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Transforming Care: Physician-Led Efforts to Promote Value

Transforming Care: Reporting on Health System Improvement

In Focus: Physician-Led Efforts to Promote Value

Doctor discusses with patient

Physicians are proposing new ways of delivering and paying for care that take aim at a key shortcoming of the nation’s fee-for-service system: lack of payment for some high-value services. Their condition-specific models encourage adherence to evidence-based guidelines and reductions in avoidable hospitalizations and testing that has little benefit.  Finding payer support for these models has proven challenging for some despite evidence of cost savings or improved health outcomes.

With the share of the nation’s gross domestic product devoted to health approaching 20 percent and a tsunami of aging baby boomers closing in, it’s clear the United States needs to find creative ways to curtail health care spending. Unfortunately, many such efforts led by payers and policymakers — including pay-for-performance, accountable care, and bundled payment programs — have produced only modest savings.

Some physicians have taken up the challenge and put forth their own ideas to achieve greater value for health care dollars. Many leverage grant funding from the Center for Medicare and Medicaid Innovation (CMMI) and elsewhere to test their ideas. Some proposals come in response to Medicare’s call for ideas on how to move away from fee-for-service payment and promote high-value care. Their new care models take aim at common and costly conditions such as cancer, cardiovascular disease, and musculoskeletal problems and seek to achieve savings by encouraging greater adherence to evidence-based guidelines, engaging patients in decision making, and avoiding complications that can lead to unnecessary care. Their condition-specific approaches could benefit patients who have frequent interactions with health care providers and may be vulnerable to complications from treatment.

Since December 2016, physicians — represented by physician groups, specialty medical societies, and others — have submitted 25 proposals to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was created under the Medicare Access and CHIP Reauthorization Act of 2015 and tasked with evaluating physicians’ ideas for new payment models.

There isn’t enough money to fund care delivery for aging baby boomers if we continue to treat patients tomorrow like we are treating them today.

Jeffrey Bailet, M.D. Executive Vice President for Health Care Quality and Affordability at Blue Shield of California and Chair of the Physician-Focused Payment Model Technical Advisory Committee

If eventually approved by the Secretary of Health and Human Services, the alternative payment models would offer physicians per member per month fees, shared savings, or other payment methods to manage care differently. These and other value-based payment approaches would overcome two main hurdles to reforming care delivery under the fee-for-service system: lack of payment for services, such as hiring nurses to triage problems, that can improve health outcomes; and the potential loss of revenue to providers who help patients avoid unnecessary care.

The physician-proposed alternative payment models also seek to redress what some see as a shortcoming of bundled payments, which cap payment for an episode such as total joint replacement but don’t offer guidelines on what providers might do to reduce spending. And unlike global payment approaches, they offer new financial support for particular services — often simple, proactive steps — that are likely to produce downstream savings. “The path to higher-value care should start by asking physicians where they see opportunities to improve care and reduce costs and then paying them in ways that enable those changes to be made,” says Harold D. Miller, president and CEO of Center for Healthcare Quality and Payment Reform and a member of the PTAC.

In this issue of Transforming Care, we look at new approaches to delivering and paying for care developed by physicians: some have been piloted through grants from the CMMI and/or submitted to the PTAC for consideration as new Medicare payment models, while others have gained support from private insurers or are being spread by physician entrepreneurs.

Transforming Care Physician-led Efforts to Promote Value

Source: A Guide to Physician-Focused Alternative Payment Models, American Medical Association and Center for Healthcare Quality and Payment Reform,

Engaging Patients in Shared Decision-Making and Avoiding Unnecessary Cardiac Procedures

Engaging Patients in Shared Decision-Making and Avoiding Unnecessary Cardiac Procedures

Many people who go to their primary care doctor or cardiologist with complaints of periodic chest pain that might suggest cardiovascular disease end up receiving tests and interventions that are not in keeping with clinical guidelines, pose risks, and drive up costs.1

The Wisconsin and Florida chapters of the American College of Cardiology led a CMMI-funded pilot that brought together several decision support, patient engagement, and performance feedback tools in an effort to promote appropriate treatment for patients whose chest pain appears to be related to stable ischemic heart disease. The aim of the Smarter Management and Resource Use for Today’s Complex Care Delivery (SMARTCare) pilot was to reduce inappropriate stress tests and imaging (e.g., angiograms to view blood vessels in the heart) as well as reduce inappropriate percutaneous coronary interventions, an invasive procedure that carries risks of bleeding and other complications. It also sought to increase the number of patients who change their behavior to reduce their risks of developing severe heart disease.2

To achieve these goals, its developers embedded evidence-based guidelines into electronic health record systems at 10 cardiology practices in Wisconsin and Florida and leveraged them to guide decision-making at the point of care. The tools didn’t dictate treatment but instead helped physicians customize guidelines to make them relevant to their patients. “Some so-called decision support tools are really documentation support: if a doctor wants to order a stress test they have to supply a reason why,” says Thomas J. Lewandowski, M.D., a cardiologist in Appleton, Wis., and principal investigator of the SMARTCare pilot. “By contrast, the SMARTCare tools ask doctors to enter in a particular patient’s symptoms and then [the tools] map each to different indications, so it helps them verify whether what they’re doing fits with clinical guidelines.”

