- Email: [email protected]
Patient-Centered Specialty Practice
Accepted Manuscript Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare Lawrence Ward, MD MPH FACP, Rhea E. Powell, MD MPH, Michael L. Scharf, MD, Andrew Chapman, DO, Mani Kavuru, MD PII:
S0012-3692(17)30013-2
DOI:
10.1016/j.chest.2017.01.006
Reference:
CHEST 905
To appear in:
CHEST
Received Date: 30 September 2016 Revised Date:
27 December 2016
Accepted Date: 4 January 2017
Please cite this article as: Ward L, Powell RE, Scharf ML, Chapman A, Kavuru M, Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare, CHEST (2017), doi: 10.1016/j.chest.2017.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare
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1. Lawrence Ward MD MPH FACP Department of Medicine, Division of Internal Medicine, Thomas Jefferson University, Philadelphia, PA [email protected] 2. Rhea E. Powell MD MPH Department of Medicine, Division of Internal Medicine, Thomas Jefferson University, Philadelphia, PA [email protected]
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3. Michael L. Scharf, MD Department of Medicine, Division of Pulmonary and Critical Care, Thomas Jefferson University, Philadelphia, PA [email protected]
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4. Andrew Chapman, DO Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA [email protected]
5. Mani Kavuru, MD Department of Medicine, Division of Pulmonary and Critical Care, Thomas Jefferson University, Philadelphia, PA [email protected]
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*Corresponding author: Lawrence Ward MD, MPH, FACP 833 Chestnut Street, Suite 701 Philadelphia, PA 19107 [email protected]
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Conflict of Interest: None
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ABSTRACT
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Healthcare is at a crossroads, under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. Yet primary care accounts for only a small portion of total healthcare spending, and there is a need for policies and frameworks to support high quality, cost-efficient care in specialty practices of the “medical neighborhood”. The Patient-Centered Specialty Practice (PCSP) model offers ambulatory-based specialty practices one such framework, supported by a formal recognition program through the National Committee for Quality Assurance. The key elements of the PCSP include processes to support timely access to referral requests, improved communication and coordination with patients and referring clinicians, reduced unnecessary and duplicative testing, and an emphasis on continuous measurement of quality, safety and performance improvement for a population of patients. Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based healthcare in specialty practices. The continued development of appropriate incentives are required to ensure widespread adoption.
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Title: Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare
INTRODUCTION
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Clinical Vignette: The Current Paradigm A previously healthy 66 year-old woman, Mrs. R., presented to her primary care physician with a dry cough of several weeks duration. Her primary care physician considered possible allergies and ordered a cough suppressant and antihistamine. When she returned with ongoing cough, and now also with mild dyspnea, he prescribed antibiotics for a possible atypical communityacquired pneumonia and ordered a chest x-ray. Her symptoms did not abate, and a few weeks later she was referred to a pulmonologist. The patient was concerned as her sister had died years earlier of respiratory failure from idiopathic pulmonary fibrosis. Three weeks later at her pulmonary consultation, a repeat chest x-ray was ordered, since her records had not yet arrived from the primary care doctor’s office. The report noted bibasilar interstitial lung disease and a chest CT scan was recommended, followed by a bronchoscopy and lung biopsy. Unsure of whether the pulmonologist or the primary care physician would be coordinating the next steps, Mrs. R. called to seek her primary care doctor’s advice. Several days passed with no response, and when she again called, she learned the doctor had not yet received the pulmonologist’s report. She then called the pulmonologist’s office and was told the pulmonologist had not yet finished dictating the letter, and it would be faxed out soon. Mrs. R was not alone in being unsure who was leading her care plan. As the primary care physician and the pulmonologist had no established referral agreement, the primary care physician assumed the pulmonologist would spearhead further evaluation and management, while the pulmonologist did not know whether she was providing a one-time consultation, was supposed to be co-managing the patient with the primary care physician, or was supposed to be taking over the care of the patient. Mrs. R, fearful that she might have the same condition as her sister and frustrated by inefficiency in care, entered the maze euphemistically referred to as “navigating the health care system”.
