Patient centered home plan gets good review

Focus is on keeping patients healthy, not treating illness

By Markian Hawryluk, The Bulletin

Don’t look now, but Oregon’s efforts to revamp its health care system might just be working.

A recent analysis concluded that the state’s Patient Centered Primary Care Home program lowered health care costs by investing more in primary care services and reducing the need for costly hospital, emergency room or specialty care services.

“The idea of these patient-centered medical homes is to transform the way care is provided to people at the primary care level,” said Neal Wallace, a health economist at Portland State University and a co-author of the study. “If you do that, it’s going to bend the use of services in downstream areas, the ERs, the hospitals. (The analysis) seemed to show that pretty strongly.”

The study found that clinics participating in the program cut health care costs by about 4.2 percent, a savings of $240 million from 2012 to 2014, despite spending about 1 percent more for primary care services and prescription drugs than clinics that weren’t in the program. For every $1 increase in primary care spending under the program, there were $13 in savings in downstream costs.

The team-based health care delivery model directly addresses some of the long-held complaints about the way the health care system pays for primary care. Physicians traditionally have been paid for face-to-face visits with patients and for the procedures they perform. Doctors were rewarded primarily for fixing health problems after they occurred, rather than keeping patients healthy in the first place.

That led to specialty physicians, who do more surgeries and procedures, being paid handsomely, while many primary care practices struggled to make ends meet. Family practice doctors had to ramp up the number of patients they saw each day, leaving little time for more in-depth patient care management or to think about their patients’ health outside the context of an office visit.

The medical home model tries to flip that approach, to build a team around the patient that can address potential health problems before they spiral into major crises that require expensive fixes. The team would have the time to be more proactive about managing a patient’s health, coordinating their care with specialists or following up after hospital stays or emergency room visits, and eliminating duplication or waste.

“Fundamentally it’s being responsible for patients who aren’t in your office that day,” said Dr. Ken Carlson, a Salem pediatrician and member of the Oregon Medical Association. “Traditionally, it was completely up to the patient or the family — maybe we would send out postcards for well-child visits — but it was up to them to engage when they needed it.”

Now as a medical home, the clinic’s nurses call to check in on kids with chronic conditions or to remind parents when it’s time for vaccinations or other check-ups. Carlson’s clinic previously saw children with asthma mainly when they were sick or wheezing. Now the clinic brings those kids and their parents in once a year to make sure they have the proper medications and to educate them about managing their condition.

“We saw a dramatic drop in kids going to the ER or needing to go to the hospital, because they had more of those tools at home,” Carlson said.

Sharing tasks

The team-based approach frees the physician, physician assistant or nurse practitioner to focus on the tasks that truly need a licensed provider, while delegating more tasks to nurses and medical assistants.

Four years ago, Mosaic Medical in Bend built care teams consisting of a primary care provider, a medical assistant, a nurse care coordinator, a triage nurse, a community health worker, a behavioral health consultant, a clinical pharmacist and a dietitian.

Nurses are tasked with managing patients with simple conditions such as urinary tract infections or blood pressure management, and prescription refill assistants handle refill requests that once went to doctors and their medical assistants. Behavioral health consultants are in the clinic to intervene with mental health concerns, and care navigators help connect patients with other services.

“If all that sits on the primary care provider, you’re really limiting the number of patients that you can care for,” said Dr. Christine Pierson, chief medical officer for the clinic. “Sharing the care across their team members helps with that.”

The proactive approach also requires clinics to invest heavily in electronic medical records that can be mined to identify which patients need help and when, and to track the clinic’s progress. The ramp-up in technology and staffing, however, come at great cost to clinics that is poorly supported by the prevailing payment system.

Over time, many clinics have participated in multiple, sometimes overlapping projects, cobbling together state and federally funded incentives and grants to implement the medical home approach.

Oregon’s Patient Centered Primary Care Home program, established by the state Legislature in 2009, is a voluntary attestation-based model, where clinics can choose to certify that they are meeting 10 basic measures and be recognized as a medical home. State officials conduct site visits to verify that clinics are meeting the standards and to provide help in advancing the model. Clinics can gain higher certification levels by expanding the types of services they provide and the measures they report.

Officials at St. Charles Family Care had been working on implementing the medical home models for several years when the state program launched.

“We were going down that path anyway and to have a benchmark or a target to seek to validate our efforts and be recognized formally for our efforts was meaningful,” said Emily Salmon, director of primary care and population health with St. Charles. “It’s better for patients … and it’s also critical to being successful in where we believe health care was going nationally.”

Funding challenge

But the program does not provide any additional funding for clinics that certify. Most clinics receive additional payments every month for patients enrolled in the Oregon Health Plan that somewhat offset their higher costs. The Public Employees’ Benefit Board also provides an monthly per-member incentive payment to Tier 2 or Tier 3 recognized homes, and Aetna offers incentives based on the Patient Centered Primary Care Home program tiers.

Oregon is one of 14 regions selected by Centers for Medicare and Medicaid Services to participate in an advanced medical home model demonstration with an innovative payment structure. The five-year federal program begins in January 2017 and clinics should know later this month whether they have qualified for the program.

