Reform Update: Coordinated care alone may not yield ROI, ACPE told

A federally funded effort to identify high-risk patients and coordinate their care is delivering modest savings, but significant cost reductions may come only after broader payment reforms take hold.

The “medical neighborhood” demonstration is generating savings of about 5%, which may not be enough to yield a return on investment for providers, according to preliminary findings shared by Dr. Bruce Bagley, president and CEO of TransforMED. “And that's a problem,” Bagley said, speaking at the American College of Physician Executives annual meeting in Chicago.

TransforMED, a consulting subsidiary of the American Association of Family Physicians dedicated to patient-centered medical homes, is carrying out the experiment with a $20.75 million grant from the CMS Innovation Center, and Bagley cautioned that the CMS had not yet certified the numbers.

The demonstration is expected to generate $53.8 million for the 15 participating healthcare organizations that coordinate primary care, specialist care and hospital services for high-need patients. It is now in its second year and will expand to include more organizations next year, so Bagley said he expects the project to register a big jump in savings after the wider implementation.

Bagley said in an interview before the ACPE meeting that, in order for the benefits of coordinated care to make an impact in terms of quality and cost, more progress needs to be made in terms of rewarding value over volume and paying for care coordination. “If all you get paid for is a visit, you're crazy to do anything different from a business standpoint,” he said.

Significant improvements in cost and quality may not be felt until fee-for-service falls below 50% of provider reimbursement, he told attendees.

The new chairman of the Senate Finance Committee, Sen. Ron Wyden (D-Ore.), introduced legislation earlier this year known as the Better Care, Lower Cost Act of 2014 that would structure payment for treating the sickest Medicare beneficiaries and focus on strategies that keep them out of the hospital. The legislation has Democratic and Republican sponsors in both the House and the Senate.

Wyden's influence as Senate Finance chairman means the bill has a good chance of gaining traction. Chet Speed, the American Medical Group Association's vice president for public policy, said recently he expects Wyden's bill to be incorporated into legislation to repeal Medicare's sustainable growth-rate formula for physician reimbursement—as long as Democrats hold the Senate and Wyden keeps his post.

Bagley also addressed the important role of team-based care, in which nurse practitioners or physician assistants handle routine cases while doctors concentrate on patients with complex problems.

“There has been a lot of lip service about team-based care but, by and large, we still have the hero model,” Bagley said. True team-based care, he said, includes creating a shared sense of responsibility for cost and quality.

An audience member, however, commented that most physicians were not trained to manage healthcare teams. “Who was taught how to use an NP?” she asked as no hands went up.

Dr. Joe Selby has been executive director of the Patient Protection and Affordable Care Act-created Patient-Centered Outcomes Research Institute for almost three years now, but he still spends a lot of time explaining what his organization does and does not do.

PCORI is not, for example, another government agency but rather an independent, self-governed entity, said Selby, who spoke at the American College of Physician Executives annual meeting in Chicago. No one has to participate in PCORI research. PCORI does not maintain a large, central patient database. Nor does it ship large amounts of identifiable patient data to researchers across the land.

What PCORI does do is assist patients, clinicians, purchasers and policymakers in making healthcare decisions, Selby said. PCORI focuses its research on findings that are likely to change clinical practice and investigations where the outcomes have to matter to patients.

“A high percentage of clinical and policy decisions are not supported by evidence,” Selby said.

Dr. Kent Bottles, a senior fellow at Thomas Jefferson University's School of Population Health in Philadelphia, noted that “half of Congress is not happy” with the ACA and asked Selby how that affected his work.

“There is a natural tendency to not like something the other side has put forth,” Selby said. “We're part of the Affordable Care Act and there's opposition to the ACA.”

At any given time, Selby said, there is legislation in place that would “wipe out PCORI” based on the premise that it sponsors research on healthcare rationing and death panels. “We are clearly not that,” Selby said, noting that the institute shies away from cost-effectiveness research.

The key to accomplishing PCORI's mission, Selby said, will be getting patients engaged in research that stands to benefit them. This includes spending $16.8 million to support new or existing “patient-powered” research networks (PDF).

“Patients are ready,” he said, describing their participation in electronically facilitated data collection as the “secret sauce” needed to successfully generate timely, useful research using data already collected in electronic health records.

“Current research is too slow, too expensive, unreliable and doesn't answer the questions that matter most to patients,” Selby said.

Follow Andis Robeznieks on Twitter: @MHARobeznieks