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Patients, clinicians, and policy makers alike recognize the challenges patients such as Mrs. R face in managing health and healthcare in the United States (US). American healthcare has long been characterized by a fee-for-service model emphasizing the management of acute episodes of care. This model incentivizes greater volume of services and procedures, often without attention to coordination, resource utilization, and long term outcomes. Recent health reform efforts, spurred by The Patient Protection and Affordable Care Act (ACA), seek to shift incentives in health care in order to reach the “triple aim” of improved patient experience, improved population health, and reduced per capita costs.1 Models of care such as Accountable Care Organizations (ACO) and bundled payments for episodes of care increasingly reward quality of care and reduced unnecessary healthcare utilization. By 2018, the Department of Health and Human Services intends for 50% of all Medicare payments to be through alternative payment models, and 90% of all payments be tied to quality.2 Even if a new administration alters the specific mechanisms of health reform, it is believed by many that the drive towards value over volume will continue. In order to adapt to this changing reimbursement and delivery landscape, healthcare providers need models to organize and coordinate care; and consumers need ways to identify providers with a commitment to high-value, outcome-driven care. The Evolution of the Patient-Centered Medical Home in Primary Care In the primary care setting, the patient centered medical home (PCMH) model has been the most widely adopted approach to facilitate care transformation. The core principles of a PCMH are provision of care that is: patient-centered, team-based, coordinated, and marked by
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enhanced access to care and communication and a systematic approach to improving quality of care.3 While various versions of the medical home model are employed, the most widely recognized is the National Committee for Quality Assurance (NCQA) PCMH recognition program. Since it began in 2008, over 11,000 primary care practices have been recognized, involving more than 50,000 clinicians, or 17.4% of all US primary care clinicians. With the widespread adoption of the program, PCMH recognition is no longer a mark of distinction, but increasingly a standard expectation for high quality care.4,5 PCMH recognition is also often considered a necessary building block for ACOs and other alternative payment models.3 The Medical Neighborhood
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Though a necessary foundation for change, it is increasingly recognized that primary care transformation alone is insufficient to fully manage costs and improve outcomes.6,7 Key concepts of patient-centered care models must be incorporated into all healthcare settings, including specialty practices, in order to realize healthcare delivery-system redesign.7,8,9 The American College of Physicians (ACP) and the Agency for Healthcare Research and Quality (AHRQ) have outlined frameworks to support effective coordination across the constellation of providers in the “medical neighborhood”, including those in specialty practices, hospital settings, urgent care facilities, pharmacy providers, and post-acute and long-term care.10,11 Though 55% of all medical outpatient visit costs are attributed to primary care, this accounts for just 6% of overall healthcare spending.12,13 Specialist clinicians, who play a primary role in the care of many high cost and complex patients and often perform procedures, are especially vital to impacting costs. To be successful as partners in the medical neighborhood, specialty practices need not fill the role of primary care, but rather coordinate effectively with primary care practices, other specialists, and acute care facilities.14 This makes specialty providers particularly important members of a “medical neighborhood”, and highlights the importance of proactively managing the care of their patients to reduce duplication and improve value.15
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Effective use of sophisticated data platforms are also necessary to provide high value care. Platforms linked to electronic health records, insurance claims data, and health information exchanges support coordination across primary care and specialty practices. These data platforms can inform population health strategies, such as feeding practice outreach efforts, and monitoring patient outcomes. Increasingly practices will be expected to demonstrate management of population outcome measures, many of which will be publically reported.16 For instance, endocrinologists will be asked to monitor diabetes outcomes; pulmonologists to monitor measures related to adherence to asthma treatment and hospital utilization; cardiologists to monitor echocardiogram use and the readmission rate for patients with congestive heart failure.17
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Patient-Centered Specialty Practice Recognition Building on the growing momentum behind medical neighborhood concepts, and learning from the success of the PCMH program, the NCQA announced a Patient-Centered Specialty Practice (PCSP) Recognition program in 2013. Major components of PCSP recognition are summarized in Table 1. In order to achieve PCSP recognition, specialty practices must demonstrate achievement in six standards: (1) working with primary care and other clinicians; (2) provide access and communication; (3) identify and coordinate patient populations; (4) plan and manage care; (5) track and coordinate care; and (6) measure and improve performance.18 Multiple elements may be incorporated into practice models to meet these standards, including six “must pass” required elements: written referral agreements, written referral response time protocols, team-based care, medication management, and a patient experience and clinical quality improvement program. At the time of this writing, NCQA’s PCSP program has recognized 221 practices across the US, involving over 1,100 specialist clinicians. Obstetrics
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and gynecology practices are the most frequently recognized practice type, followed by medical oncology. Multiple cardiology and endocrinology practices are recognized with only four pulmonary practices recognized to date.
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Several major health systems, including the Dana Farber Cancer Center, Johns Hopkins University, Thomas Jefferson University and the University of Kansas, have adopted the PCSP model among their employed specialty practices. Additional networks including Eastern Maine Medical Center, Inova Medical Group (VA), Unified Women’s Health (NC) and Meridian Medical Group (NJ) have also widely adopted the model for their practices. Evidence for PCSP Effectiveness
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For any given practice, potential benefits of PCSP adoption include increased patient volume from improvements in access and referral tracking, and relationships with referring providers. For the broader health system, potential benefits include improved patient satisfaction, and improved efficiency, quality and safety of care.19 Adoption of PCSP models is at an early stage, and specific evidence on the effectiveness of the PCSP model is scant. Some direction can be gleaned from evidence from the PCMH model. Early PCMH studies reported mixed success, but as PCMH-recognized practices have had more time to implement and customize the model, increasingly robust improvements have been demonstrated.20 A recent review of thirty publications from 2015 concluded that advanced primary care models like PCMH contribute to lowering health care costs and reducing unnecessary hospital-based utilization.12 The most successful approaches were those involving multi-payer collaboratives with specific incentives linked to quality, utilization, patient engagement or cost savings.
