At World Health Care Congress, Examining How Innovative Care Delivery Models are Disrupting Primary Care

During the April 12 closing keynote at World Health Care Congress 2016, healthcare executives discussed the impact that new care delivery models will have on patient outcomes and the industry. 

The panel discussion at the Marriott Wardman Park Hotel in Washington, D.C., included: Rushika Fernandopulle, M.D., CEO of Iora Health, a healthcare services firm based in Cambridge, Mass.; Martin G. Kirstin, M.D., professor of medicine, division of gastroenterology and hepatology, University of New Mexico (Kistin is also currently a part of the replication team at the Extension for Community Healthcare Outcomes, ECHO, Institute at the University of New Mexico); and Ellen-Marie Whelan, Ph.D., chief population health officer, Center for Medicaid and CHIP Services (CMCS), and senior advisor, Center for Medicare and Medicaid Innovation (CMMI), Centers for Medicare & Medicaid Services (CMS), all gave different perspectives on how these innovative models are gaining scale nationally and globally. Below are excerpts of their panel discussion:           

Fernandopulle: We have been trying to build a fundamentally new model of primary care. The job that I think everyone wants us to do is improve people's health and keep them out of trouble. You have to build from the ground up, and we are focused on changing four things in general: you have to change the payment model; we won't make the difference if we don't. Then we have to change the care delivery model. Third, we need [to see] a difference in technology platforms, we need technology that is relational, and can manage populations, beyond the documental tasks that EMRs do currently. Culture change is the last thing, as you can be a good Level 3 patient-centered medical home and have a crappy culture. At Iora Health, our approach [has led to] a 40 percent drop in hospitalizations and a, 50 percent drop in ER visits. 

Whelan: When we transform the payer mix, we are hoping that changing payment does change care delivery. And we have to make sure that we have a workforce that could make that happen. We worked with folks to look at the role of the RN in primary care. What role might the RN have in a primary care delivery system? The baseline role of nurses, when we started, was that they provided a basic level of care, oftentimes in the home. So we were wondering what this looked like in a new care delivery model. With a bigger role of the RN, providers themselves felt happier [as studied by the American Board of Internal Medicine]. Nurses were helping in coaching and wellness training, and HEDIS [Healthcare Effectiveness Data and Information Set] measures were improved as result. Practices by and large were much happier. 

Kistin: ECHO was conceived and developed in New Mexico back in 2004, and it was designed to take care of one single problem, chronic hepatitis C. In those days, the treatment for hepatitis C was very toxic with severe side effects, and providers in New Mexico were not willing to treat patients for this condition. We had a specialty clinic, but the wait time was 10 months; if you were to get return visit, the wait was 18 months. Some patients drove 250 miles to get there as well. So our model uses video conferencing technology to train providers in underserving areas, and we set up virtual clinics in this initial model where providers would login to this clinic once a week for two hours. Providers and specialists would [confer] and then manage the case of the patient. Using this model, we have demonstrated that you can provide care as safe and effective as if they had access to this specialty clinic. And the providers loved it, they had a mentoring relationship with specialists, and relationships with other providers. It's important to recognize that this is a little different then telemedicine, as we don't treat patients directly, but give them support and tools. This model has been used around the world for 50 different chronic complex conditions. Our goal is to touch the lives of 1 billion people by 2025, and I think we can do it. 

Fernandopulle: I think we have a primary care shortage only if you think that  primary care doctors will do exactly what they're doing now. Part of the job is seeing people and making diagnoses and prescribing treatments. We have a physician who will have a whole team with him including a nurse and health coaches—each doctor has three health coaches, and when people fail protocol they go to the primary care practitioner. You give him or her downstream and upstream support to manage his or her population. The doctor can manage more people with a lot more help, and that's the idea behind [our model].

Whelan: As a clinician at CMS, we change payment to change the care delivery system. The payment change should allow for the improved care delivery model to be enhanced. Now you have an entire team as we are moving from fee-for-service [FFS] models towards focusing on the community members, care to be delivered in the home, and telehealth.  

Kistin: What we have discovered is that it's important to look at who is delivering care at every level and how those patients are being treated. We have had medically underserved areas traditionally, and there is little in the way of education, so we need to provide them with a better work/education balance by giving them mentors, people they could relate to. We believe strongly in having everyone working at the top of their licenses. We have a big training program for community health programs, as we think this is the key for managing chronic conditions. Maybe there are people in the community with high school degrees who know the patients and can spend time with them, allowing doctors and nurses to do the things they are trained to do, and that makes everyone more satisfied. 

Fernandopulle: We find that people should believe in this, and if not, you don't belong here. We had a senior doctor at one of places we work with who said he doesn't know about these health coaches, because they will get in the way of the doctor-patient relationship. But just because someone else has a relationship with that patient doesn't mean your relationship with that patient will get worse. In fact, it could get better. He wasn't convinced, so we didn't hire him. You cannot convert everyone, so find those who believe and bring them on. Those others might need some more time. 

Whelan: As we move from FFS we can better understand how the entire team can come together to provide better care. It's about maximizing those contributions that everyone can bring. If we are now looking at patient outcomes, is the practice happier and is the outcome better, taking away the underlying payment of who's getting what, and looking at broad aspect of the care being given. 

Kistin: In our setting, we use the technology as a tool to mentor and support. Our patients are seen by their providers in their homes, so we eliminate expensive travel costs. In addition to that, if you don't have the right knowledge at the right place at the right time, you have a problem. When that happens, physicians will do tests. And those tests may be appropriate, but often they are not, and they are really expensive. If you make sure only the necessary tests are done, that will decrease costs.  

Fernandopulle: Folks in Silicon Valley say that technology will replace humans. Maybe someday, but today it's about leveraging the human relationship. Technology can amplify that. We want to meet you at least once, and that changes the nature of the relationship. After that we can use a ton of technology. When you schedule a visit online, we will ask if you prefer a phone, online or in-person visit, and that is after we met you once. And we're indifferent to the answer. 

In every other industry such as banking and the airlines, you see that technology and culture have allowed the customers to do more of the work. You go to the ATM whenever you want and book your travel tickets online. We have just begun to scratch the surface here in healthcare. What about the patient and the family themselves? With the right tools they can take their blood pressure, for example. I think we can get away with the same or less doctors than we have now. 

Whelan: We have had a geographic shortage of doctors, not as much an overall shortage. For those remote areas, technology will help get people the right care they need. Also, the projected shortages we see are based on the traditional FFS model. 

We won't flip a switch and solve the shortage. Folks need to want to change and make a difference. CMS is moving along the continuum of moving away from FFS, while working with other private payers. As that becomes more pervasive, the bend will slowly get there, but shortages will exist in the short run. 

Fernandopulle: The first thing we do is help people coordinate their care better and go to the right place. There are lots of shenanigans going on in the healthcare system; there are crooks and we want to keep people away from them. Second, we are helping people improve their self-efficacy. We need to teach people how to deal with their [conditions] and give them confidence. And finally, of course, improve their health. Treat the issue, whatever it is. One of the big problems we have reached6 in U.S. healthcare is that if we want to save money we have to improve people's health in the big picture. You may spend more money in the very beginning, but over time, if you're caring for a population, you will see savings. The problem is that capturing a patient for three years is really hard with one-year exchange contracts. There are ways to generate savings, but you need multiple years.