Extending APM Models Critical to Care Transformation, Clinical Leaders Say

April 12, 2021
Focus on social determinants, home-based care not possible in fee-for-service mode, they say

During a recent webinar hosted by Premier Inc., two physician leaders described how value-based care arrangements have bolstered their efforts to redesign patient care. They also described some barriers they’ve had to overcome in the shift to alternative payment models.

Rakesh Patel, M.D., is CEO of Neighborhood Health Care, a nonprofit community health organization in San Diego County, and board chair of Integrated Health Partners (IHP), a clinically integrated primary care network of nine federally qualified health centers that care for 270,000 people in San Diego and Riverside counties.

IHP works under alternative payment model contracts with Medicaid managed care organizations in California, Patel said. “Under these APM models we have been able to innovate by cultivating a collaboration of clinical and operational changes through incentives, networks, support tools, and network staffing,” he said, adding that it has led to improvement in quality outcomes year over year. Pay-for-performance models create accountability for quality. “To achieve this quality we've implemented and maximized the use of telemedicine during COVID. We've developed clinical protocols and care pathways and deployed a population health platform across the network,” he said.

Telemedicine has greatly reduced inequity for Integrated Health Partners’ patients, especially around transportation. Their historic pre-COVID no-show rates for behavioral health visits was over 30 percent and now it's less than 10 percent. “During COVID, we have seen higher incidences of depression, anxiety and substance abuse, all of which we've been able to address via telemedicine,” Patel said.

By sharing best practices across the network, they have decreased disparities in care and have a no-wrong-door policy. “When a patient enters into one of our IHP network health centers, they're treated according to evidence-based algorithms that have been jointly designed and adopted by the chief medical officers of our member health centers,” Patel said. “Variations in care —  whether it be for diabetes or hypertension or other chronic disease— are extremely costly. Through these algorithms, patients receive evidence-based care that reduces their risk of high-cost hospitalizations related to complications of chronic diseases like diabetes. The key to all of this is population health and making sure we connect with all of our patients, especially those that have fallen through the cracks.”

Traditional fee-for-service models do not support this work, Patel stressed. “Many of us have made these investments in the space because we know this is the right thing to do,” he added. But payment models have been slow to support it.

“APM models foster innovation and care delivery that is just not possible in a fee-for-service environment, Patel stressed. “Our work has garnered the interest of payers and other health systems because of our ability to innovate and provide comprehensive care to those who tend to suffer the most from health disparities. FQHCs have a longstanding commitment to delivering culturally sensitive healthcare to those who have been underserved for whatever reason. At IHP, we have made a commitment to making sure health equity is woven into all of our work both clinically and operationally.  Our patients are screened utilizing a low-literacy questionnaire that helps identify potential challenges in the areas of social determinants of health, like housing, food or income. We know when we start to address the social determinants of health, we not only see improvement in clinical outcomes across the communities we serve, but more importantly, each individual patient has a better chance of living their best life. And we can finally start to change the conversation from disease to wellness.”

Moving care into the home

Richard Shuman, M.D., is CEO of Baycare Health Partners, a physician hospital organization in the Pioneer Valley of Western Massachusetts. He gave a few examples of how participating in an APM has allowed Baycare to transform the care that it provides — things that could never have done in the standard fee-for-service models. “We are able to embed care managers into almost all of our practices,” Shuman said. “They manage some of the sickest patients in those practices and the results have been amazing — significant reduction in total cost of care and amazing net promoter scores of greater than 80. They are really part of the clinician practices in a way that remote care management never really accomplished for us,” he said. “We've been able to work with skilled nursing facilities and developing high-performance networks. Basically, we've been able to get those the skilled nursing facilities to commit to high-quality measures, and that's allowed us to work with them create a preferred network and dramatically reduce the length of stay for all of our patients that are going in those facilities.”

In addition, Shuman said, Baycare has been able to shift care from the emergency room to the home. “That’s really part of our vision. We’re here to make sure that people get care where they most need it, and often that is not the hospital or the emergency room. And by working with a third-party vendor like Dispatch Health, for us, we've been able to actually move the place of service for moderately ill patients to the home,” he explained. “They don't have to go to the emergency room or the hospital. Those things would never happen in our routine payment systems. We would just never be able to fund them. But it's what people want. It's what we want for ourselves, what we want for our parents. We don't want to have to spend hours in the emergency room when people can come to our house and provide those services to us in an equally high-quality manner.”

Shuman said the thing he is the proudest of is that during the pandemic Baycare has been able to look at its population and stratify them by medical condition, population density, low income, housing, COVID cases and location, etc. “Then we did a cultural and linguistically sensitive needs assessment. We took those results, and provided our population with facemasks, cleaning supplies, thermometers, pulse oximeters, home delivery of pharmacy,” he said. “We also provided room dividers and air mattresses so that so that those that are in close quarters had means of isolating during the COVID crisis. “The  bottom line is that the model allowed us to do things that the fee-for-service model would never allow us to do. None of it would be possible without the APM for us.”

Barriers to overcome

Asked to talk about barriers to their work, Patel said the first of their big challenges is around data. “As members of a clinically integrated network, we have made a commitment to invest in population health IT tools to aggregate data from our EMR systems, but we really do need more cooperation and coordination with our payers,” he said. “They hold all the data and as a network we've implemented tools and techniques to try to get as much of that as we can, but in many instances, we're duplicating efforts, which is just really unnecessary. As we evaluate risk-based contracts, we have little visibility into the historical total cost of care.”

A second challenge, Patel said, is around educating the staff and providers on risk-based arrangements. Change management is critical because risk is scary to some of the partners, he said. “We've lived in this fee-for-service world for all of our lives, which really made us focus on the care of the patient sitting in front of us and rarely have we ventured outside of our four walls to deliver care or understand what was happening with our patients.” He also mentioned that regulations and traditional payment arrangements for FQHCs can complicate the picture.

Shuman said organizations such as his need adequate financial support to build and maintain the infrastructure to move the place of service away from the hospital into the home.

“We always talk about the money to build something new, but we rarely talk about the money to maintain it,” he said, adding that Baycare needs continued support to move the dial in a meaningful way. He also said the APMs have not adequately incentivized specialists to move from fee-for-service medicine to value-based medicine. “It's hard to create systems that that really incentivize not only primary care providers but specialists as well, but we need to engage them,” Shuman said.

Another challenge is that models such as Medicare Advantage are often more attractive to providers than total cost of care models. “I find that unfortunate. I'm really in love with the total cost of care models," he said. "They really speak to us. And yet, we see so much movement away to Medicare Advantage in this country. I really would like us to be able to grow the total cost of care models and make them attractive, so they can be continued to be successful.”

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