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Some inferences can also be made from specialty practices that have adopted similar patientcentered models of care. An oncology practice in Pennsylvania, originally one of the few and short-lived PCMH-recognized specialty practices, successfully demonstrated that implementation of a PCSP-like model resulted in fewer ER visits and hospital admissions, more patients receiving hospice care at the end of life, and an overall savings of nearly $1 million per physician per year.21 Other evidence may eventually be learned from an ongoing three-year study assessing the impact of the Patient-Centered Oncology Care model, an oncology-specific model of care, on patient experiences, quality of care, and acute care utilization. Early reports from this study find little standardization across pilot practices converting to patient-centered oncology care models, and suggest that establishing structures for care coordination, quality measurement and improvement should be priorities for practices considering transformation to a patient-centered model of care.22 Undergoing the PCSP transformation
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Achieving PCSP recognition may require structural changes in practice infrastructure and workflows as well as cultural shifts towards team-based coordinated care. Practices seeking to achieve PCSP recognition will benefit from strategies that have proven useful in supporting primary care practice transformation. Adopting an approach recommended for primary care practices looking to transform to PCMH,23 specialty practice leaders should consider completing a practice assessment that includes examining the competencies of existing staff, reviewing workflows, assessing status of referral management and communication, and evaluating information technology needs. Once completed, the practice can then introduce new care coordination workflows, implement communication agreements with referring providers, and engage in new modes of communication with patients. Office policies and clinical workflows must be clearly documented and key practice administrative and clinical quality data must be able to be produced on a regular basis. Though not a specific requirement, an electronic health record is vital to the recognition effort. A physician champion and an administrator or project manager with time dedicated to the transformation effort can facilitate operationalizing new
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workflows and facilitate culture shift. When available, external consultants, sometimes referred to as practice coaches, can help practices navigate these changes. Upfront changes and the actual application process may take from 6-12 months to complete, but maintenance of workflows and sustained efforts are required. Incentives for PCSP Recognition
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Financial incentives through insurance company programs were integral to widespread PCMH adoption, and similar incentives can encourage PCSP adoption. Notably, the recently finalized Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may propel adoption of models like PCSP forward. The law created two reimbursement pathways: Alternative Payment Models (APM) and Merit-Based Incentive Payment System (MIPS). Providers who are part of programs that accept potential downside risks, such as certain ACOs or CMS’s Oncology Care Model, fall into the APM pathway. Specialty providers who are not part of an APM, likely the majority of specialists, are reimbursed through the MIPS pathway. The first MIPS performance year began January 1, 2017 and MIPS-qualifying practices will be subject to adjustments in their 2019 Medicare fee-for-service payments that are based on performance year 2017. MIPS payment determinations will be based on performance in four categories: cost, quality, clinical practice improvement activities and advancing care information. Under the proposed rules, PCSP-recognized practices would receive the highest potential score for the clinical practice improvement activity category.24 Meeting the requirements to achieve PCSP recognition will also position a practice to succeed in other categories by facilitating optimal resource use, quality measure reporting and performance, and use of technology.
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Insurance company programs may also incentivize adoption of the PCSP model. Currently, there are several major insurers supporting the model including Blue Cross-Blue Shield of North Carolina, and UPMC Health Plan. A PCSP pilot program supported by Anthem Blue Cross has demonstrated positive initial results, reporting reductions in over-utilization, enhanced access to care and improved care coordination. Payer support for PCSP varies by market and may include transformation assistance, practice coach support, and limited incentive payments for PCSP recognition. In primary care, per-member per-month bonus payments in capitated networks or similar plans reward practices for achieving and maintaining PCMH recognition, however few such payments for PCSP recognition exist to date. As specialty practices adopt and grow PCSP models, payment models will need to align with stages of model development.23 Practice Transformation and Recognition Costs
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Financial incentives may help offset costs related to building PCSP infrastructure, applying for recognition and sustaining the effort over time. Costs will vary by practice size, type, and setting. Upfront costs may include hiring new personnel to implement team-based care and manage population outreach. Some practices may also make investments in information technology tools for population management. With the appropriate personnel and support in place, a practice will incur additional costs for the application development and submission. Though exact estimates of the cumulative cost for this process are unknown, some inferences can be made from PCMH experiences. One primary-care based study of PCMH application costs estimated between $11,453–$15,977 to develop and submit a successful application, including salary support for staff preparing the application and submission costs.25 Many practices engage consultants to assist with the application process, which would bring additional costs unless incentivized from payer or other sources. Costs related to sustaining PCSP recognition are also not yet known, though again, inferences may be made from primary care. A recent study estimated the average per-member per-month cost of maintaining a highperforming PCMH of 2,000 patients to be $3.85 in Utah and $4.83 in Colorado.26 These
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estimates, however, do not distinguish between incremental costs and shifting of existing costs, and practices will need to evaluate existing costs and estimate net costs compared to net benefits to understand value for the practice.27
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Some cost considerations underscore tensions inherent in transforming from a fee-for-service to a value-based reimbursement landscape. Pre-consultation exchanges between primary care and specialist clinicians, encouraged by the PSCP model, have potential to decrease revenue for specialists if they replace revenue-generating consultations.28 Overcoming challenges such as this will require incentivizing innovative and nontraditional methods for communication that do not entirely rely on an office visit.29 Reimbursement models must support specialty practices to make these types of leaps into the value-based future.