Physicians participating in the pilot also educated patients about their unique risk factors, engaged them in shared decision-making, and collected feedback on their care experiences. At the Medical College of Wisconsin, patients were shown an educational video explaining the risks and benefits of various cardiac procedures before meeting with a cardiologist. They also completed the Seattle Angina Questionnaire to assess their symptoms and severity (at other sites, patients completed the Heart Quality of Life questionnaire). Cardiologists drew on the survey data and videos to help patients understand their risks and options — putting some guide rails around what can be a highly charged conversation. Without information, “patients often push for more invasive procedures,” says Nicole Lohr, M.D., a cardiologist at Medical College of Wisconsin. “They say, ‘Doc, it’s my heart; you better do something about it because I don’t want to die.’”

Transforming Care Engaging Patients in Shared Decision-Making

Thomas J. Lewandowski et al., “Unlocking the Power of Data: Information Technology Implementation for Smarter Management and Resource Use for Today’s Complex Care Delivery,” poster published by the American College of Cardiology Foundation, 2017.

The reality is most primary care doctors and even some cardiologists who order cardiac diagnostic tests don't always choose appropriate, evidence-based testing because of the time constraints within an office visit and a lack of exposure to changing guidelines.

Nicole Lohr, M.D. Assistant Professor of Medicine, Cardiovascular Division,Medical College of Wisconsin

Some SMARTCare participants also used the IndiGO tool, a simulation model that calculates a patient’s risk for having a heart attack or stroke based on their cardiovascular disease history, comorbidities, body mass index, and lifestyle behaviors. It then models the potential benefits of behavior changes (e.g., smoking cessation or weight loss) and medications. Cardiologists used the tool to encourage patients to make behavior changes and identify where they had opportunities to intervene. “Take a 75-year-old whose coronary disease, diabetes, and blood pressure are under control, and who exercises and does not smoke: there is nothing left to do with that patient to reduce their risk,” says Lewandowski. “But the role of IndiGO is to identify which patients have risk factors that we still have ability to affect. That is something that our current tools don’t do.”

Data on patients were collected throughout the course of treatment, enabling clinicians to benchmark their performance against peers and receive rapid feedback on health outcomes and costs.

The SMARTCare pilot was prompted, in part, by data from Wisconsin’s all-payer claims database showing wide variation in cardiology resource use, information that also caught the attention of the WEA Trust, a self-insured plan that covers 110,000 Wisconsin public employees. WEA Trust is now encouraging health systems to negotiate for payment to embed the system as a means of offsetting the revenue they may lose from avoiding stress testing, nuclear stress testing, and catheterizations. “Payment is a signal of what we value,” says Tim Bartholow, M.D., vice president and chief medical office at WEA Trust. “If we want better medical decision making, we need to increasingly focus payment on team-based decision making and more realistic, cost-based reimbursements for commodities such as imaging, laboratory tests, and drugs."

Heading Off Complications for Oncology Patients

Heading Off Complications for Oncology Patients

In 2014, cancer care accounted for $87.8 billion of health care spending for noninstitutionalized Americans; of that, roughly 28 percent went to emergency department and hospital care. Barbara McAneny, M.D., a New Mexico oncologist and president of the American Medical Association, says a large portion of the hospitalizations and emergency department visits are to treat fevers, dehydration, and other complications of chemotherapy that could be avoided with closer management in outpatient settings, where patients typically receive chemotherapy infusions. Avoiding unnecessary hospitalizations may also prevent further deterioration, she says. “In addition to the risks of infections and bed sores, if you take someone who isn’t healthy and can’t rebuild muscle mass, and you put them in a hospital bed for a few days, they end up with less muscle tone and a reduced quality of life.”

The problem is that oncology practices can’t bill Medicare or most private insurers for services like educating patients on how to recognize warning signs or hiring a nurse to answer calls and triage problems. At the same time, patients may be reluctant to trouble physicians when they first notice symptoms.

