TEN TRANSFORMATIVE TRENDS 2021 Primary Care continued from page 20
for primary care practices to use. That is a natural second stage after you make a policy commitment. It leads into issues like community health teams and greater integration of behavioral health,” he adds. “Those are all capacities we need to fi ght the pandemic. It is of grave concern that the money appropriated under the CARES Act has subsequently gone to bail out hospitals. It hasn’t gone to build up primary care. I think we who are concerned about this are doing our best to raise awareness about the fact that if you want to have a pandemic-resilient delivery system, you have to have strong primary care.”
Christopher Koller
Maryland’s approach For several years, the State of Maryland has been working with the Center for Medicare & Medicaid Innovation to move all the hospitals in the state from fee-for-service to a globally budgeted system. Both the federal government and the state soon recognized that they couldn’t achieve a balance and effectively reduce the hospital and emergency department high cost and unnecessary utilization without engaging with ambulatory providers at the same time. That led to the creation of the Maryland Primary Care Program, a voluntary program open to all Maryland primary care practices and modeled after the CMMI’s national Comprehensive Primary Care Plus (CPC+) pro- gram. More than 560 practices —about two-thirds of the practices in Maryland — are participating in the network. In the fi rst year of the program, Medicare was the only payer. CareFirst BlueCross BlueShield, the state’s largest commercial payer, joined in 2020. Several of Maryland’s federally qualifi ed health centers joined in January 2021. “What we really want to do is change the way we deliver healthcare in the state to make it equitable, and we provide suffi cient resources, particularly for those previ- ously under-resourced Medicare fee-for-service benefi ciaries by making strategic investment in primary care,” explains Howard Haft, M.D., the program’s director. “We knew there was insuffi cient care management in primary care, insuffi cient access, and insuffi cient data manage- ment across the continuum of care. We knew there was virtually no behavioral health integration into primary care — and that was a big issue.” One of the things the Maryland team saw when look- ing at the CPC+ program was that for small and medium-sized practices, it was hard to access care management, pharmacists, and social workers. “We created care transformation organizations around the state that can use economies of scale and serve these practices with a simplifi ed contractual design to provide a pro-rated amount of pharmacist or LCSW (licensed clinical social worker) or care manager,” Haft explains. “We have 24 of those across the state,
and 70 percent of the practices choose to contract with those to one degree or another. In addition, 96
percent of practices had integrated behavioral health to some degree by the end of the fi rst year.” One ingredient of the “secret sauce” making the program work involves feeding data back to practices in individualized dashboards through the state health informa- tion exchange, CRISP. “We provide meaningful, actionable data to everyone in the program,” Haft says, “as well as the resources that allow them to understand how to use that data in their work fl ow. We engage a team of practice coaches and we do ongoing education.” The federal Primary Care First alternative payment model is enrolling practices
now. It is intended for practices that are willing to accept a small amount of downside risk for the total cost of care in exchange for upside benefi ts. “Think of it as more than CPC+ but less than an ACO [accountable care organization],” Koller explains. “It is meant for primary care practices that have transformed and are ready to take on risk. I think there needs to be a focus on the primary care practices that are still being paid in fee-for-service. There are practices ready to do the complex and comprehensive payment mechanisms, but the majority of doctors are still on fee-for-service and we have to get them off of that. That left us very poorly prepared for the pandemic, and I think that should be a policy goal.” Haft stresses that other nations around the world that have better health outcomes and lower costs are largely characterized by making more investment in primary care and having larger, more effective primary care programs. “We can’t fi x the vexing problem of higher per capita expense and mediocre results with the same tools that created it,” he says. “We need different tools.” HI
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Plunge Into Risk continued from page 22
So when you have huge fi xed-cost assets to pay down, you go for what’s easier, which is more fee-for-service encounters, rather than ensuring a wider catchment of patients assigned to you, and keeping them out of inpatient. It’s not that hospitals have anything but the best interests of patients in mind, but they have ORs and staff, and have to cross-subsidize a lot of operational costs that frankly, primary care physicians just don’t have to do.” Still, in the next two years, he says, “You’ll see all payers push- ing more downside risk onto all providers. So you’ll see Medicare Advantage [MA] growing signifi cantly over the next couple of years. Just remember, with ACOs, you might achieve savings, but it’s not so cer- tain, whereas MA has a lot more certainty, because of the risk adjustment scores, so physicians can more accurately prospec- tively prepare for their risk, whereas in ACOs, it’s retrospective.”
Elements involved in moving into risk Meanwhile, what are some of the elements playing an active role in the calculations of provider organizations of all kinds, in choosing to get involved in two-sided risk? “Whether you’re a multispecialty group practice, a large integrated system, or anywhere in between, you’re looking for a couple of things before moving into risk, says Darryl Drevna, senior direc- tor, regulatory affairs, at the Alexandria, Va.-based AMGA (American Medical Group Association). “First, do you have the population to support it? How many covered lives do we have? The other thing is stability in the framework around the regulations that manage these programs. Per the MSSP, there’s been a whole lot of shifting in terms of what’s expected, under Pathways to Care. In this latest round of rulemaking, they made fairly signifi cant changes to how providers have to report on quality. And those are major for providers, because they have to dig in and fi gure out whatever they need to change care delivery models, workfl ows, staffi ng; you can’t turn these ships around in mid-ocean.” Meanwhile, those organizations push-
ing for payment innovation will continue to do so; certainly, Drevna says, AMGA will be in that group of providers. “AMGA and its membership will continue to go towards value-based and population health-based models, because there’s really no alternative,” he says. “That said, what HHS [the Department of Health and Human Services] is going to do in this area will depend on who’s staffi ng HHS, how we come out, post-pandemic, and what our capacity is. But we’re going to keep moving ahead, and I’m going to be working to make sure that HHS and Congress see us.” HI
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