Warren Clinic, a division of St. Francis Health System in Tulsa, Okla., has a nurse on staff who keeps in touch with high-risk patients and their doctors.
Using data, a team approach, and plenty of follow-ups, this nurse standardized the way diabetic patients at two of the system's practices would be treated. In less than two years, the tactic dropped the rate of diabetic patients with elevated blood sugar levels from less than 96% to 24%.
The care guidance nurse role was created after Warren enrolled about a dozen or so of its practices in a primary-care pilot program aimed at reaching the triple-aim goal of lower costs and improved care quality without sacrificing patient satisfaction.
Now, Warren's experience and the data gathered from participants across the country is paving the way toward value-based payment.
The CMS last week announced it is expanding the four-year pilot launched in October 2012. The federal government will engage public and private payers and about 20,000 providers in 20 regions.
Just as before, providers will be encouraged to identify and work with patients who had multiple conditions that led to frequent doctor visits and hospitalizations.
The clinics will be given monthly care-management fees for each beneficiary in addition to regular fee-for-service payments. The monthly amount will come whether or not a patient interacted with the practice that month.
The practices will need to revamp their delivery care models to focus on five areas: access to and continuity of care; planned care for preventive and chronic needs; risk-stratified care management; engagement of patients and their caregivers; and coordination of care with patients' other providers.
In Warren's case, the care guidance nurse helped zero in on those goals. Providers also began “huddles” every morning to discuss patients. The clinics created patient-family councils for regular roundtable discussions of a person's care.
Change was slow for the first several months, but now doctors don't want to return to their previous methods, said Warren's chief medical officer, Dr. Steve Sanders.
In a JAMA piece last week, CMS officials said they want the expanded pilot called the Comprehensive Primary Care Plus Initiative to make physicians' practices “incentive neutral” and free them from feeling “tethered to the 20-minute office visit.”
The CMS will offer two ways to incentivize providers.
In the first track, the CMS will pay a risk-stratified monthly fee for each patient's care- management services, in addition to fee-for-service Medicare payments for primary care.
In the second track, physician practices will receive reduced Medicare fee-for-service payments and more generous upfront care-management payments. The CMS says this “hybrid” payment model will allow providers flexibility to experiment with telemedicine visits or provide longer office visits for patients with complex needs.
In both tracks, providers must return incentive payments (awarded per beneficiary, per month) if they fail to meet cost and quality targets.
Sanders was so pleased by the pilot's success that he's ready to get on track 2.
“I think this model has demonstrated intangible results . . . and I think it's really the wave of the future,” he said.
The agency estimates that track 1 will be budget-neutral and that track 2 will save about $2 billion over the initiative's five-year run, assuming physicians are willing to take the risk.
Cigna Corp., which participated in the pilot, said the savings were not enough to expand the program.
In a New England Journal of Medicine article, Mathematica Policy Research evaluated the initiative's first two years and found modest but impressive improvements.
The pilot has not yet shown net cost savings, but reduced spending enough to almost cover the monthly care-management fees. These results should be interpreted with caution but are “promising and more favorable than might be expected,” according to the report.
A CMS official said the overall savings of the expanded program are not expected to offset its fees in the first years. The agency expects to see more savings as practices learn and make adjustments. The pilot's savings came mostly from a reduction in inpatient and skilled-nursing-facility payments as well as outpatient primary-care services.
Quality changes were more difficult to determine because of limited data, but there were positive notes. The CMS expects to learn more when provider-level data becomes available in addition to claims data.
There is not a lot of research on different models of delivering primary care. Previous studies were usually too small to produce actionable results or did not gather enough information on costs.
Stacy Dale, associate director of health research at Mathematica, said the pilot required a dramatic cultural shift for many practices. They added clinicians, redesigned workflow and began evaluating more data. A doctor participating in a similar program said it was like changing a plane's course in midflight.
“It takes some time for the changes . . . to actually translate in cost reductions,” she said.
So despite the limited improvement, the results exceeded expectations, said Deborah Peikes, a Mathematica senior fellow.
She said she was surprised that patient satisfaction appeared to improve slightly even when practices were in the process of transitioning.
Dr. John Ayanian, director of the Institute for Healthcare Policy and Innovation at the University of Michigan, said the modest results show that efforts should go beyond just primary care and may need to incorporate additional alternative payment models.
But some experts believe that the expanded program could siphon attention from more robust alternative payment models such as the Medicare Shared Savings Program for accountable care organizations.
Ayanian, who was not involved in the study, co-authored an accompanying editorial in the NEJM.
Individualized and more intense primary care should be included in payment reform models for effective, comprehensive change, he said.
“Primary care, while important, represents only a fraction of the total spent and the care needs of these patients,” he said.
More and stronger incentives may be needed to get practices involved, but “most providers realize this is the direction our healthcare system is moving in, and it's important to adapt,” he said.