Michael Pramenko, M.D., executive director of Primary Care Partners, the largest primary care practice in Western Colorado, recently described navigating changes in the value-based care landscape, working to do more chronic disease management, and why it was important to form a clinically integrated network.
Pramenko was speaking on a panel during a recent webinar put on by Colorado Healthcare Strategy and Management, a nonprofit organization serving the needs of the state’s healthcare community. He also serves as chairman of the board for Monument Health, a clinically integrated network formed via a partnership between Primary Care Partners, St. Mary’s Hospital, and Rocky Mountain Health Plans.
He began by defining the scope of their practice. “We've got over 70 providers. We see a mix of patients from infants all the way through geriatric years. We have many, many Medicare patients, I think Medicare standard is about 30 percent of our practice, so we certainly have a mix of payment types,” he said. They have some capitated payments via contracts with Rocky Mountain Health Plans. “We run some risk via our clinically, integrated network, Monument Health with some shared savings, and most recently, we have joined the Aledade family with our MSSP contract. We've been a Comprehensive Primary Care clinic, but that ended last Dec. 31, so we're navigating those changes and trying to do more chronic disease management.”
Pramenko was asked to talk about what his organization has done under value-based care to bend the cost curve.
He said that for several years they have operated an after-hours clinic that is designed to provide an opportunity for people to be seen in their clinic after hours as opposed to the emergency room. “That keeps our ER numbers down,” he said. “We've also had really good success at generics utilization within our practice. We also have our own physical therapy and occupational therapy team,” he said, adding that their outpatient therapy costs are significantly lower than the hospital-based PT/OT team.
One of the more innovative things they’ve done in the last five years was becoming part of Monument Health. “We are a minority owner in Monument Health, a clinically integrated network here in Western Colorado that is growing. That was designed to help us not only move in a faster position toward value-based payments, but we also wanted to be able to have a seat at the table with the largest local hospital, St. Mary's Hospital, now joined up with Intermountain, and be at the same table as they were talking rates, because in a value-based payment world, as primary care physicians, we only have a small part of the pie that we can influence on total cost of care.”
He stressed it was important to figure out ways to have more of a partnership with where a lot of this money is being spent, “and that's at the hospital,” he added. “That Monument Health partnership over the last five years has had its ups and downs, but has allowed us to have more conversations with the local hospital, where most of the patients here in Mesa County are served. And then, of course, we needed an ability to manage the Medicare population after the Comprehensive Primary Care (CPC) initiative, and that brought us into MSSP.”
Primary care covers only about 10 to 15 percent of overall spending, he said, but it can influence other spending indirectly — where do you send your patients? Where do you refer them? How often do you refer them? What's your ratio of primary care visits to specialty visits? Are you creating an environment where the physicians have to run a treadmill? “If they're on a treadmill, they're going to refer more, so we try to keep the number of patients our physicians and providers have to see down on the lower end. It is probably closer to 17 patients a day to keep that ratio a bit lower, and that is difficult. You’ve got the financial elements that you have to balance with the volume you need to see.”
Pramenko was asked to talk about the impact of this value-based care work on quality and outcomes.
“If we're going to talk quality, we have got to talk about patient experience,” he replied. “It is a very complex medical environment these days. It is a pretty bewildering experience these days for people entering the healthcare realm with a new illness. What services do you have available right here in your own practice, like care managers, embedded behavioral health, which we have at our practice, instead of referring somebody out to somebody at a place they've never been, or maybe that visit is two, three weeks down the road,” he said. “Getting them right in to see a behavioral health person on the same day as they are presenting with a crisis. Our geriatric patients that have a care manager that can help people walk through that complex environment of growing older and transitioning from home environment to an assisted living situation, or where you just simply need more help at home.”
Quality will always mean good medical care, too, he added. “That means right care, right place, right time, and not overutilizing specialty care. A lot of times the experience for our patients is just overly complex and they just feel like they've been sent on whereas oftentimes we can take care of them here.”
Pramenko noted that quality measurement is important but can be a burden to small providers. “We report on well over 30 metrics for various different programs with different payers,” he said. “That in of itself is huge effort, especially for the small practices. You can see why they're oftentimes selling out because it's getting to be pretty complex. That's some of the downside of all the value-based metrics on smaller practices and even big practices — the amount of energy and effort it takes to do the reporting.
He said we should also have our eye on quality and cost and what it means 10 to 15 years down the road. “That means having more conversations with public health, and aligning the incentives such that the volume of patients that have chronic diseases decreases 5, 10, 15 years from now. That is also a quality metric that's going to require conversations with public health, and getting more alignment.”
Pramenko noted that Costa Rica has passed us in terms of life expectancy despite spending one-tenth the amount per capita that we do on healthcare. “They're focusing on prevention and targeting those things that cost them the most. What we do in the United States is waiting for all these things to happen, and then we take really good care of folks once they get the disease, but we're not so much about prevention," he explained. "We need to focus more effort on that side of the equation. We all need to be talking about that as we move forward and have conversations with policymakers, as well as the health system folks that are redesigning the system. There needs to be greater emphasis on public health. We need to stop the stream of production of chronic disease in the United States. We did really badly with COVID, because we have such a chronic disease burden, with diabetes and obesity. And we just got pummeled over the head with it, because of our inability to manage chronic diseases in the United States.”