Through a grant from CMMI, McAneny led a trial of an alternate approach. From 2012 to 2015, the Community Oncology Medical Home (COME HOME) tested whether providing advanced access to patients and closer care coordination could lead to earlier detection of problems and avoid hospitalizations. Seven cancer centers offered on-demand visits, including on nights and weekends, for emergent issues such as pain, dehydration, nausea, or fevers; hired a nurse to respond to patients’ question and triage problems; and implemented 37 unique care pathways for diagnosis, treatment, and symptom management of different types of cancers. “We make our triage pathways available, so people can figure out which patient with left-sided pain is having a heart attack and needs to go to hospital and which has bony metastasis and doesn’t need their fourth cardiac workup,” McAneny says.

An evaluation of the pilot found this approach led to significant reductions in emergency department visits and hospitalizations for ambulatory care–sensitive conditions, as well as significantly lower average cost of care ($601 less per patient per quarter). McAneny says that practices that enabled nurses to execute standing orders to address patient complications achieved the most dramatic reductions in hospitalizations; at her own practice, hospitalizations were cut in half.

This February, McAneny submitted a proposal to the PTAC for consideration of an alternative payment model to support COME HOME, and 16 practices have agreed to participate, should it be funded. Notably, the practices have also agreed to share clinical and claims data to feed into a software platform that would be leveraged to create customized treatment plans for patients and offer real-time physician education and performance feedback. Eventually, the goal is to use this pooled data to cluster cancer patients according to their risks and disease severity, then compare variations in spending and outcomes in each of the clusters; such information could help Medicare and other payers develop appropriate alternative payment models.

“Right now, nobody has the ability to accurately predict costs for a cancer patient who has x, y, and z characteristics,” McAneny says. “Even if you have multiple patients with stage 4 colon cancer, some are going to cost a whole lot of money and some will cost much less. We hope to learn which factors make the difference and to identify things that are modifiable through better coordination or different types of care.”3

Improving Quality and Reducing Costs for Back Pain Treatment

Improving Quality and Reducing Costs for Back Pain Treatment

Back problems are among the most common reasons people visit a doctor, leading to more than $47 billion a year in medical costs. A review of 10 years’ worth of medical visits for back pain found ample evidence of overtreatment: instead of starting with anti-inflammatory drugs and physical therapy, as recommended by clinical guidelines, physicians have increasingly prescribed narcotics, ordered imaging, and referred patients to specialists. Overuse of opioids, in particular, has fueled the epidemic of addiction.

Andrew Haig, M.D., a physiatrist (a physician specializing in rehabilitation) and active emeritus professor of physical medicine and rehabilitation at the University of Michigan, thinks clinicians in his field are well positioned to manage back pain by serving as “midfield players”: given their expertise, they are better able than primary care clinicians to explore the many potential causes of patients’ suffering and may be less wedded to high-cost interventions, like surgery and injections.

In 2008, Haig partnered with the Michigan insurer Priority Health to test this approach: all patients who were referred by their primary care physician to a surgeon for back pain were first required to see a physiatrist. The health plan waived members’ copayments for this visit, and physiatrists were given a $50 bonus, on top of the visit fee, to help patients talk through options. “I hold up five fingers and say, ‘When you leave here you are going to put something in your shopping cart: surgery, injection, pills, some kind of therapy, or doing nothing,’” Haig says. Without such guidance, patients may hold out hope there’s a magical solution to their problem. “It’s important for patients to leave with a finite sense of their options,” he says.

Over two years, Priority Health saw a 25 percent reduction in spine surgery among its members, as well as a 12 percent reduction in overall spine-related costs per member per month and continued member satisfaction, compared with the year before implementation of this approach.

Haig has since developed and tested other parts of a continuum of back pain management and has spun off a consulting firm to encourage providers and health plans to adopt the “Operation FastBack” model.

Under Operation FastBack, all patients with chronic back pain, for example, would be screened by a physiatrist. Those whose pain does not appear to be related to a serious medical condition (e.g., cancer) would then receive a multidisciplinary team assessment that can consider the wide range of factors and available treatments. Haig’s research found that psychological factors like depression, fear, and avoidance, as well as poor physical conditioning, are common among patients with back pain. The team includes a physical therapist to consider anatomical issues; an occupational therapist to explore how disability affects people’s lives; an exercise specialist to explore the role of physical conditioning; a psychologist to consider contributing psychiatric factors; and a representative for complementary/alternative medicine to consider such therapies. After their initial assessment, the team would work with a physiatrist and the patient to develop a holistic care plan. In a trial of 500 patients who underwent these team assessments, 17 people who received one type of complex intervention (functional restoration) had less work disability, fewer diagnostic tests, and fewer surgeries than those who were recommended this treatment but did not receive it.