Statewide, some 635 clinics have been certified under the Patient Centered Primary Care Home program, including Mosaic, High Lakes Health Care, Bend Memorial Clinic and St. Charles Family Services. About half of all primary care in the state is now being delivered through certified clinics. If all primary care shifted in that direction, the Portland State researchers said, savings could double to $160 million per year.

The report also found that the longer that clinics operated as medical homes, the better they did. “It appears that PCPCH clinics ‘mature’ over time,” the authors wrote.

Clinics in their third year as a medical home lowered costs by 8.6 percent, about $85 per person per quarter, twice the savings achieved by clinics in their first year. The authors said that if all clinics in the state participated and were given time to mature as medical homes, the savings could reach $320 million per year.

Dr. Steve Mann, medical director at High Lakes, said patients have to adapt to the new model as much as clinics do, learning how to access care from their medical home, rather than heading for the ER at the first sign of trouble.

“They start to get oriented towards coming in and calling for advice and not waiting for a crisis,” he said. “It’s a complete shift in the way that providers and patient interact.”

Patients must accept that they may not always speak to the doctor directly, that a nurse or care manager can help them with their problem. Mosaic Medical has a care navigator in place at Bend Memorial Clinic’s Urgent Care clinic, to redirect patients who don’t have emergent health needs back to their primary care provider.

“A lot of patients just don’t know to call their primary care provider first,” Pierson said.

The long haul

The potential savings in building out the medical home model in Oregon could go a long way toward moderating the growth in health spending. But there are serious questions about the longterm sustainability of the program.

As some of the early demonstration projects end, and grant funding or other medical home incentive payments dry up, clinics are unsure whether they will be able to continue operating under that model.

“They’re really feeling stressed,” said Kate Elliott, a program director with Oregon Health Care Quality Corp., which has helped the state support clinics in the primary care home program. “They’ve hired all these people to do this new model, and they’ve expanded to take care of patients, but they don’t know how to continue to pay for them.”

The state relies on regional coordinated care organizations to manage the care of Oregon Health Plan patients, and those CCOs are evaluated in part by the number of patients they have enrolled in primary care homes. Clinics receive a monthly payment for each OHP member, but care for all their patients, regardless of their insurance plan, in the same way.

That means many of the private insurance plans are realizing the same downstream savings without paying any of the added costs. Dan McCarthy, administrator of Adaugeo Healthcare Solutions, which own High Lakes, said that’s unsustainable.

“You can’t have one or two players, whether it’s Medicaid, Medicare or a few progressive payers carry the load and create this free-riding system for insurance companies,” he said. “It’s got be a holistic approach.”

McCarthy said clinics like High Lakes don’t pursue primary care home models with the intent of making money, particularly in the short run. Organizations have to believe that the new model is an inherently better way to provide health care to patients.

Pay to play

There are efforts in the state to bring commercial payers into the fold. State legislators passed Senate Bill 231 in 2015, to study how much money was being spent on primary care and to establish a work group including private insurance plans to talk about payment reform. Advocates of the medical home approach hope the cost savings identified by the PSU report will prompt private plans to play ball.

“There was the belief that this would work, but studies to date have been sort of equivocal,” Wallace said. “I think it’s important that they see they’re getting something. Then there’s much more of an incentive for them to pony up.”

While the report’s findings are promising, they may not be definitive, as patients and clinics weren’t randomly chosen to participate in the program or not. It’s not clear whether the medical home model is truly improving clinic performance, or whether the program simply appeals more to the better clinics in the state.

The authors also noted that it was difficult to separate the impact of the medical home from many of the other transformations occurring in health care at the same time, including the formation of the CCOs, the Medicaid expansion under the Affordable Care Act and the launch of the health insurance exchange. And it may also be tough to get widespread consensus on primary care payment increases, if that leads to lower spending for hospitals or specialists.

“There’s no way this program will survive and the great work will continue unless we find a way to make it viable for the providers across Oregon,” said Mylia Christensen, executive director of the Oregon Health Care Quality Corporation, “We’ve heard loud and clear that a lot of this work was difficult and challenging. But we need to figure out a way to pay providers in a different way than we have.”

Meanwhile, clinics are facing increasing reporting requirements from various public and private health plans, in addition to the measures needed to be certified as medical homes under various programs. Senate Bill 231 suggested that payment reform should be done in a way that aligns those requirements with those of federal healthcare programs.

“We’re trying to look for opportunities to standardize and align so that we can reduce the amount of variation across payers,” said Leslie Clement, director of health policy for the Oregon Health Authority. “We’re not there yet.”

Even if all those hurdles can be cleared, primary care homes may represent only a part of the solution to bending the cost curve and transforming health care. Rising costs for prescription drugs and new technology, expensive hospital stays and specialty care all remain drivers of health care spending.

But proponents believe the medical home model could provide a foundation on which further reforms can happen. The approach could begin to change the culture of health care from a reactive system to a proactive system, from one that rewards doctors and hospitals for surgeries and procedures, to one that rewards keeping patients healthy.

“I think it’s a big piece to hang this on structurally,” Wallace said. “If you can get people moving through the system the right way, it gives you a chance to get everything else right.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

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