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There are yet other challenges to implementing and optimizing coordinated, patient-centered care. Lack of EHR interoperability may be one barrier to fully coordinated care. The culture shifts required to move towards value-based care models may present another challenge, including the shift towards measuring and reporting of process measures, which are often proxies to outcome measures. These measures can be coupled with qualitative feedback from patients to ensure that a practice has a full understanding of the quality of care provided. Feedback from patients through patient advisory councils are encouraged in the PCSP model and can help to assure that a practice is truly delivering patient-centered care. Clinical vignette: A Potential Future Paradigm
Conclusion
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Envisioning an alternative, patient-centered pathway for the patient described at the outset, Mrs. R, potential benefits of the PCSP model become clear. A PCSP-recognized practice would have mechanisms in place to offer patients quick access for consultation, and Mrs. R would have seen a pulmonary specialist promptly. Communication with the referring provider would have been optimized, reducing the need for redundant testing, and referral a thoracic surgeon for biopsy could be well coordinated, with her primary care doctor involved at each step in her care. Mrs. R could focus less on “navigating the health system” and more on her health.
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The US healthcare system is under scrutiny from the public, regulators, and payers, and innovative models are needed to deliver timely, high-quality care, using appropriate resources. The PCSP model, like its predecessor PCMH, offers a path for specialty practices to coordinate care, improve access and communication, and reduce duplicate testing. As health reform efforts to improve quality and experience of care move forward, pulmonary and other specialists have an opportunity to shape the vision of patient-centered care through adoption of the patientcentered specialty practice model of care.
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Huang X, Rosenthal MB. Transforming Specialty Practice — The Patient-Centered Medical Neighborhood. N Engl J Med 2014;370(15):1376–1379.
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Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q 2011;89(1):39–68.
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O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med 2011;171(1):56– 65.
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10. The Patient Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with specialty/subspecialty practices [Internet]. American College of Physicians; 2010. Available from: https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/ pcmh_neighbors.pdf
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11. Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms [Internet]. Agency for Healthcare Quality and Research; 2011. Available from: https://pcmh.ahrq.gov/sites/default/files/attachments/Coordinating%20Care%20in%20the% 20Medical%20Neighborhood.pdf
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12. Nielsen, M. Buelt, L. Patel, K. Nichols, L. The Patient-Centered Medical Home Impact on Cost and Quality, Review of Evidence, 2014-2015 [Internet]. Patient-Centered Primary Care Collaborative; 2016. Available from: https://www.pcpcc.org/sites/default/files/resources/The%20PatientCentered%20Medical%20Home%27s%20Impact%20on%20Cost%20and%20Quality%2C %20Annual%20Review%20of%20Evidence%2C%202014-2015.pdf 13. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007;22(3):410–415. 14. Kirschner N, Barr MS. Specialists/Subspecialists and the Patient-Centered Medical Home. Chest 2010/1;137(1):200–204. 15. Laine C. Welcome to the patient-centered medical neighborhood. Ann Intern Med 2011;154(1):60.
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16. Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N Engl J Med 2016;374(6):504–506. 17. Spatz C, Gabbay R. The Patient-Centered Medical Neighborhood and Diabetes Care. Diabetes Spectr 2014;27(2):131–133.
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18. 2016 National Committee of Quality Assurance PCSP Recognition Standards [cited 2016 Dec 18]; Available from: http://www.ncqa.org/programs/recognition/practices/patientcentered-medical-home-pcmh/during-earn-it-pcmh/other-pcmh-resources/pcsp-2016recognition-scoring.
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19. Kim B, Lucatorto MA, Hawthorne K, et al. Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities. J Multidiscip Healthc 2015;8:47–58. 20. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care 2012;18(2):105–116.
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21. Sprandio JD. Oncology Patient–Centered Medical Home. J Oncol Pract 2012;8(3S):47s– 49s. 22. Tirodkar MA, Acciavatti N, Roth LM, et al. Lessons From Early Implementation of a PatientCentered Care Model in Oncology. J Oncol Pract 2015;11(6):456–461. 23. Barr MS. The Patient-Centered Medical Home: Aligning Payment to Accelerate Construction. Med Care Res Rev 2010;67(4):492–499.
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24. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models [Internet]. Department of Health and Human Services Centers for Medicare and Medicare Services; 2016 [cited 2016 Aug 15]. Available from: https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-program-meritbased-incentive-payment-system-mips-and-alternative-payment-model-apm
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25. Halladay JR, Mottus K, Reiter K, et al. The Cost to Successfully Apply for Level 3 Medical Home Recognition. J Am Board Fam Med 2016;29(1):69–77.