Haig is now working with Blue Cross and Blue Shield of Vermont to develop the infrastructure to support this model, starting with creation of a hub at one hospital that has the full staff and other resources to assess back pain patients, treat the ones with the most complex needs, and refer others to treatment at local clinics. Hub clinicians also would support the local clinics in providing best practice care in three regional emergency departments and primary care settings. Haig and Blue Cross and Blue Shield are tracking expenses and outcomes under this approach, with the goal of modeling how a bundled payment might support it.

Evidence-Based Prescribing to Control Costs for Rheumatoid Arthritis Treatment

Evidence-Based Prescribing to Control Costs for Rheumatoid Arthritis Treatment

Rheumatoid arthritis plagues some 1.3 million Americans with chronic joint pain and other problems. While biologic drugs have helped many patients who don’t respond to other types of medication, their price is much higher (around $50,000 a year) than traditional antirheumatic therapies (e.g., methotrexate, which can cost around $100 to $200 a year).3 This has raised concerns among some payers as well as patients, who may have to shoulder high copayments for a lifelong condition. Articularis Healthcare, which has 12 specialty rheumatology practices in South Carolina and Georgia, collaborated with a local insurer to develop a rheumatoid arthritis treatment pathway to ensure lower-cost medications are effectively tested before doctors recommend more expensive treatments.

Under the pathway, rheumatologists are prompted by their electronic health record system to follow American College of Rheumatology guidelines, which generally suggest an initial period of treatment with a traditional antirheumatic drug prior to escalating therapy to a biologic agent. The pathway also reminds physicians to periodically measure the effects of drug treatment on disease activity using a validated tool — another clinical guideline but one that may not be followed in all cases.

The “traditional medication is slow acting, and patients may not feel relief initially,” says Colin Edgerton, M.D., who practices at Articularis’s Low Country Rheumatology clinic, in Charleston. “A doctor may react to patients’ lack of relief and suggest switching to the biologic without really having a good metric built into the system to realize, ‘Oh, it’s only been six weeks. We should wait a bit longer to see if it can work.’”

Edgerton says this approach led to a 10 percent to 20 percent decline in the use of high-cost biologics, mainly achieved by identifying more patients whose conditions responded to the lower-cost medication. The local insurer pays Articularis a per member per month case management fee (around $500 to $1,000 a year) to defray the cost of staff required to implement the pathway and educate providers in its use; the two parties share in the savings that result from reduced use of biologic drugs.

Challenges to Spreading Physician-Led Alternative Payment Models

As these examples make clear, changing how care is provided and paid for in health care must begin by integrating new tools into electronic health record systems. This can be expensive and cumbersome; McAneny, for example, has struggled to enlist her electronic health record vendor in making changes needed to aggregate data across practices.

Those who are able to overcome technological challenges may find it hard to gain the attention and support of payers. While Medicare has called for new proposals, it has not yet acted on any of PTAC’s recommendations. Private payers have also been slow to support new care models. Edgerton, for example, has found it hard to enlist support from large national insurers for the rheumatoid arthritis pathway, perhaps because it has only been tested among a small number of patients. Banding together across practices, as is being proposed under the COME HOME model for oncology, could create the critical mass of patients needed to demonstrate efficacy for new care models and garner support from payers to invest in them.

Lewandowski says that Medicare could encourage multipayer support for initiatives like SMARTCare, thus ensuring that payers share equally in developing and testing new care models. The Centers for Medicare and Medicaid Services could also require accountable care organizations to pursue new approaches to high-cost specialty care, including orthopedics and cardiovascular care, rather than just meeting benchmarks on a relatively small number of performance metrics to qualify for shared savings, he says.

Brian Klepper, Ph.D., founding principal of Orange Park, Florida–based Worksite Health Advisors, a consulting firm that advises self-insured employers on how to find high-value clinical partners, says physician innovators often succeed by going directly to employers and offering them a financial guarantee of savings. “Like Amazon, they make people an offer they can’t refuse,” he says.

Perhaps most important, it will be crucial to enlist support for new care models from physicians; some may feel new decision support tools or care pathways are too prescriptive, while others may perceive a threat to their revenue stream from efforts to avoid high-cost services. But some of the models could make some physicians’ jobs easier. “Doctors are burning out in droves, and we can’t keep adding to their plate,” says John Mafi, M.D., M.P.H., assistant professor of medicine and health services research at UCLA’s David Geffen School of Medicine. “Making the right thing to do the easy thing is really the promising way to get real change to happen. It’s easier said than done.”

