Authors: Heather Angier, Erika Cottrell, David Cameron
We are excited to report that our research team received funding from the Agency for Healthcare Research and Quality to conduct quantitative analyses assessing the impact of the innovative APM natural experiment. Led by Jen DeVoe, MD, DPhil, the Evaluating Community Health Centers’ Adoption of a New Global Capitation Payment (eCHANGE) project will utilize electronic health record and Medicaid claims data to study changes in service utilization, quality and cost of healthcare when community health centers (CHCs) shift from fee-for-service to global per-member per-month (PMPM) capitation payments. This study expands on our qualitative evaluation, which collected invaluable baseline data from Phase 1 of the APM demonstration project.
The eCHANGE study will compare key measures of service utilization, quality, and cost of healthcare before and after APM implementation in the 8 Phase 1 CHC clinics to understand the impact of APM. To isolate the APM impact from other concurrent primary care delivery transformation initiatives, we will match each Phase 1 intervention site with a non-intervention (or ‘control’) site that is similar on a number of factors – such as patient population, geography, and clinic size – but has not implemented APM.
Findings from eCHANGE will have national relevance and will help inform the efforts of other states who are interested in implementing APMs. Specifically, insight gained through this study has the potential to greatly improve primary care delivery and patient health by:
- Filling a critical knowledge gap: understanding whether APMs can improve patient health at reduced cost is imperative as traditional fee-for-service reimbursement models are not achieving improvements;
- Measuring the real-time effects of health policy changes on care delivery in CHCs;
- Evaluating the APM ‘natural experiment’ to assess service utilization, quality of care, and cost of healthcare;
- Engaging CHCs in a study that will inform ongoing / future policy and practice changes; and
- Informing the potential dissemination of APM methods to additional CHCs and/or other primary care settings.
Today’s link round up covers national initiatives focused on increasing value over volume and data sharing as a key player in alternative payment methods.
The Health Care Payment Learning and Action Network, made up of the Department of Health and Human Services and partners in the private, public and non-profit sectors, is working towards a transition to value based payment. This collaboration between payers, providers, consumers and other key stakeholders will align efforts and lay the groundwork for payment reform. The network’s work is linked to increasing the percentage of Medicare fee-for-service payments linked to quality. Read more in this press release and this article from Health IT Outcomes.
An article over on Health Leaders Media discussed the need for more “accurate, actionable and timely information” for physicians. While physicians are interested in alternative payment models, they’re also overwhelmed by the required metrics and reporting required by payers. This is an area that’s been heavily discussed within the APM pilot clinics here in Oregon. The article highlights a study by RAND researchers that found practices are collaborating with others to support the upfront investment required by alternative payment models, but challenges arise when payment models conflict with one another.
However, at the same time alternative payment models have prompted more health data sharing, as the New York Times published: “the economic incentives for data-sharing, some medical experts say, are beginning to fall into place.” The article discusses sharing data with patients, in particular, to improve health outcomes.
By Jen Coury
As we’ve highlighted in prior posts , the Alternative Payment Methodology (APM) has freed up health systems to dive into alternative ways of providing care. Many of these health systems were already experimenting with new approaches, and APM was designed to bring payment more in line with this kind of care innovation. For many health systems, part of this shift in practice management involves more team-based care including increased responsibilities for Medical Assistants (MAs). In fact, the Bureau of Labor Statistics estimates the employment of Medical Assistants will grow 29% from 2012 to 2022.
MAs are finding themselves with more to do, specifically related to panel management and health maintenance activities for patients. An MA has always had a broad role in medical practices. They perform a wide variety of tasks such as: reception, medical chart filing, escorting patients to rooms, getting medical history and vital signs, basic lab tests, patient instructions, and telephone calls to patients. Under the new model in many practices, the MAs are now “scrubbing” or reviewing a patient’s medical chart when they come in for an appointment to make sure the clinical staff cover preventive health needs. Continue reading Today’s Healthcare Team and the Growing Medical Assistant Role
By Deborah Cohen, PhD
(Note: This article originally appeared in Health Affairs Blog on April 20, 2015. An edited version is being reposted here as part of the research effort investigating the impact of Alternative Payment Methodology (APM) on the delivery of primary care in safety-net populations. Through this website, Frontiers of Health Care, we are sharing lessons learned and perspectives from key stakeholders on the frontlines of reform.)
Primary care practices in Oregon and elsewhere have been moving toward the Patient Centered Primary Care Home (PCPCH) model. As they emphasize whole-person primary care that is accessible, high in quality, and safe, Oregon’s Alternative Payment Methodology (APM) pilot is an important step to align payment with these core principles. The APM pilot has been described as a bridge to value-based care. It isn’t the solution to the fee-for-service treadmill, but some think it’s a step in the right direction.
The APM pilot is testing the idea that a per-member-per-month (PMPM) fee to care for a population can support comprehensive care. Integration of physical and behavioral health care is a great case for examining alternative payment methodologies, and it gives us a peek into what Oregon’s APM is (and isn’t) achieving.
Integration of behavioral health and primary care by health care systems is one of the most robust examples of patient-centered, comprehensive care that I have observed in this model. We know that emotional and behavioral issues commonly compound physical health risks and lead to worsening health outcomes. We also know that primary care is where most people struggling with these commonly co-occurring conditions are seen by health care professionals. Continue reading Addressing Behavioral Health Integration With Payment Reform
By Jen Coury
“Patient engagement” is a buzz word that, in some ways, reveals how far away much of the health care system has strayed from truly serving patients. Most doctors are used to thinking about things like “compliance” and “adherence.” For example, are patients taking their medication as prescribed? But think of how much more powerful this question is: What would motivate my patient to take this prescription?