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26. Magill MK, Ehrenberger D, Scammon DL, et al. The cost of sustaining a patient-centered medical home: experience from 2 states. Ann Fam Med 2015;13(5):429–435. 27. Barr M. Payment Should Align with Patient-Centered Care: NCQA Responds to Annals of Family Medicine PCMH Costs Study [Internet]. NCQA Blog. 2015 [cited 2016 Sep 22];Available from: http://blog.ncqa.org/payment-should-align-with-patient-centered-carencqa-responds-to-annals-of-family-medicine-pcmh-costs-study/ 28. Greenberg JO, Barnett ML, Spinks MA, Dudley JC, Frolkis JP. The “medical neighborhood”: integrating primary and specialty care for ambulatory patients. JAMA Intern Med 2014;174(3):454–457. 29. Yee HF Jr. The patient-centered medical home neighbor: A subspecialty physician’s view. Ann Intern Med 2011;154(1):63–64.
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Acknowledgements: The authors would like to thank Dr. Michael Barr from the NCQA for his assistance in reviewing this manuscript.
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Table 1: Major Components of PCSP Recognition Basic Description
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PCSP 2016 Recognition Category
The specialty practice promotes effective communication and care coordination between themselves and primary care physicians/referring providers. The referring provider sends appropriate information and the specialist provides a timely response with a process to transition patients back to primary care. If a self-referred patient does not have a primary care physician, the specialist has a process to connect them with one.
2. Provide Access and Coordination
The practice has processes to facilitate access for patients and advice to referring providers. A clearly defined care team exists at the practice and meets regularly (e.g. huddles).
3. Identify and Coordinate Patient Populations
The practice collects patient information and clinical data, which is used to generate lists for outreach to close care gaps. Clinical decision-support interventions are implemented (e.g. point of care reminders).
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Plan and Manage Care
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1. Working with Primary Care and Other Clinicians
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5. Track and Coordinate Care
6. Measure and Improve Performance
The practice collaborates with patients and their caregivers to develop and implement a care plan. Practices review and reconcile medications and have the ability to e-prescribe.
The practice is able to track and follow-up on referrals, labs and studies. The results can be exchanged with referring providers and coordination occurs with ERs and hospitals. The practice is able to measure multiple aspects of their performance and performs continuous quality improvement.
Based on 2016 National Committee of Quality Assurance PCSP Recognition Standards18
1
S0012-3692(17)30013-2
DOI:
10.1016/j.chest.2017.01.006
Reference:
CHEST 905
To appear in:
CHEST
Received Date: 30 September 2016 Revised Date:
27 December 2016
Accepted Date: 4 January 2017
Please cite this article as: Ward L, Powell RE, Scharf ML, Chapman A, Kavuru M, Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare, CHEST (2017), doi: 10.1016/j.chest.2017.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare
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1. Lawrence Ward MD MPH FACP Department of Medicine, Division of Internal Medicine, Thomas Jefferson University, Philadelphia, PA [email protected] 2. Rhea E. Powell MD MPH Department of Medicine, Division of Internal Medicine, Thomas Jefferson University, Philadelphia, PA [email protected]
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3. Michael L. Scharf, MD Department of Medicine, Division of Pulmonary and Critical Care, Thomas Jefferson University, Philadelphia, PA [email protected]
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4. Andrew Chapman, DO Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA [email protected]
5. Mani Kavuru, MD Department of Medicine, Division of Pulmonary and Critical Care, Thomas Jefferson University, Philadelphia, PA [email protected]
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*Corresponding author: Lawrence Ward MD, MPH, FACP 833 Chestnut Street, Suite 701 Philadelphia, PA 19107 [email protected]
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Conflict of Interest: None
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ABSTRACT
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Healthcare is at a crossroads, under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. Yet primary care accounts for only a small portion of total healthcare spending, and there is a need for policies and frameworks to support high quality, cost-efficient care in specialty practices of the “medical neighborhood”. The Patient-Centered Specialty Practice (PCSP) model offers ambulatory-based specialty practices one such framework, supported by a formal recognition program through the National Committee for Quality Assurance. The key elements of the PCSP include processes to support timely access to referral requests, improved communication and coordination with patients and referring clinicians, reduced unnecessary and duplicative testing, and an emphasis on continuous measurement of quality, safety and performance improvement for a population of patients. Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based healthcare in specialty practices. The continued development of appropriate incentives are required to ensure widespread adoption.
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Title: Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare
INTRODUCTION
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Clinical Vignette: The Current Paradigm A previously healthy 66 year-old woman, Mrs. R., presented to her primary care physician with a dry cough of several weeks duration. Her primary care physician considered possible allergies and ordered a cough suppressant and antihistamine. When she returned with ongoing cough, and now also with mild dyspnea, he prescribed antibiotics for a possible atypical communityacquired pneumonia and ordered a chest x-ray. Her symptoms did not abate, and a few weeks later she was referred to a pulmonologist. The patient was concerned as her sister had died years earlier of respiratory failure from idiopathic pulmonary fibrosis. Three weeks later at her pulmonary consultation, a repeat chest x-ray was ordered, since her records had not yet arrived from the primary care doctor’s office. The report noted bibasilar interstitial lung disease and a chest CT scan was recommended, followed by a bronchoscopy and lung biopsy. Unsure of whether the pulmonologist or the primary care physician would be coordinating the next steps, Mrs. R. called to seek her primary care doctor’s advice. Several days passed with no response, and when she again called, she learned the doctor had not yet received the pulmonologist’s report. She then called the pulmonologist’s office and was told the pulmonologist had not yet finished dictating the letter, and it would be faxed out soon. Mrs. R was not alone in being unsure who was leading her care plan. As the primary care physician and the pulmonologist had no established referral agreement, the primary care physician assumed the pulmonologist would spearhead further evaluation and management, while the pulmonologist did not know whether she was providing a one-time consultation, was supposed to be co-managing the patient with the primary care physician, or was supposed to be taking over the care of the patient. Mrs. R, fearful that she might have the same condition as her sister and frustrated by inefficiency in care, entered the maze euphemistically referred to as “navigating the health care system”.