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1 In spite of clinical guidelines recommending lifestyle changes and/or medication instead of coronary interventions for patients with stable ischemic heart disease, sizeable numbers receive angioplasty or stenting. See, for example, a 2011 study of data from the National Cardiovascular Data Registry which estimated that 11.6 percent of percutaneous coronary interventions (PCIs) for nonacute indications (e.g., suboptimal antianginal therapy, low-risk ischemia on noninvasive stress testing, or no angina) did not meet appropriateness criteria; the proportion of inappropriate procedures for non-acute indications varied substantially across hospitals, ranging from 6 percent or lower in some hospitals to 16.7 percent. Paul S. Chan et al., “Appropriateness of Percutaneous Coronary Intervention, Journal of the American Medical Association, 306, no. 1 (July 6, 2011): 53–61, A 2014 study estimated Medicare spending on PCI with angioplasty and stenting for patients with stable ischemic heart disease may be as much as $2.8 billion, not including the cost of treating complications or providing follow-up care. See Aaron L. Schwartz et al., “Measuring Low-Value Care in Medicare, JAMA Internal Medicine, 174, no. 7 (July 2014): 1067–76, To discourage unnecessary testing and treatment, the U.S. Preventive Services Task Force recently recommended against routinely performing electrocardiograms on patients at low risk for heart disease. See U.S. Preventive Services Task Force, “Screening for Cardiovascular Disease Risk with Electrocardiography,” Journal of the American Medical Association, 319, no. 22 (June 12, 2018): 2308–14,

2 The SMARTCare project is supported by Grant Number 1C1CMS331322 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The description of SMARTCare here is solely the responsibility of the authors and does not necessarily represent the official views of the US Department of Health Human Services or any of its agencies.

3 McAneny and others have expressed concerns that the oncology care model, another CMMI-funded approach in which nearly 200 oncology practices are providing advanced access and care coordination in exchange for additional Medicare funding, creates incentives for practices to cherry-pick patients with less complex needs by holding them to financial spending targets that don’t account for patients with greater risk factors and needs.

4 As per personal conversation with Colin Edgerton, M.D, Articularis Healthcare. Biologic drug therapy for rheumatoid arthritis (infliximab) entered the market in 1998. Two biosimilar medications became available in the last 12 months; competition from these and other drugs may help drive down prices.

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Creating Incentives for High-Value Care

A Q&A with Harold D. Miller and Jeffrey Bailet, M.D.

Transforming Care spoke to Harold D. Miller and Jeffrey Bailet, M.D., about their work with the Physician-Focused Payment Model Technical Advisory Committee, which was created under the Medicare Access and CHIP Reauthorization Act of 2015 to evaluate physicians’ proposals for new payment approaches.

harold miller

Miller is president and CEO of the Center for Healthcare Quality and Payment Reform and has written extensively about how to reduce health care costs without denying patients the care they need.

Transforming Care: You’ve said fee-for-service payment systems prevent providers from delivering lower-cost care. Why is that?

Miller: A big reason is there is no fee at all for many high-value services. A physician practice can lose money doing things that would improve care for patients and reduce overall spending. For example, responding to a patient phone call might avoid an emergency department (ED) visit, but we only pay physicians when they see patients in the office, so it’s not surprising that we have a lot of unnecessary ED visits. Patients with cancer often end up in the hospital due to dehydration and other complications of chemotherapy because we don’t pay for the triage or intravenous hydration services that can avoid the hospitalizations. If we want patients to get higher-value care, we need to ensure physician practices receive enough revenue to cover their costs when they do the right thing for patients.

Transforming Care: Global payment models are intended to address this by giving providers the latitude to use capitated or bundled payments as they see fit. But even in countries that use global budgets for payment, such as Canada, you still see high rates of low-value care. Accountable care organizations, which also encourage providers to pay attention to resource use, meanwhile haven’t produced dramatic results. Why aren’t these approaches as effective as we expect?

Miller: The problem with typical capitation and other global payment models is there is no change in the way most doctors are actually paid, so the payment barriers don’t disappear. Capitated medical groups may pay the primary care providers (PCPs) differently (e.g., with a monthly payment instead of visit fees), but all of the specialists are still paid using the standard fee-for-service system. Capitation simply shifts the responsibility for limiting utilization of specialty care from the health plan to the PCPs, rather than giving the specialists the ability to actually redesign the care they deliver. There are more ways to pay than just global payments and fee-for-service, but we need to be clear about what we want to pay for before we can design a payment model that will support that.

Transforming Care: What are some examples of better alternative payment models for specialists?

