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Physician collaboration is difficult for small practices under today’s payment models, but its importance is growing.
Small physician practices are struggling with the burden of implementing care coordination strategies that they say stretches their finances, strains their workload and impedes their ability to deliver quality healthcare.
Designed to improve collaboration among care teams spanning the continuum of care, care coordination efforts at small practices have had the opposite effect.
Just ask internist Michael Soppet, MD, who signed up for a three-year pilot program that began in 2010 to establish a patient-centered medical home (PCMH), a model of care that relies on increasing the extent and effectiveness of care coordination for chronically ill patients.
“Care coordination was one of our major difficulties because of the interoperability problem,” Soppet says. “Sharing information between providers has not been made any better by our electronic capabilities. That’s still something we have to do by hand.”
Doctors are inundated with data entry chores to meet regulatory requirements and are disappointed that after substantial investments in electronic health records (EHRs) they can’t exchange patient data with outside hospitals or other providers using different EHRs.
Typically, care teams working closely together can improve patient outcomes, prevent hospitalizations and improve healthcare overall. Yet for small, independent practices, the goal of developing an effective care coordination plan is unachievable.
The problem, physicians say, boils down to limited resources, the lack of interoperable health IT systems and payment plans that don’t offer enough money to cover care coordination costs.
While care coordination isn’t possible today, it could be. The federal government has outlined an interoperable health IT infrastructure plan, and notes that by 2024 the healthcare system will have an array of interoperable health IT products and services that will support transparency and provide access to real-time patient data.
This coincides with healthcare policymakers’ focus on care coordination that aims to replace a fragmented system of care with a more cohesive model. For care coordination to work, healthcare facilities must collaborate better on the planning, execution and management of patient care through integrated systems and processes that prevent bottlenecks during the course of the patient’s treatment.
The promise of care coordination was one feature of the PCMH that attracted Soppet to signing up for this model of care.
Soppet, who until last January was one of seven physicians in a group practice in Dothan, Alabama, says care coordination required him to develop a closer working relationship with other physicians as well as nurses, social workers and other caregivers, and he expected clinical teamwork to be a forceful driver in the effort to improve quality measures for patients.
During the pilot program, which ran from 2010 to 2013, there were improved quality performance metrics for patients with diabetes in several areas including hemoglobin A1c monitoring, low-density lipoprotein (LDL) cholesterol monitoring, nephropathy screening and treatment, and retinal exam rates.
Additionally, colon cancer screening rates for patients exceeded 70%, and immunization rates improved for pneumococcal vaccinations to over 80%, Soppet says.
While patients were seeing improvements under the PCMH model, the attempt to redesign the practice to support care coordination goals was financially burdensome, physically exhausting and deeply frustrating to Soppet and his staff.
For a start, care coordination was hamstrung by the lack of interoperability among different EHR systems. The inability of Soppet’s EHR to interact with those used at hospitals, specialists’ offices and pharmacies slowed the practice’s systems and increased the manual tasks its staff members were required to perform.
“To exchange data with other physician offices we had to print and fax pages to their offices to facilitate care,” Soppet says. “The promise of EHRs simply evaporated as soon as they had to perform.”
Added to this, the need for seamless bidirectional communications between pharmacy systems and the EHR at Soppet’s practice, which was crucial to care coordination, didn’t occur.
Soppet says while he could authorize refills and new prescriptions with the click of a button, he couldn’t electronically cancel a medication that he wanted a patient to stop taking. To do this someone had to call the pharmacy or send a note by fax.
As the PCMH program evolved, Soppet’s practice implemented staffing changes to accommodate the growing workload. For instance, the receptionist took on the responsibility of ordering immunizations and vaccines and making sure the office had enough of these to meet patient demand.
The practice hired seven new full-time employees to support care coordination efforts, including a receptionist, a person to oversee medical records, two nurse practitioners, a nurse for each nurse practitioner, and an IT professional.
Soppet says that for the practice’s efforts, Blue Cross Blue Shield of Alabama paid $5,750 for practice transformation to PCMH in the first year, and for performance improvements the practice received $11,000 and $20,000 for the second and third years respectively. These didn’t come close to covering the added costs of running the practice, however. Staff salary and benefits (excluding physician salary and benefits) increased from $810,000 in 2010 before adopting the PCMH model to $1.2 million in 2015.
According to Soppet, the effort to coordinate care as a PCMH increased almost every cost of running the practice.
Like many other small practices that have embarked on initiatives that depend on care teams to manage patient care, Soppet says, his practice was exposed to increased risk. That’s because the care coordination model comes with higher operational costs and less income to offset those expenses.
As physicians increasingly transition to models of care that rely on care coordination-such as accountable care organizations (ACOs), bundled payment programs and population health initiatives, in addition to PCMHs-they will need four key elements to successfully coordinate care, says Peter Cunningham, PhD, professor in the department of health behavior and policy at Virginia Commonwealth University in Richmond, Virginia.
“First, there needs to be an integrated delivery system that spans across all the different sectors-primary care, inpatient care, specialty care and even rehabilitative services,” Cunningham says.
He adds that each member of the care team must be connected to a single EHR and must be able to access and exchange data with full interoperability with all other members of the care team.
Second, the system needs non-clinicians to support care coordination. These include social workers, case managers and others who will follow up with patients before, during and after hospitalization.
For example, when a patient is discharged from the hospital the social worker needs to ask questions such as does the patient have a place to go? Do they have transportation to take them to their medical appointments? And are they going some where family members can follow up with tasks like taking their medications on-time?
“It’s important to track the minute details of the care being delivered within the system to the patient,” Cunningham says.
Third, small-practice physicians need financial incentives that can cover the additional costs of care coordination. Finally, they need a higher level of patient engagement through communication via email, mobile apps, web portals and other technologies that can help patients better manage their health.