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Patients, clinicians, and policy makers alike recognize the challenges patients such as Mrs. R face in managing health and healthcare in the United States (US). American healthcare has long been characterized by a fee-for-service model emphasizing the management of acute episodes of care. This model incentivizes greater volume of services and procedures, often without attention to coordination, resource utilization, and long term outcomes. Recent health reform efforts, spurred by The Patient Protection and Affordable Care Act (ACA), seek to shift incentives in health care in order to reach the “triple aim” of improved patient experience, improved population health, and reduced per capita costs.1 Models of care such as Accountable Care Organizations (ACO) and bundled payments for episodes of care increasingly reward quality of care and reduced unnecessary healthcare utilization. By 2018, the Department of Health and Human Services intends for 50% of all Medicare payments to be through alternative payment models, and 90% of all payments be tied to quality.2 Even if a new administration alters the specific mechanisms of health reform, it is believed by many that the drive towards value over volume will continue. In order to adapt to this changing reimbursement and delivery landscape, healthcare providers need models to organize and coordinate care; and consumers need ways to identify providers with a commitment to high-value, outcome-driven care. The Evolution of the Patient-Centered Medical Home in Primary Care In the primary care setting, the patient centered medical home (PCMH) model has been the most widely adopted approach to facilitate care transformation. The core principles of a PCMH are provision of care that is: patient-centered, team-based, coordinated, and marked by
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enhanced access to care and communication and a systematic approach to improving quality of care.3 While various versions of the medical home model are employed, the most widely recognized is the National Committee for Quality Assurance (NCQA) PCMH recognition program. Since it began in 2008, over 11,000 primary care practices have been recognized, involving more than 50,000 clinicians, or 17.4% of all US primary care clinicians. With the widespread adoption of the program, PCMH recognition is no longer a mark of distinction, but increasingly a standard expectation for high quality care.4,5 PCMH recognition is also often considered a necessary building block for ACOs and other alternative payment models.3 The Medical Neighborhood
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Though a necessary foundation for change, it is increasingly recognized that primary care transformation alone is insufficient to fully manage costs and improve outcomes.6,7 Key concepts of patient-centered care models must be incorporated into all healthcare settings, including specialty practices, in order to realize healthcare delivery-system redesign.7,8,9 The American College of Physicians (ACP) and the Agency for Healthcare Research and Quality (AHRQ) have outlined frameworks to support effective coordination across the constellation of providers in the “medical neighborhood”, including those in specialty practices, hospital settings, urgent care facilities, pharmacy providers, and post-acute and long-term care.10,11 Though 55% of all medical outpatient visit costs are attributed to primary care, this accounts for just 6% of overall healthcare spending.12,13 Specialist clinicians, who play a primary role in the care of many high cost and complex patients and often perform procedures, are especially vital to impacting costs. To be successful as partners in the medical neighborhood, specialty practices need not fill the role of primary care, but rather coordinate effectively with primary care practices, other specialists, and acute care facilities.14 This makes specialty providers particularly important members of a “medical neighborhood”, and highlights the importance of proactively managing the care of their patients to reduce duplication and improve value.15
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Effective use of sophisticated data platforms are also necessary to provide high value care. Platforms linked to electronic health records, insurance claims data, and health information exchanges support coordination across primary care and specialty practices. These data platforms can inform population health strategies, such as feeding practice outreach efforts, and monitoring patient outcomes. Increasingly practices will be expected to demonstrate management of population outcome measures, many of which will be publically reported.16 For instance, endocrinologists will be asked to monitor diabetes outcomes; pulmonologists to monitor measures related to adherence to asthma treatment and hospital utilization; cardiologists to monitor echocardiogram use and the readmission rate for patients with congestive heart failure.17
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Patient-Centered Specialty Practice Recognition Building on the growing momentum behind medical neighborhood concepts, and learning from the success of the PCMH program, the NCQA announced a Patient-Centered Specialty Practice (PCSP) Recognition program in 2013. Major components of PCSP recognition are summarized in Table 1. In order to achieve PCSP recognition, specialty practices must demonstrate achievement in six standards: (1) working with primary care and other clinicians; (2) provide access and communication; (3) identify and coordinate patient populations; (4) plan and manage care; (5) track and coordinate care; and (6) measure and improve performance.18 Multiple elements may be incorporated into practice models to meet these standards, including six “must pass” required elements: written referral agreements, written referral response time protocols, team-based care, medication management, and a patient experience and clinical quality improvement program. At the time of this writing, NCQA’s PCSP program has recognized 221 practices across the US, involving over 1,100 specialist clinicians. Obstetrics
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and gynecology practices are the most frequently recognized practice type, followed by medical oncology. Multiple cardiology and endocrinology practices are recognized with only four pulmonary practices recognized to date.