Miller: In many cases, a fairly simple change in payment can enable specialists to make a significant improvement in patient care and save considerable money for Medicare and other payers. For example, many patients with a chronic disease have trouble controlling their symptoms and are hospitalized frequently as a result. Paying the specialist a monthly amount tied to the severity of the condition and the outcomes achieved, rather than paying based on the number of office visits or how many different conditions the patient has, can dramatically reduce spending. In addition, we need bundled payments for diagnosis, not just treatment. When physicians are forced to evaluate symptoms during short visits, it’s not surprising that patients end up getting a lot of unnecessary tests and potentially the wrong treatments.

Transforming Care: If you were to give the Centers for Medicare and Medicaid Services (CMS) one piece of advice about developing alternative payment models what would it be?

Miller: I would be creating more payment models tailored to specific patient conditions and providing flexibility to the specialists who treat them. CMS has been so focused on trying to control the total cost of care through global payments and integrated systems, it is missing the opportunity to engage specialists in improving care and reducing spending for many high-cost conditions.

Jeffrey Bailet

Jeffrey Bailet, M.D., an otolaryngologist and executive vice president of health care quality and affordability at Blue Shield of California, is chair of the Physician-Focused Payment Model Technical Advisory Committee.

Transforming Care: What are the biggest obstacles physicians face in developing and implementing alternative payment models?

Bailet: There clearly are significant infrastructure investments that the provider community needs to make to effectuate these models or enable them to be successful — whether it’s investing in a medical record system or connecting to a health information exchange or tracking performance and providing intelligent, real-time interventions. This is a challenge for smaller and rural practices not tethered to large systems. They don’t have the resources required to stand these models up.

Transforming Care: What are some of the strengths and weaknesses of the proposals you’ve seen to date?

Bailet: We’ve seen proposals from providers who are very experienced with clinical delivery and are incredibly innovative in designing new clinical delivery strategies. Where the models struggle is on the payment part of their submission because they don’t have access to data to be able to model the benefits, the outcomes, or the return on investment. And yet those steps are required when you scale these models or evaluate them to determine their impact.

Transforming Care: Can the Physician-Focused Payment Model Technical Advisory Committee assist them?

Bailet: We can and do direct the stakeholders to areas within Medicare where they can get access to certain data and reports. So, we are helping them but there is opportunity to be more purposeful. Congress has given us more latitude to provide initial feedback to the stakeholders. Some have taken that feedback and, in some instances, withdrawn their proposals to go back to the drawing board and strengthen them.

Transforming Care: What about proprietary data? How big an impediment is limited access to that?

Bailet: That is a national challenge obviously. We have a lot of data that is walled off within health care delivery systems and electronic medical records. Where we need to go is having real-time data that is available on an open platform to appropriate parties: the payers, the patients, and the providers. I believe CMS is moving in that direction.

Transforming Care: Is there a limit to the number of condition-specific models CMS or other payers can administer?

Bailet: Yes. CMS only has so much capacity to get one of these models stood up. We are looking for synergies between some of the models. Where overlap exists, we should seize upon it. Our challenge is to create models that are big enough to allow people to participate across the country to get to scale and to drive savings and increase quality but customized enough to have an impact and allow specialties to participate and contribute.

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Publications of Note: March–June 2018

Alternative Payment Models May Add to Risks for Vulnerable Populations

The author of a commentary in the New England Journal of Medicine cautions that alternative payments models (APMs) may have negative consequences for vulnerable populations because current risk adjustment methods are not sophisticated enough to reliably distinguish between poor-quality care and high medical and social risk. They also fail to fully account for functional status and social support needs. The author outlines several principles policymakers should follow to avoid unnecessary harm to vulnerable populations, including evaluating APM participants on improvement rather than solely on achievement of performance targets to avoid penalizing providers caring for patients with more complex needs. She also recommends APMs reward quality improvements proportionally rather than taking an all-or-nothing approach, and that APMs link payment to measures that examine access to care and reductions in health disparities for vulnerable populations. Karen E. Joynt Maddox, “Financial Incentives and Vulnerable Populations — Will Alternative Payment Models Help or Hurt?New England Journal of Medicine 378, no. 11 (March 15, 2018): 977–79.


Home Food Delivery Programs Reduce Inpatient Admissions, Spending for Medically Vulnerable

A study of medical claims for adults dually eligible for Medicare and Medicaid found those who received home delivery of either medically tailored or non-tailored meals had fewer emergency department visits. Participants in the medically tailored meal program also had fewer inpatient admissions and lower health care spending. Participation in the non-tailored food program in contrast was not associated with reduced inpatient admissions but was associated with lower health care spending. Seth A. Berkowitz et al., “Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries,” Health Affairs 37, no. 4 (April 2018): 535–42.