Patients are not used to being asked what they want to accomplish for their own health. Yet, a new movement is changing things. Health care systems large and small are trying to get patients involved, not only in their own self-care, but also in the way health care systems, clinics, and doctors provide care. For individuals seeing a doctor, a partnership looks something like the doctor and patient determining the best treatment together. Health systems and clinics could involve patients as advisers, or even have them co-leading quality improvement efforts with staff members. Continue reading When’s the Last Time Your Doctor Inspired You to be Healthy?
By Scott Fields, MD
Many people are working to develop methods for value-based pay. In fact, the US government aims to tie 50 percent of Medicare payments to value or quality by the end of 2018. And the State of Oregon also hopes an Alternative Payment Methodology (APM) will create opportunities to change the system of care. They are changing the way people are paid by changing the incentives for work that is done.
The first three clinic systems to launch the APM pilot are helping to lead the way. They were working to develop innovative care delivery even before APM, so it would be unfair to look at these cutting edge, raise-my-hand clinics, and say that nothing is measurably different. APM has not created innovation, but rather it creates the opportunity for innovation. We’re trying to engage the entire community to do something different, and that’s where the innovation is happening. To succeed at this, we need to make sure that incentives are aligned correctly.
Our clinical team is looking at how people are responding to the new incentives. Many different types of outcomes may answer the question: What is the health care system doing differently than it has done in the past? You can look at what people are doing differently in the clinics and whether clinicians have changed their behavior. You can measure what happens to our patients, which is what we really care about. And within that measure you could look at what types of services they receive or what happens to their health. Once we determine if patient health has changed, we can decide if we were successful—at least in one dimension. Continue reading Innovative Incentives for a New Model of Health Care
Team-based Care Requires Team-based Metrics
By Jen Coury
The old adage goes, “You get what you pay for.” But what are you paying a health care provider for if it’s not a doctor’s visit? The Alternative Payment Model (APM) has shifted payments away from the number of clinic visits with a doctor and towards a per-patient monthly rate. This means that somehow the health care systems in the pilot need to demonstrate what care they are delivering. But measuring population-based health management is a lot trickier than counting how many times a patient walks through the door of the clinic.
What defines success? The State, Oregon Primary Care Association, and the health care systems taking part in the APM Pilot have been working together to answer this question. The ideal health care scenario is to deliver the right care, at the right time, to the right person. They are working towards a metric that captures the accountability of a health care provider.
Ultimately, the State will want to pay primarily for health outcomes, but that’s a long way from now. For example, if you think of a health care system as managing the health of a population (in the new model), then one measure might be what percent of the population is the provider in touch with. Meanwhile, we have to pay health providers while moving towards this future ideal model of care. Continue reading Measuring the New Doctor “Visit”
By Glenn Kautz, MPH
In October 2014, I attended the Oregon Rural Health Conference in Bend, OR. It was my third time attending the conference and I found a familiar forward-thinking amalgam of healthcare leaders from all corners of Oregon. Most conferences exude some level of enthusiasm for networking and new ideas, along with a feverish craze for self-serve coffee. However, this is always a unique conference experience for me. In addition to the usual conference tones, there is an extra helping of camaraderie, shared purpose and family that is inspiring for a medical student such as myself.
Presentations covered the areas of Alternative Payment Models (APMs), workforce issues, and data-driven process improvement approaches. While these topics are interesting in-and-of-themselves, looking at them through a rural lens also spurred my curiosity for how rural and underserved are defined, and how this affects the structure of the primary care system. Throughout the conference, I repeatedly heard the term, “Rural Health Clinic” (RHC), and wondered what they were and how they compare to Federally Qualified Health Centers (FQHCs).
Next year, as an Oregon Rural Scholar, I will spend 12 weeks in a clinical rotation at a family medicine clinic in a rural area of our state. I am honored to have such an opportunity, and I am incredibly excited to learn more about healthcare issues in rural settings by listening to patients, working with providers and getting to know the community. For now, however, I want to understand what rural means through healthcare policy and research lenses.
Continue reading A Conference Inspired Look at the Rural Primary Care System
Locally: The Corvallis Gazette Times profiled the alternative payment methodology pilot taking place in the Community Health Centers in Benton and Linn Counties.
Nationally: Last week the federal government announced their intention to move towards the model of value-based care, with a focus on care coordination for the Medicare population. A number of news outlets reported on the story. You can read about it on The Washington Post, CNBC and NPR.
By Jen Coury
Anyone who works in health care knows how important mental health treatment is to overall patient care, and at the same time, how difficult it is to provide that treatment. Some clinics, however, are shifting to a team-based care model and, more often than not, including behavioral and mental health providers in the team.
“We’re talking about team-based care,” says a behavioral health consultant in a clinic implementing Alternative Payment Methodology (APM). “This new model will essentially make us more like team members. The PCPs need to know that, essentially we’re specialists. We’re consultants that will help people with particular things. But we’re not going to take the patient and treat the patient. We’re going to help them treat this patient. And I think that’s a huge culture shift, and particularly for us.” Continue reading Treating the Whole Person