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APM: Empowering New Ways Of Providing Care

Part 1

By Erika Cottrell, Jill Arkind and Sonja Likumahuwa 

(Note: This article originally appeared in Health Affairs Blog on July 21, 2014. 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.)

The Alternative Payment Methodology (APM) demonstration project enables participating Oregon community health centers to receive a monthly payment based on the size and composition of their patient population. This payment replaces the model of earning revenue based on the number of individual patients seen, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

So what are the real changes physicians are seeing on the ground in clinics where APM is being implemented?

According to Dr. Chris Hill, a physician and co-director of the Virginia Garcia (VG) Hillsboro Clinic and Medical Center, primary care was once so focused around payment it was like a “hamster wheel” of patient visit after patient visit. Under the new Alternative Payment Methodology (APM) pilot in community health centers throughout Oregon, care teams are freed up to do other things, such as managing panels of patients and designing programs to promote healthy behaviors and prevent illness. Dr. John Guerreiro, also a physician at VG, is enthusiastic; he sees APM as a pathway to realizing the full promise of team-based care.

Team-Based Care, Longer Visits, And New Ways To Reach Patients

The changes at VG, a federally qualified health center with multiple locations in Oregon, started about five years ago with a shift to the patient-centered primary care medical home.

“That’s when we first put a group of staff into a care team,” explains Hill. Care teams are typically comprised of a physician lead, physician assistants or nurse practitioners, nurses, and medical assistants. At VG, these teams are the hub of patient care. “What’s changed with APM is that we’ve really put the focus on the care teams to be the place where we start managing the panel.” Continue reading

How Many Uninsured Americans is our Country Willing to Continue to Tolerate?

By Heather Angier, MPH

Health insurance increases access to healthcare services. This is true whether providers are paid on a fee for service or capitated basis. A recent study concluded increases in uninsured middle-income families over the past decade are likely due to their inability to afford private insurance, which has been steadily increasing in price yet they make too much money to be eligible for public health insurance (i.e., Medicaid). (Changes in Health Insurance for US Children and their Parents: Comparing 2003 to 2008)

Research teams at OHSU and OCHIN interviewed Oregon parents who corroborated these findings:

  • “Even if two people are working, they’re making barely enough money but to the state it’s too much to cover them under their health care [Medicaid].”
  • “We made too much money for it [Medicaid]. It was only $200 [to pay for insurance] at the time, which doesn’t sound like a lot but the other two kids would be another $200, so it’s $600 a month.”
  • “You can make like $50,000 a year. It’s a reasonable amount…but at the same time I can’t afford $1000 a month for insurance.”

Luckily, the Affordable Care Act (ACA) has provided solutions for middle-income families. A private health insurance marketplace and expanded Medicaid eligibility began covering Americans at the start of the year, but there is another controversy brewing with regard to the subsidy made available through the ACA to help Americans afford coverage. One court has ruled that only states with their own exchange can provide the subsidy, while another has contradicted that ruling. (Implementing Health Reform: Appellate Decisions Split On Tax Credits In ACA Federal Exchange)

An Oregon parent the teams interviewed commented on health reform, saying: “I think that in the future it’s still not going to be good because lots of people will be left without insurance still.  We hope not, we hope that they will continue making change to the system each year to improve it.”

Decisions about the subsidy have consequences; a potential 7 million Americans may remain uninsured if the subsidy is not upheld. This is in addition to the 5 million who remain uninsured because they live in a state that did not expand Medicaid. These numbers beg the question: how many uninsured Americans is our country willing to continue to tolerate?

Data readouts

Link Round Up #3

Welcome to the third installment of our Link Round Up posts. Check out the links below for some weekend reading:

Nick Gideonse, MD, medical director at Family Medicine at Richmond Family Medicine (an APM pilot site) has been on sabbatical in New Zealand. He is sharing his experience through an article, which has been serialized into a seven-day blog, complete with photos. Follow along here!

A new blog, “In the Trenches”, over at AAFP tackles health policy relevant to family physicians. The first post discusses Direct Primary Care – check it out here.  

The Khan Academy has partnered with The Brookings Institution to create a series of tutorials on the U.S. health care system and payment and delivery reform efforts. The content was designed for clinicians and the general public to help frame the health care reform discussion. Access the full series here.

Two recent articles published by the Journal of the American Board of Family Medicine touch on some of the work we’re doing here evaluating the APM pilot: Panel Workload Assessment in US Primary Care: Accounting for Non-Face-to-Face Panel Management Activities and Challenges of Medical Home Transformation Reported by 118 Patient-Centered Medical Home (PCMH) Leaders

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This Is Not Your Mother’s Payment Model: Reflections On The APM Pilot

Part 2

By: Elizabeth Steiner Hayward, MD

In Part 1 of this post, Sen. Elizabeth Steiner Hayward discussed the range of structural and environmental challenges that undermined the managed care payment structure that arose in the 1990s. She concludes that this time around is different, encompassing multiple methods of financing care.

(Note: This article originally appeared in Health Affairs Blog on June 18, 2014. 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.)

Alternative Payment Methodologies in Oregon

Why am I optimistic about current efforts to implement alternative payment methodologies in Oregon? First, no longer do we face a one-size-fits-all strategy. We are no longer in the world of straight capitation regardless of quality, risk stratification of one’s patient panel, or practice location. Instead, practices can work with payers to develop the structure that fits their circumstances best.

Second, current payment reform efforts in Oregon are driven not by commercial insurers, but by the state’s expansion of comprehensive care delivered through Coordinated Care Organizations (CCOs). The Federally Qualified Health Centers (FQHCs) taking part in the APM pilot are all part of a larger CCO. CCOs are locally controlled health entities—including hospitals, primary care and sub-specialty providers, mental health, and dental care—that deliver health care and coverage to people eligible for Medicaid (Oregon Health Plan), with an emphasis on expansion of patient-centered primary care homes, integration of physical and mental health, prevention, and reducing costs through fixed global budgets and quality improvement initiatives.

We have, in essence, placed a $1.9 billion bet with the federal government that by implementing this new CCO structure, we can dramatically diminish the inflation in medical costs while preserving, and preferably improving, the quality of care for Oregonians served by the Oregon Health Plan. Continue reading

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This Is Not Your Mother’s Payment Model: Reflections On The APM Pilot

Part 1

By: Elizabeth Steiner Hayward, MD

(Note: This article originally appeared in Health Affairs Blog on June 18, 2014. 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.)

In early 1994, as I went about finding a practice to join after residency, every physician with whom I spoke discussed managed care at length. As a young family physician dedicated to prevention and early intervention, I was convinced that managed care answered many of the historical challenges faced by primary care physicians. At last we’d be able to pay for the social workers who could facilitate important mental health care and human services for our patients and for the group nutrition classes we wanted to run in our practices.

Yet just four years later, as I left private practice to return to academic medicine, managed care was virtually dead. All its promise had been undermined by a range of structural and environmental challenges. Continue reading