Primary Care Clinic at Recreational Center Lowers Spending, ED Use

A primary care clinic established in a recreational center in a low-income area of Dallas that focused on addressing wellness, prevention, and the social determinants of health reduced emergency department (ED) use by 21.4 percent and inpatient care by 36.7 percent for patients in the year after they first sought care at the clinic. Costs related to both services decreased by 34.5 percent and 54.4 percent, respectively. Residents who joined the Baylor Scott & White Health and Wellness Center completed health risk assessments and were served by multidisciplinary teams that included social workers, nutritionists, and community health workers who assisted with patient education, navigation, and social needs such as transportation and access to healthy food. Members also had access to health and wellness activities including cooking demonstrations, prevention programs for diabetes, and weight management and fitness classes, as well as access to fresh fruit and vegetables. The study sample included patients who had at least one ED or hospitalization in the year before or after receiving care at the center. Donald Wesson et al., Innovative Population Health Model Associated with Reduced Emergency Department Use and Inpatient Hospitalization,” Health Affairs 37, no. 4 (April 2018): 543–50.


Crowdsourcing Platform Leads to Improved Asthma Outcomes and Policy Recommendations

AIR Louisville, a public–private partnership that brought city leaders together with a local nonprofit (the Institute for Healthy Air Water and Soil) and a digital health company focused on improving asthma outcomes (Propeller Health), leveraged information drawn from sensors attached to asthma inhalers to identify hot spots of respiratory disease symptoms and their environmental correlates. They found use of the digital health platform — which captures the data, time, and location of inhaler use and enables users to share records with physicians and access educational material, improved clinical outcomes — reducing inhaler use by 78 percent and increasing by 48 percent the number of symptom-free days users experienced. The data collected from the platform informed the group’s policy recommendations for reducing respiratory risks. These include enhancing tree canopy, promoting tree removal mitigation, zoning for air pollution emission buffers, altering truck routes, and developing a community asthma notification system. Meredith Barrett et al., “AIR Louisville: Addressing Asthma with Technology, Crowdsourcing, Cross-Sector Collaboration, and Policy,” Health Affairs 37, no. 4 (April 2018): 525–34.


Core Components of Community-Based Population Health Strategy Outlined

A journal article that describes five core components of community-based population health strategies illustrated them with Vermont’s multipayer delivery system reform efforts. The five include: an inventory of evidence-based interventions for addressing the social determinants of health; a diverse collection of financial sources to fund the interventions; a selection process that prioritizes interventions according to community needs; the capability to capture and share a portion of savings for reinvestment; and an accountable health community — that is, community infrastructure that can build and maintain a balanced portfolio of interventions to address community needs and adjust as conditions change. James Hester, “A Balanced Portfolio Model for Improving Health: Concept and Vermont’s Experience,” Health Affairs 37, no. 4 (April 2018): 570–78.


U.S. Health Investment Portfolio Requires Rebalancing

In a commentary in Health Affairs, two authors argue a major reason for the poor performance of the nation’s health investments is that too much is spent on health care services and too little on establishing social, economic, and environmental conditions vital to maintaining health and well-being. Their commentary summarizes the evidence for this assertion and outlines opportunities and challenges involved in rebalancing these investments. David A. Kindig and Bobby Milstein, “A Balanced Investment Portfolio for Equitable Health and Well-Being Is an Imperative, and Within Reach,” Health Affairs 37, no. 4 (April 2018): 579–84.


Readmissions Reduction Program Narrowed Health Disparities

A study of the effect of the Hospital Readmissions Reduction Program on racial disparities compared trends in 30-day readmission rates for congestive heart failure, acute myocardial infarction, and pneumonia among non-Hispanic whites and non-Hispanic blacks and among minority-serving hospitals and others. It found during the penalty-free implementation period (Apr. 2010–Sept. 2012), readmission rates improved over pre-implementation trends (Jan. 2007–Mar. 2010) for both whites and blacks, with a significantly greater decline among blacks than among whites. In the period  from October 2012 through December 2014, after penalties began, readmission improvements slowed for both races. Following a similar pattern, minority-serving hospitals saw greater reductions in readmissions than other hospitals did. The authors say it remains to be seen whether new policy efforts will narrow these gaps and reduce the disproportionately high penalties that minority-serving hospitals face. Jose F. Figueroa et al., “Medicare Program Associated with Narrowing Hospital Readmission Disparities Between Black and White Patients,” Health Affairs 37, no. 4 (April 2018): 654–61.


