Jeffrey Bullard, M.D., moved full-time into the position as chief medical officer and executive director for Texas-based Catalyst Health Network just before the pandemic struck in early 2020. In a recent interview with Healthcare Innovation, he spoke about some of the benefits independent primary care practices gained from being part of the clinically integrated network during COVID-19.
Plano, Texas-based Catalyst, the largest primary care clinically integrated network in the Lone Star State, has nearly doubled in size over the past few years to approximately 1,000 providers. It offers scalable revenue cycle, EHR, financial management, reporting and contracting to independent practices, so that they can focus on the clinical practice and patient care.
Bullard said there is still some room for growth for Catalyst in Texas. He noted that about 40 percent of the primary care physicians in the state are considered independent. “Some of those are already aligned or connected with other organizations that are trying to do similar things as our organization, so that's good,” he said. “But there are definitely practices out in West Texas or Southern Texas that are trying to figure out how to navigate the system and stay independent. But it's also very sad, because we've seen almost 20 percent of practices have to eventually throw in the towel and sell to a hospital system or another organization because they just can't keep the doors open.”
I asked Bullard what he saw as some of the real downsides from these physician practice consolidations?
“I think the biggest downside is that you lose that ability to really innovate and think about how you can adjust or change your practice in a way that's best for your patients,” he said. “When you drop into an employee model, there's an expectation that things are to be done a certain way. It creates a scenario where your mentality as a physician is to check a different set of boxes as you are running through the process.”
Because he mentioned that his taking the full-time job as chief medical officer coincided with the beginning pandemic, I asked him which what membership in the network has been able to do for practices during the public health emergency.
“I would say there are three really dominant things that we were able to help with,” he said. “First was just the overwhelming amount of information that was coming out. Sometimes there would be updates several times a day, and that was really difficult. We pivoted and our role shifted from helping folks succeed in value-based care to really helping our doctors ingest the information. We were pushing out care alerts every single day for a while, and then that moved to three times a week. We were doing webinars two times a week where we were updating them around all kinds of things —access to testing, how you code and bill for things.
The second thing was the network helped practices pivot quickly to telehealth. “Early in March 2020, about five to 10 percent of our practices actually had the capacity to do telehealth, but only about 2 percent of visits were actually conducted via telehealth,” Bullard said. “By mid-March, we had 100 percent of our practices able to telehealth, with between 90 percent to 95 percent of our practices all doing telehealth for that eight-week period of time where people just couldn't get into a doctor's office.”
The network also helped with telehealth vendor recommendations and EHR and billing issues around telehealth.
“The third and probably most important thing was helping our folks set up for the PPP loans, where almost all of our practices, if they needed to, were able to get their paperwork in and get approved for loans, so that they could have that financial stability get through that time, because it was a huge hit,” Bullard said. “I'm proud to say that none of our practices had to close their doors as a result of the pandemic, which isn't the case, unfortunately, across America. That's a huge win.”
I asked Bullard about value-based care models designed for primary care that his organization has had success with and whether there are other policy changes they would like to see in the payment world.
Since its inception Catalyst has really focused on value-based contracts in the commercial space, he said. “We had essentially enhanced fee schedules with a shared savings type model, where if we were able to save dollars, we were able to share in those savings with commercial payer,” he explained. “We've had great success in that space. Since we started, we've saved across those payers over $100 million. It has been a win for all involved. It's very much like the Medicare MSSP world.”
He added, however, that this work gets more and more challenging because it's still built on a fee-for-service chassis. “Our market is very PPO [preferred provider organization]-heavy in terms of the market structure,” Bullard explained. “That limits our ability as a network to really help navigate patients strategically to what we consider high-value facilities or high-value resources where you're seeing great outcomes at the best costs. We find ourselves right now in a challenging place. We'd like to do more, but because we're in a fee-for-service-dominant world, that makes it really challenging.”
He said other models like the Medicare Advantage capitated model is one they would like to see more of across the commercial space. The advanced primary care offers more of a prospective payment, he added. “We would like to see a move back to some sort of capitation in primary care, but in a model where we're investing more in primary care, so that we've actually have the resources available to make a true pivot in terms of the way care is delivered.”
Bullard mentioned the concept of team-based care, and I asked if that was something that's spreading across their network.
“Without a doubt,” he responded. “From a network standpoint, we've always had as one of the benefits of our network a centralized care team with care coordinators of nurses and dietitians and even pharmacists, where we can pull patients into that care team experience. Right now, that's barely covered through some funds that we get from the payers under our value-based contracts. It would be nice is to be able to expand that, so that we can actually reach more patients, because we really want to be able to address more of the psychosocial issues that our patients may have with a chronic disease. They may have other struggles that put them at higher risk. We want to be able to touch more of our patients from a behavioral health standpoint, but the way healthcare is paid for currently, we have resources available for severely impacted multiple chronic disease-type patients, but we don’t have the resources that we want to really bend the cost curve and improve the outcomes.”
He said states such as Oregon and Rhode Island, as well as other countries, are starting to see improved outcomes because they have invested more in primary care. “They double the dollars that go toward primary care from a payments standpoint, so that now I can take those dollars and really apply it to a team that can touch your patients in a way that we just don't have the ability to do right now with our patients.”
The United States has been talking about the importance of behavioral health integration for decades, and there's been a huge push in the last 10 years, Bullard added, “but it is so challenging to bring it to fruition. At our practice, we integrated behavioral health in 2007. We have counselors and psychologists and the ability to deliver therapy within our practice, The impact can be dramatic, when you're able to walk down the hall, and do that warm hand-off. But we had to be super creative about how we financed that. We have got all kinds of services that we tried to deliver — some of them are covered by insurance, some of them aren't. We shouldn't be struggling this hard to make it happen.”