizations.

THE ROLE OF PTNs AND SANs IN DELIVERING EXEMPLARY PRACTICE

In a classic report on quality in health care, the Institute of Medicine concluded that, “All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”³

Twenty-nine organizations received TCPI PTN awards¹ from CMS to provide technical assistance and peer-level support to prepare more than 140,000 clinicians and more than 22,000 practices for APM adoption and participation in other value-based payment arrangements. This support includes organizing enrolled practices into a large community of practice so that best ideas and innovations from exemplary practices are brought to the surface and spread across the networks. As a result, PTNs are serving as trusted partners for practices in preparation for nationwide practice transformation.

Ten organizations representing more than 300,000 clinicians received competitive SAN awards from CMS (Table 1). In addition to supporting the PTNs and practices enrolled in the TCPI, the associations designated as SANs have translated what trans formation means for preparing their clinician membership for participation in quality payment programs. In partnering with CMS in the TCPI, the SANs themselves have been transformed in organizational focus and engagement with their membership and professional sectors, and are key in sustaining practice transformation efforts initially undertaken within the TCPI community. The focus of the SAN work has been on building the evidence base for successful solutions that support exemplary practice and prepare their membership for participation in value-based payment arrangements. The SANs also engage with professional associations outside of TCPI to support clinicians and other health care providers and practices in delivering value-based care.

The SANs have identified criteria that define exemplary practice within their own professional sector, as well as more broadly across the health care system. This definition includes a core set of 6 objectives for exemplary practice, namely: sustainable business operations; patient and family engagement; a culture of joy and satisfaction in work; understanding data; care coordination; and evidence-based care. To improve on these objectives, the SANs developed a structured process for defining service delivery challenges that influence the patient experience of care and outcomes, and for presenting solutions that have been successfully implemented by practices.

The resulting product, referred to as a Power Pack,⁴ identifies service delivery bundles that offer high value for specific situations, including specific areas of specialty practice (eg, radiology, internal medicine, family medicine, psychiatry, and emergency medicine), in 2 aspects of care. First, they identify actual value delivered: population groups and organizational situations that are well defined and offer great opportunities for improvement in quality and cost of care for achieving value-based performance. Second, they identify proven solutions: solutions being used by practices that are able to deliver high-value and lower-cost care through a service delivery configuration that meets a specific performance challenge.