Zip Code Changes, Missed Clinic Visits Predictive of Hospitalization, Emergency Department Use

Researchers using readily available clinical and administrative data successfully identified risk of future “super-utilization” of inpatient and emergency services for both uninsured and insured patients at NYC Health + Hospitals, a large safety-net health system. Proxies such as zip code changes, payer flux, and missed clinic visits represented poorly documented social determinants of health. Such a payer-agnostic approach to risk scoring may increase clinician buy-in, the authors say, because it covers a provider’s full panel of patients and improves targeting of resource-intensive interventions. Jeremy Ziring et al., “An All-Payer Risk Model for Super-Utilization in a Large Safety Net System,” Journal of General Internal Medicine 33, no. 5 (May 2018): 596–98.


Pennsylvania Launches a Global Payment Program for Rural Hospitals

A commentary in the Journal of the American Medical Association describes the Pennsylvania Rural Health Model, a global budget payment method that is intended to improve population health outcomes and lower health care spending in rural communities. The program provides rural hospitals with a global budget based on historic net revenues with the expectation that hospitals will use a portion of the budget to invest in community health, which could include working with community-based organizations like the United Way, Area Agencies on Aging, and drug and alcohol treatment facilities to address local needs. To support the program, which engages six hospitals in the first year and will expand to 30 within three years, the Centers for Medicare and Medicaid Services is providing $25 million, which funds a Rural Health Redesign Center that will provide technical assistance to the hospitals. The program is expected to save Medicare a minimum of $35 million over five years. The hospitals will retain a significant portion of savings in the first three years as an incentive to engage in practice transformation. Karen M. Murphy, Lauren S. Hughes, and Patrick Conway, “A Path to Sustain Rural Hospitals,” Journal of the American Medical Association 319, no. 12 (March 27, 2018): 1193–94.


Readmissions Higher for Homeless Patients Discharged to the Community After Surgery

A study assessing the risk of readmission for homeless veterans following inpatient surgery found they were more likely to be readmitted to the hospital than non-homeless patients. They were also younger, more likely to have psychiatric comorbidities, and less likely to have other medical comorbidities such as hypertension. Discharge destination other than community, recent alcohol abuse, and elevated American Society of Anesthesiologists classification were significant risk factors associated with readmissions within the homeless cohort. The study examined inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration between 2008 and 2014. Ashley Titan et al., “Homeless Status, Postdischarge Health Care Utilization, and Readmission After Surgery, Medical Care 56, no. 6 (June 2018): 460–69.


Medicare ACOs Underused Primary Care Physicians

An analysis of claims and enrollment data for Medicare beneficiaries enrolled in accountable care organizations (ACOs) through the Medicare Shared Savings Program in 2013 found many ACOs underutilized primary care physicians for chronic disease management. The study found nearly 40 percent of evaluation and management visits for patients with one or more of eight chronic conditions (asthma, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, high cholesterol, high blood pressure, and osteoarthritis) were provided by specialists rather than primary care physicians (PCPs). The rate of PCP use ranged from 34 percent to 81 percent across the 219 ACOs. The share of visits made to PCPs was higher in ACOs that had a higher proportion of PCPs and lower in communities with a higher proportion of white or college-educated patients. Evan S. Cole, Cassandra Leighton, and Yuting Zhang, “Distribution of Visits for Chronic Conditions Between Primary Care and Specialist Providers in Medicare Shared Savings Accountable Care Organizations,” Medical Care 56, no. 5 (May 2018): 424–29.


More Refined Methods Needed to Identify Patients Who Are Appropriate for Care Management

A study that asked care managers working in an intensive care management program to categorize patients who were referred for services into three groups — those who were good candidates for care management, those who were not, and those who needed more than traditional care management could provide — found less than two-thirds (62%) were deemed to be good candidates. Nineteen percent were classified as needing more services. Compared with the other two categories, “good candidates” were older, prescribed more medications, and had more prior year outpatient visits. Based on their findings the authors recommend the systematic collection of information on social supports, patient motivation, and information on recent nonmedical life changes (e.g., a divorce) to better identify patients who could benefit from care management. The study involved nearly 1,200 patients treated in outpatient medical centers within Kaiser Permanente Northern California. Maria E. Garcia et al., “Which Complex Patients Should Be Referred for Intensive Case Management? A Mixed-Methods Analysis,” Journal of General Internal Medicine, published online ahead of print, May 24, 2018.

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Editorial Advisory Board, June 2018

Special thanks to Editorial Advisory Board members Anne-Marie Audet, Michael Chernew, Michael Rothman, and Mark Zezza for their help with this issue.

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Michael Chernew, Ph.D., professor of health policy, Harvard Medical School

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, Rand Corp.

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, managing principal, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, UCSF School of Medicine

James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, director of quality and operations support, The Permanente Medical Group

Stephen Somers, Ph.D., president and CEO of Center for Health Care Strategies

Mark A. Zezza, vice president, Lewin Group

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