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Several major health systems, including the Dana Farber Cancer Center, Johns Hopkins University, Thomas Jefferson University and the University of Kansas, have adopted the PCSP model among their employed specialty practices. Additional networks including Eastern Maine Medical Center, Inova Medical Group (VA), Unified Women’s Health (NC) and Meridian Medical Group (NJ) have also widely adopted the model for their practices. Evidence for PCSP Effectiveness
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For any given practice, potential benefits of PCSP adoption include increased patient volume from improvements in access and referral tracking, and relationships with referring providers. For the broader health system, potential benefits include improved patient satisfaction, and improved efficiency, quality and safety of care.19 Adoption of PCSP models is at an early stage, and specific evidence on the effectiveness of the PCSP model is scant. Some direction can be gleaned from evidence from the PCMH model. Early PCMH studies reported mixed success, but as PCMH-recognized practices have had more time to implement and customize the model, increasingly robust improvements have been demonstrated.20 A recent review of thirty publications from 2015 concluded that advanced primary care models like PCMH contribute to lowering health care costs and reducing unnecessary hospital-based utilization.12 The most successful approaches were those involving multi-payer collaboratives with specific incentives linked to quality, utilization, patient engagement or cost savings.
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Some inferences can also be made from specialty practices that have adopted similar patientcentered models of care. An oncology practice in Pennsylvania, originally one of the few and short-lived PCMH-recognized specialty practices, successfully demonstrated that implementation of a PCSP-like model resulted in fewer ER visits and hospital admissions, more patients receiving hospice care at the end of life, and an overall savings of nearly $1 million per physician per year.21 Other evidence may eventually be learned from an ongoing three-year study assessing the impact of the Patient-Centered Oncology Care model, an oncology-specific model of care, on patient experiences, quality of care, and acute care utilization. Early reports from this study find little standardization across pilot practices converting to patient-centered oncology care models, and suggest that establishing structures for care coordination, quality measurement and improvement should be priorities for practices considering transformation to a patient-centered model of care.22 Undergoing the PCSP transformation
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Achieving PCSP recognition may require structural changes in practice infrastructure and workflows as well as cultural shifts towards team-based coordinated care. Practices seeking to achieve PCSP recognition will benefit from strategies that have proven useful in supporting primary care practice transformation. Adopting an approach recommended for primary care practices looking to transform to PCMH,23 specialty practice leaders should consider completing a practice assessment that includes examining the competencies of existing staff, reviewing workflows, assessing status of referral management and communication, and evaluating information technology needs. Once completed, the practice can then introduce new care coordination workflows, implement communication agreements with referring providers, and engage in new modes of communication with patients. Office policies and clinical workflows must be clearly documented and key practice administrative and clinical quality data must be able to be produced on a regular basis. Though not a specific requirement, an electronic health record is vital to the recognition effort. A physician champion and an administrator or project manager with time dedicated to the transformation effort can facilitate operationalizing new
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workflows and facilitate culture shift. When available, external consultants, sometimes referred to as practice coaches, can help practices navigate these changes. Upfront changes and the actual application process may take from 6-12 months to complete, but maintenance of workflows and sustained efforts are required. Incentives for PCSP Recognition
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Financial incentives through insurance company programs were integral to widespread PCMH adoption, and similar incentives can encourage PCSP adoption. Notably, the recently finalized Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) may propel adoption of models like PCSP forward. The law created two reimbursement pathways: Alternative Payment Models (APM) and Merit-Based Incentive Payment System (MIPS). Providers who are part of programs that accept potential downside risks, such as certain ACOs or CMS’s Oncology Care Model, fall into the APM pathway. Specialty providers who are not part of an APM, likely the majority of specialists, are reimbursed through the MIPS pathway. The first MIPS performance year began January 1, 2017 and MIPS-qualifying practices will be subject to adjustments in their 2019 Medicare fee-for-service payments that are based on performance year 2017. MIPS payment determinations will be based on performance in four categories: cost, quality, clinical practice improvement activities and advancing care information. Under the proposed rules, PCSP-recognized practices would receive the highest potential score for the clinical practice improvement activity category.24 Meeting the requirements to achieve PCSP recognition will also position a practice to succeed in other categories by facilitating optimal resource use, quality measure reporting and performance, and use of technology.