“A lot more attention needs to be paid to using technology as a tool to teach patients how to manage their health conditions to enhance preventative care and reduce hospital readmissions,” Cunningham says.
Unfortunately, small practices face many barriers to implementing effective care coordination measures. For one, Cunningham says, many small group practices don’t have enough patients to enable economies of scale, and therefore can’t afford care coordination services.
Furthermore, many large hospital systems are purchasing small physician practices, thus controlling the entire continuum of care and excluding independent practices, Cunningham says.
As hospitals contribute to a realignment in healthcare that changes where care is delivered, and who will provide it, small practice physicians are also facing more stringent guidelines from the Centers for Medicare & Medicaid (CMS).
The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), places an even greater focus on tying clinical performance to quality metrics.
For example, under the coming Merit-based Incentive Payment System’s composite performance score, practices failing to meet quality measures could see a 4% drop in their Medicare payments in 2019 and as much as a 9% cut by 2022.
Cunningham points to the agency’s growing requirements for practices to document performance metrics, as another reason why many small group practices are finding it harder to survive.
“Most solo and small group practices won’t be able to sustain themselves in the future, and a lot of them are willing to sell their practice because it’s just too hard to stay independent,” Cunningham says.
In the meantime, small practices are having a big impact on one of healthcare reform’s primary goals: keeping patients healthy and out of the hospital.
In a 2014 study published in Health Affairs, researchers at Weill Cornell Medical College in New York City, conducted a national survey of 1,045 primary care practices with 19 or fewer physicians. The study highlighted the critical role these small practices play in lowering the rate of preventable hospital admissions.
Researchers used Medicare data to calculate practices’ rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). It showed that compared with practices with 10 to 19 physicians, practices with one or two doctors had 33% fewer preventable admissions, and practices with between three and nine physicians had 27% fewer. Additionally, physician-owned practices had fewer preventable admissions than did hospital-owned practices.
Keeping small physician-owned practices in business should be the business of every healthcare stakeholder, says Oscar Lovelace, MD, a physician in a small primary care practice in Prosperity, South Carolina.
“I’m concerned that many private practice physicians are being forced into hospital employment and can no longer be the kind of advocate for a patient that they could be if they were in private practice,” Lovelace says.
As a PCHM, his practice has added staff members to coordinate care. The new employees include a full-time nurse to manage calls dealing with patient appointments, referrals and other patient-related issues, another part-time nurse who follows up with care management related issues for all Medicare recipients and another full-time staff member with a master’s degree in health administration who updates performance metrics for preventive care and chronically ill patients.
Lovelace says the biggest barrier to meeting performance targets is the financial toll that comes with monitoring patients and documenting their care.
For example, Medicare’s Chronic Care Management (CCM) program-which covers non-face-to-face services related to visits by patients with multiple chronic conditions-requires too much documentation and timekeeping to be worthwhile financially, especially when other program may provide a better return, Lovelace says.
He estimates that it costs the practice $1,000 to $1,500 per month to collate minutes spent caring for patients enrolled in the program, construct a care plan and bill for CCM. However, under the program his office is paid between $2,500 to $3,000 per month.
A better incentive plan could be the Comprehensive Primary Care Plus (CPC+) program, a national advanced primary care medical home model that CMS says is designed to strengthen primary care through regionally-based multi-payer payment reforms and care delivery improvements.
Many of the goals of the CPC+ program, which starts January 2017, will focus on critical areas of patient care that will impact care coordination efforts, such as payment reform, performance-based incentives and improvements to health IT systems.
The CPC+ plan includes two primary care practice tracks, each with its own care delivery requirements and payment options. For example, Track 1 will include practices that are capable of delivering comprehensive primary care, while in Track 2 practices must demonstrate they can advance comprehensive care through enhanced health IT, an ability to improve care among patients with complex medical conditions and the resources and support to provide care to patients with psychosocial needs.
The tracks also have different payment plans. In Track 1 the average Medicare care management fee is $15 per beneficiary per month (PBPM), while in Track 2 the average fee is $28 PBPM.
Lovelace says he’s interested in Track 1 and its $15 PBPM fee, which when multiplied by the 800 patients that could qualify from his practice would bring in $12,000 a month. That sum could make a world of difference to his practice, Lovelace says.
Similarly, Brad Klein, MD, would like to practice medicine as an independent physician for as long as he can. Klein is a 40-year-old neurologist, and one of eight physicians in a group practice in Abington, Pennsylvania. His office participates in a bundled payment program for stroke patients.
Bundled payment programs replace the traditional practice of charging separately for services such as surgical procedures, post-operative care, and physical therapy, which generates multiple claims from multiple providers, with a model that compensates care teams with a target amount under one bundled payment.
Because care teams rely on the work of their colleagues to keep patients healthy, Klein says CMS’ requirement for quality measures in determining reimbursements raises two key questions: To whom will these quality measures be attributed in a coordinated care model? And who will be penalized if physicians can’t control the quality of their colleagues’ work or the patient’s adherence to the care plan?
“It seems that physicians become liable for patient outcomes, resulting in more responsibility and financial risk on them in the process,” Klein says. “At that point it becomes demotivating to a practicing physician who provides excellent care to patients, but may not be able to succeed in providing idealized clinical measures despite their best efforts.”
Another element of care coordination is improving patient education and engagement. Under Meaningful Use, doctors are required to provide information to patients to advance education and knowledge about their condition. However, Klein says there’s no data showing this works.
“With all the additional measures required by physicians to ‘prove’ quality, it’s as if the physicians and patients are now facing death by a thousand clicks,” Klein says. “I have to find an alternative because supporting new models of care that drain a small practice’s budget is not going to fly.”