Employer Healthcare Solutions

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 20 The CMS requirements and unintended consequences.  In the typical FFS ACO, one of the previous core metrics that CMS has offered is the percent of patient enrolled in care management.  That metric drives care managers to “enroll” patients within the ACO by completing an intake process.  The payment associated with that metric was tied to the percent of the population enrolled in a measurement period. So how does this work in the real world? With that as the primary incentive to drive the ACO bonus payment then the nurses are asked to enroll as many patients as possible, regardless of risk, need or outcome.  Enrolling patients is the focus, not the actuation of patients to follow their care plan, nor the engagement of the patient with the CM nurse or their care team.  The result is a churn of patients with brief stints with care managers, then being discharged back to their own devices whether or not they have actually changed behaviors in a meaningful way.  Nurses asked to work this way are keenly aware that they are not able to build relationships effectively nor are they always proactively seeking out those patients with the greatest need, as they are often the harder to engage.  When volume is the primary metric, we see burnout and frustration wearing down these nurses from this moral injury. The 2024 MIPS Quality Benchmarks continue to evolve with both process and outcomes measure with highly detailed definitions of each numerator and denominator that qualifies a system to gain a tic mark towards achieving the metric.  The 466 potential measures boggle the mind and are largely process measures and a number of these measures are very targeted to specific actions (i.e., perform screening for social determinants of health, a charge submitted for advanced care planning, a plan of care after a fall).  Nowhere is there a reward for reducing the health risk of the patient as a whole person.  There is a nod to patient engagement with the Person Centered Primary Care Measure, which is one of the few measures that actually looks at a person’s relationship to their care team, and especially a care management nurse if they are high risk and are lucky enough to have a care manager embedded in their primary care team. We so need fewer but better, more manageable metrics that focus on outcomes, lowering health risk and thus lowering costs.  The complexity of data collection for 466 measures and even to know if they are accurate, is an enormous challenge.  As a primary care physician, I want my care management nurse to work alongside me with my complex high-risk patients to help them understand their plan of care and adhere to it as much as possible, given the constraints of their life.  The number of patients my care manager follows should be dependent on their complexity and the amount of engagement effort it takes to get them to change behavior in a positive way.   This is where an accurate risk tool truly pays off – to both identify the best patients for care management but also to understand the workload posed by each of those patients. Kathleen Dalton, RN, CCM, CMGT-BC [email protected] Michael Tuggy, MD [email protected] Scott Conard, MD                   Susan Lindstrom             Laurence Bauer, MSW, MEd [email protected]       [email protected]     [email protected]

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 19 One of the main objectives of primary care and within value-based payment models is to improve patient outcomes and reduce the cost of care.  The top 8-10% of the population consumes about 80% of the healthcare dollar in the United States.  The highest risk patients on every primary care clinician’s panel are those with complex medical, psychological and social needs. In the current fee-for-service paradigm, many health systems, insurers and ACO’s have moved nursing resources from direct clinical nursing to care management roles to try to assist this highly vulnerable population.  However, care (or case) management has often grown out of inpatient nursing departments, moving to transitional care management (to prevent readmissions) and now are trying to perform in outpatient settings with very mixed levels of success. We have observed and scrutinized a number of care management services, and we see several common themes that we feel need to be addressed if we are to truly have an impact on improving patient outcomes AND retain skilled, caring nurses to perform this vital service.  We will dissect these in a series of blogs to dig deeper into the issues that many if not most care management services face. Kathleen Dalton, RN, CCM, CMGT-BC [email protected] Michael Tuggy, MD [email protected] Scott Conard, MD                 Susan Lindstrom                 Laurence Bauer, MSW, MEd [email protected]        [email protected]       [email protected]

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 18 The message is clear: Investing in primary care is a powerful and effective strategy to improve healthcare outcomes, reduce costs, and promote equity. Decades of research have consistently shown that enhanced primary care leads to: Focusing efforts and resources on primary care rather than trying to reduce spending on sub-specialty and hospital-based care is a more efficient approach. Strengthened primary care has a ripple effect, improving the entire healthcare system by forcing downstream players to adapt and improve their practices. This shift can lead to significant reductions in the administrative super-structure and overall costs. Attempting to reduce costs by focusing on sub-specialty and hospital care is arriving at the dance too late. By the time patients require these high-level services, the opportunity to avoid, mitigate, or reverse disease has often passed. Here’s why: For employers, investing in primary care can result in better health for their employees, effectively providing a pay raise and increasing payments to shareholders. We have the evidence to support these claims. The data is clear: enhancing primary care is the key to a healthier, more equitable, and cost-effective healthcare system. Scott Conard, MD              Michael Tuggy, MD                       Susan Lindstrom         Laurence Bauer, MSW, MEd [email protected]     [email protected]   [email protected]   [email protected]

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 9 Sponsored by              WWW.THEMDCEO.COM A care plan is what the clinicians do all the time. We see patients and decide here’s how we’re going to manage this problem either with medication or behavior changes or testing that needs to be done for follow-up. We do a lot of this work already in our clinical notes. What we’re asking the clinicians and the clinical team to do is to write notes in order to share that information across the teams and across the specialties. It provides a consistent place where we look in order to know what the current plan of care is for that particular problem. That’s really the goal of what we’re trying to work on. Find a place in your electronic record where this communication can happen. We believe the best place for this to happen is in the problem list. You keep an active problem list that’s up to date on every patient with active problems. Here’s the plan of care for each of those problems. It’s in a centralized location so you don’t have to dig through encounters or notes in order to figure out what’s the plan for their CHF. It’s right there in the problem list so everybody’s clear what the care plan is and then if somebody needs to modify it, whether it’s another specialty clinician that’s seeing the patient or maybe the care management nurse who’s on the phone with the patient, if something needs to be changed or updated it can be done in one place We love the term “storyboard” where in an EMR it tells the story of a person and their needs and the commitment of the team to execute against that. We don’t know if that’s common in all EMRs but that’s the one that we’ve been using in Jamaica Hospital that works. Many of the other EMRs have a similar kind of panel that shows what the overall care is for the patient, but it’s often very broken up. But the problem list in Epic, for instance, is in the Storyboard and you can hover your mouse over it and it pops up another window and it shows all the active problems. Brilliantly it also includes the content in the overview box of Epic in that snapshot view which actually has their care plan written in it if you’ve put it in there. That’s why we’re working with those teams to use that overview section of the Epic problem list in order to record the care plans. The key to implementing the Advanced Primary Care model is to increase case management and clinical integration. The patient is connected to the primary care team and both are connected to the sub-specialty services when those are needed. It must all be woven together seamlessly. Scott Conard, MD              Michael Tuggy, MD                  Susan Lindstrom                 Laurence Bauer, MSW, MEd [email protected]   [email protected]   [email protected]   [email protected]