By John Findley, MD, Caravan Health Medical Director, ACO Programs
Evidence is mounting about the importance of robust primary care in achieving the Triple Aim of advancing quality of care, reducing costs, and improving the patient experience. Primary care initiatives across the country have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare accountable care organizations (ACOs), primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for patients, providers, and payers.
Health care leaders and our government have invested both money and effort in improving primary care. The goal is a more patient-centered approach that prevents costly hospitalizations or other interventions for serious health conditions. In addition to the Triple Aim, this approach can lead to greater physician satisfaction, an important issue in light of widespread concern about physician burnout that is especially prevalent in our country’s rural communities.
Primary Care Transformation in the Medicare Shared Savings Program: The Caravan Health Experience
The Medicare Shared Savings Program acknowledges the central importance of primary care by attributing Medicare beneficiaries based on where they receive primary care services. Primary care enhancements, such as annual wellness visits (AWVs), behavioral health integration, and chronic care management (CCM), have helped ACOs to successfully achieve quality goals and to save money.
In ACOs nationwide, Caravan Health has approached primary care as a team activity, rather than a task just for an individual primary care physician. In a team-based system, each clinician in a practice contributes to patient care at the top of his or her license for a more seamless patient experience with strong outcomes. This team-based approach has also addressed the ever-present issue of physician burnout, which can put tremendous stress on physicians as leaders of care teams.
Caravan Health ACOs use a proven methodology, based in rigorous primary care, that leads to high quality and satisfaction, as well as strong financial results. For many Caravan practices, this starts with offering every Medicare patient an AWV. The AWV has been a Medicare-covered service since 2011 and is distinct from a the familiar annual physical. The AWV features an extensive interview focused on overall health status, rather than specific acute conditions. This AWV can be used as a roadmap for creating a care plan that includes important preventive elements and opportunities for enhanced care management for complex conditions.
New Federal Primary Care Initiatives
The Centers for Medicare and Medicaid Services (CMS) is taking strides in primary-care–based transformation. In April, 2019 CMS introduced new model options called Primary Care First and Direct Contracting. These value-based model options build on the successful Comprehensive Primary Care Plus and Next Generation ACO models.
The new models use capitated payments and streamlined quality measures to encourage providers to take responsibility for the costs of care for their patients as well as care quality. CMS is seeking new types of entities, beyond providers and payers, to participate. This reach could create some true innovation, such as the entry of technology companies, employer groups, and others into the primary care transformation space.
Experience of One Rural Caravan Health ACO Practice
Team-based primary care can increase primary care capacity while reducing burnout rates for physicians. For example, population health nurses can make a substantial contribution to the AWVs, freeing up other clinicians to handle follow-up or create a care plan as appropriate. This team-based approach encourages all members of the care team to contribute at a high level and relieves stress on overworked clinicians.
As part of an ACO, Clearwater Valley Hospital in Orofino, Idaho is changing the way it delivers primary care services. The hospital was an early adopter of some enhanced primary care practices, such as patient-centered medical homes, and achieved early results in the form of lower emergency department utilization, admissions, and readmissions. While pleased with this shift, hospital leaders grew concerned about reduced revenue for their rural critical access hospital. Rural facilities often run on extremely thin financial margins and simply can’t afford to bring in less income. The hospital had to consider ways to get the upside of care delivery reform without avoidable financial downsides.
To sustain the momentum of their practice transformation, the hospital incorporated a team-based approach to care. Dr. Kelly McGrath, Chief Medical Officer at Clearwater Valley Hospital and an ACO Medical Director, saw the effect of high-performing team-based primary care on the overall clinical performance of his medical team. According to Dr. McGrath, “We fundamentally improved the annual wellness visits by getting our nurse case managers to be more of an integral part of care delivery. That was probably the single most transformative piece in this first year in the ACO.”
Dr. McGrath continued, “In the process of implementing annual wellness visits and chronic care management visits, we created revenue that simply wasn’t there before. As with most critical access hospitals in rural America, we are really feeling the squeeze on revenue, and we now have an opportunity for a financial plan, a bridge, as we dive into value-based health care.”
Physician Burnout in Rural Hospitals
The team-based approach to care has helped reduce physician burnout, which is a major concern in rural parts of the country that may struggle to recruit health care workers to less-populated, remote areas. Clearwater Valley Hospital became concerned about burnout years ago and began using a quarterly survey tool to measure provider wellness and burnout. In 2016, Clearwater physicians reported high levels of burnout — about 60 percent. After creating a team-based care approach to AWVs and CCM, as well as other interventions, the self-reported level of burnout dropped below 10 percent. The hospital continues to measure physician well-being and reports to the hospital board on a quarterly basis.
Dr. McGrath notes, “As a physician, it’s a beautiful thing when I walk through the door to the next patient, and all those care elements that I used to focus on and make sure were being delivered have already been addressed by the care team. It means I can actually focus on the patient’s immediate needs, and to manage the more complex patient care. I can also see it has empowered the nurses and the medical assistants to take the initiative to deliver the care elements that we know that the patients need.”
The Bottom Line: Primary Care Doctors Can’t Go It Alone
Years of experience tell us that primary care must be a team sport. In the next few years, physicians must move from fee-for-service to fee-for-value to maintain their incomes. We can’t continue to ask physicians to take on more and more tasks. The only way to accomplish true practice transformation is to engage the entire clinical team and non-clinical staff.