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Insurance company programs may also incentivize adoption of the PCSP model. Currently, there are several major insurers supporting the model including Blue Cross-Blue Shield of North Carolina, and UPMC Health Plan. A PCSP pilot program supported by Anthem Blue Cross has demonstrated positive initial results, reporting reductions in over-utilization, enhanced access to care and improved care coordination. Payer support for PCSP varies by market and may include transformation assistance, practice coach support, and limited incentive payments for PCSP recognition. In primary care, per-member per-month bonus payments in capitated networks or similar plans reward practices for achieving and maintaining PCMH recognition, however few such payments for PCSP recognition exist to date. As specialty practices adopt and grow PCSP models, payment models will need to align with stages of model development.23 Practice Transformation and Recognition Costs
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Financial incentives may help offset costs related to building PCSP infrastructure, applying for recognition and sustaining the effort over time. Costs will vary by practice size, type, and setting. Upfront costs may include hiring new personnel to implement team-based care and manage population outreach. Some practices may also make investments in information technology tools for population management. With the appropriate personnel and support in place, a practice will incur additional costs for the application development and submission. Though exact estimates of the cumulative cost for this process are unknown, some inferences can be made from PCMH experiences. One primary-care based study of PCMH application costs estimated between $11,453–$15,977 to develop and submit a successful application, including salary support for staff preparing the application and submission costs.25 Many practices engage consultants to assist with the application process, which would bring additional costs unless incentivized from payer or other sources. Costs related to sustaining PCSP recognition are also not yet known, though again, inferences may be made from primary care. A recent study estimated the average per-member per-month cost of maintaining a highperforming PCMH of 2,000 patients to be $3.85 in Utah and $4.83 in Colorado.26 These
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estimates, however, do not distinguish between incremental costs and shifting of existing costs, and practices will need to evaluate existing costs and estimate net costs compared to net benefits to understand value for the practice.27
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Some cost considerations underscore tensions inherent in transforming from a fee-for-service to a value-based reimbursement landscape. Pre-consultation exchanges between primary care and specialist clinicians, encouraged by the PSCP model, have potential to decrease revenue for specialists if they replace revenue-generating consultations.28 Overcoming challenges such as this will require incentivizing innovative and nontraditional methods for communication that do not entirely rely on an office visit.29 Reimbursement models must support specialty practices to make these types of leaps into the value-based future.
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There are yet other challenges to implementing and optimizing coordinated, patient-centered care. Lack of EHR interoperability may be one barrier to fully coordinated care. The culture shifts required to move towards value-based care models may present another challenge, including the shift towards measuring and reporting of process measures, which are often proxies to outcome measures. These measures can be coupled with qualitative feedback from patients to ensure that a practice has a full understanding of the quality of care provided. Feedback from patients through patient advisory councils are encouraged in the PCSP model and can help to assure that a practice is truly delivering patient-centered care. Clinical vignette: A Potential Future Paradigm
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Envisioning an alternative, patient-centered pathway for the patient described at the outset, Mrs. R, potential benefits of the PCSP model become clear. A PCSP-recognized practice would have mechanisms in place to offer patients quick access for consultation, and Mrs. R would have seen a pulmonary specialist promptly. Communication with the referring provider would have been optimized, reducing the need for redundant testing, and referral a thoracic surgeon for biopsy could be well coordinated, with her primary care doctor involved at each step in her care. Mrs. R could focus less on “navigating the health system” and more on her health.
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The US healthcare system is under scrutiny from the public, regulators, and payers, and innovative models are needed to deliver timely, high-quality care, using appropriate resources. The PCSP model, like its predecessor PCMH, offers a path for specialty practices to coordinate care, improve access and communication, and reduce duplicate testing. As health reform efforts to improve quality and experience of care move forward, pulmonary and other specialists have an opportunity to shape the vision of patient-centered care through adoption of the patientcentered specialty practice model of care.
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Acknowledgements: The authors would like to thank Dr. Michael Barr from the NCQA for his assistance in reviewing this manuscript.
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Table 1: Major Components of PCSP Recognition Basic Description
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PCSP 2016 Recognition Category
The specialty practice promotes effective communication and care coordination between themselves and primary care physicians/referring providers. The referring provider sends appropriate information and the specialist provides a timely response with a process to transition patients back to primary care. If a self-referred patient does not have a primary care physician, the specialist has a process to connect them with one.
2. Provide Access and Coordination
The practice has processes to facilitate access for patients and advice to referring providers. A clearly defined care team exists at the practice and meets regularly (e.g. huddles).
3. Identify and Coordinate Patient Populations
The practice collects patient information and clinical data, which is used to generate lists for outreach to close care gaps. Clinical decision-support interventions are implemented (e.g. point of care reminders).
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Plan and Manage Care
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1. Working with Primary Care and Other Clinicians
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5. Track and Coordinate Care
6. Measure and Improve Performance
The practice collaborates with patients and their caregivers to develop and implement a care plan. Practices review and reconcile medications and have the ability to e-prescribe.
The practice is able to track and follow-up on referrals, labs and studies. The results can be exchanged with referring providers and coordination occurs with ERs and hospitals. The practice is able to measure multiple aspects of their performance and performs continuous quality improvement.
Based on 2016 National Committee of Quality Assurance PCSP Recognition Standards18
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