The Oregon Experiment: A Qualitative Examination of the Alternative Payment Methodology

The Oregon Experiment: A Qualitative Examination of the Alternative Payment Methodology

By Glenn Kautz & Erika Cottrell

A recent qualitative study has been published in the Journal of Ambulatory Care Management that examined clinic level changes made by clinics participating in the Oregon Primary Care Association (OPCA) Alternative Payment & Advanced Care Model (APCM) program. Based on interviews conducted early in the OPCA APM transformation process, the study was part of the larger eCHANGE study and led by Dr. Erika Cottrell of OCHIN in a collaboration with the OHSU Department of Family Medicine.

In earlier blog posts, we have discussed the adoption of the Patient-centered Primary Care Home (PCMH) model as an approach to providing comprehensive, coordinated and accessible team-based care, and the need for Alternative Payments Models (APMs) to facilitate this model. In contrast to Fee-For-Service (FFS) payment models, APMs can facilitate greater flexibility in their approaches to patient care, allowing clinics to provide services not traditionally reimbursed under FFS.

This model is especially important for Federally Qualified Health Centers (FQHCs) which serve primarily uninsured and Medicaid populations across the country. The number of FQHCs achieving PCMH recognition has steadily increased over the past several years. Alternative payment models (APMs) take a variety of forms and continue to be implemented across the country in a variety of settings. One example of a wide-scale APM model for FQHCs is the California Department of Healthcare Services FQHC APM Pilot, which is planned to begin late 2017.

The team found a number of interesting and exciting transformative approaches to providing care including; diversifying the ways that care is delivered, adapting staff roles to meet patient needs and finding ways to document new care modalities.

No longer bound by the requirement of FFS to fit in as many patients as possible, clinics were able to lengthen visit times from 15 to 20 minutes. The extra time allowed clinicians to focus on a broader array of patient needs and facilitated warm hand-offs to other care team members providing services such as social and behavioral health. Clinics also created more time for administrative tasks such as charting, billing and care planning.

Additionally, practices utilized non-traditional methods of care delivery such as group visits, telephone visits and use of online patient portals, diversifying the ways clinics could educate and communicate with patients. New care team members were hired to assist with the broader number of services and care modalities, and the roles of existing team members were changed as part of clinics’ adapting to workflows and services. For example, Medical Assistants began to perform diabetic foot exams while front office staff created and disseminated patient education materials.

The APCM demonstration project required practices to document the visit and non-visit based care that they provided. To understand what clinics are doing more, the OPCA created a list of 18 specific visit and non-visit care activities called, “Services That Engage Patients,” (STEPs), which included interactions between the patient and the patient’s family or authorized representative and the healthcare team. Clinics were required to document STEPs in their EHR. Additionally, clinics needed to provide that patients received care at their clinic and no other FQHC. Both documentation requirements represented sources of increased administrative burden. It is important to note that refining these documentation requirements has been a focus of the OPCA and the state since this early point in the APCM.

FQHCs and other primary care clinics all over the nation are attempting to meet the needs of their patients and communities through the PCMH model. However, the FFS payment model provides a disincentive for many PCMH-related approaches. This study demonstrates that payment models such as APCM are related to transformative approaches related to the PCMH model of care.

Importantly, these results represent changes made soon after implementation of the APCM model. Since that time, the scope of care provided by clinics has continued to evolve, including a focus on care related to social determinants of health. However, the findings from this study are important for understanding early changes to clinics necessary for future innovations.