icon-    folder.gif   Conference Reports for NATAP  
 
  Value-Based Healthcare / Patient Care

 
 
 
 
Sustained Participation in a Pay-for-Value
Program: Impact on High-Need Patients

 
 
  Download the PDF here
 
from Jules: Our healthcare system is broken, WHY? Because the time allocated & quality of care has been drastically diminished. Value Based Healthcare is generally viewed that it means for example "pay for performance", in other words patient outcome or results dictate payment for a drug or therapy to the drug maker from the insurance company or payer. For example, in HCV, achieving an SVR would prompt payment while no SVR achieved would mean no payment, this example is a little simplified because its vey easy to understand cure in HCV, either its an SVR or not but further complicating this example is that 95+ achieve an SVR or cure. In cardiovascular disease or cancer outcomes may be more difficult to define, but they are definable: a cancer cure, an elongated cancer in remission, extended life, etc. In heart disease perhaps normalization of lab values, like cholesterol or LDL, or other general health related markers. In HIV many doctors & clinicians are leaving the field because the healthcare system is broken across the board for all diseases, but in HIV its a unique situation because having HIV requires a lifetime of ongoing care including to monitor the success of ART/HAART, viral load, CD4, adherence, the development of drug resistance, and the need to change therapy vey quickly if necessary. Much of the patient population consists of marginalized patient communities who need even closer attention. In addition let's not forget all the many comorbidities people with HIV can develop which requires close monitoring, prevention education, intensive lab testing & monitoring and care & treatment. And with the aging population the intensity of these needs will substantially increase creating a very strained system of care & costs. Here is an article reporting on testing a unique model for care in High-Need Patients, HIV+ of all types are High-Need. Unfortunately patients & care providers are suffering under the current system. Reimbursement for doctors & clinicians has declined so much requiring substantial reductions in time spent with patients. Often a visit to an HIV doctor or clinicians gets 10-15 minutes, or even for a specialist in kidney or cardiovascular disease can get as little as 10-15 minutes at a major academic medical center. This results in lower quality care and I contend will result in patients getting sicker, disease progression & higher mortality rates. I do not hold any great hopes that in the short term or ever this problem will even begin to be discussed in a real way at major academic care centers in HIV. In the meantime patient care will suffer and doctor dedication & quality of care they deliver will decline.
 
Published Online: December 21, 2016
American Journal of Managed Care
 
Dori A. Cross, BSPH; Genna R. Cohen, PhD; Christy Harris Lemak, PhD; and Julia Adler-Milstein, PhD
 
Author Affiliations: Department of Health Management and Policy, School of Public Health (DAC, JAM) and School of Information (JAM), University of Michigan, Ann Arbor; Mathematica Policy Research (GRC), Washington, DC; and Department of Health Services Administration (CHL), School of Health Professions, University of Alabama at Birmingham.
 
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Integrating Community Health Workers into Care Teams: Lessons from the Field
 
http://www.chcs.org/integrating-community-health-workers-care-teams-lessons-field/?platform=hootsuite
 
Caring for people with complex medical and social needs requires a holistic person-centered approach that recognizes non-medical factors such as housing, transportation, food insecurity, addiction, and social supports. To help patients address these underlying needs, many provider organizations are tapping the unique skill set of community health workers (CHWs).
 
http://costsofcare.org/
 
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"....these programs suggest that policy makers may want to consider conditional payments or additional incentives for providers who continuously participate in an initiative..."
 
http://www.ajmc.com/journals/issue/2017/2017-vol23-n2/sustained-participation-in-a-pay-for-value-program-impact-on-high-need-patients/P-1
 
Among Michigan primary care practices, sustained participation in a pay-for-value program appears to contribute to improved utilization outcomes for high-need patients. "....high-need patients are likely to have a high volume of healthcare encounters with many different providers, both specialists and hospital-based clinicians. Providers need time to develop and implement new systems and workflows for managing patient transitions and the volume of information flowing in and out of their practice, such as regular medication reconciliation checks and active follow-up after hospital discharge......Significantly improving these outcomes, even among high-need patients who offer the greatest opportunity for gains, likely requires broader changes to the health system and to patient behavior-both of which are complex and require a long time frame to address"

 
Among Michigan primary care practices, sustained participation in a pay-for-value program appears to contribute to improved utilization outcomes for high-need patients.
 
Comprehensive primary care has long been recognized as the cornerstone of a high-performance health system.1,2 In response to rising healthcare costs and inconsistent quality
 
performance, strengthening primary care is a critical part of the US health policy agenda. A specific target is to improve care for patients with the greatest healthcare needs: those with complex conditions, multiple chronic illnesses, and mental health disorders. Such high-need patients use a disproportionate share of health services and the nature of their care needs provides opportunities for increased efficiency, quality improvement, and associated cost savings.3
 
To promote new approaches to primary care that improve outcomes for high-need patients, an array of quality improvement initiatives have proliferated in recent years.4-6 Growing evidence indicates that these efforts can reduce medical expenditures and increase quality of care.7-10 However, the evidence is still emerging about what is required for these efforts to actually result in improved performance.6,11-16 The answer likely involves myriad factors, as substantial, multifaceted organizational changes are required to improve care for high-need patients.17,18 These changes-such as aligning intrinsic motivation with external performance incentives,19-21 creating an organizational culture of deliberate learning,22 and acquiring and deploying specific organizational resources required for targeted improvements-likely take time to become accepted and embedded. Thus, whether practices sustain their commitment to improved performance for high-need patients may be a critical piece to understanding variation in performance improvement under pay-for-value initiatives.
 
This paper builds on existing research and attempts to fill key knowledge gaps about the impact of primary care practices' continued participation in a pay-for-value program. Prior work has had limited access to robust longitudinal data and/or significant sample sizes to assess practice performance over time,23 and the majority focus specifically on participation in patient-centered medical home (PCMH) demonstrations, rather than broader pay-for-value programs. Among the studies that do examine the effects of sustained program participation, findings are inconsistent. Friedberg et al examined a broad range of outcome metrics over a 3-year period in the context of a PCMH demonstration and found minimal change in quality with no significant effects on cost or utilization.11 Lemak et al analyzed a broader pay-for-value program, also over a 3-year period, and found positive effects on quality and on a subset of cost categories.24 However, neither paper assessed the impact on outcomes for complex, high-need patients. High-need patients represent an understudied group that is particularly critical to study, given that they are likely to disproportionately benefit from improved care delivery, but may not benefit equally under performance improvement programs.25,26
 
To help better understand the impact of sustained participation in care delivery transformation efforts for high-need patients, we sought to answer the following specific research question: Is continuous participation in a fee-for-value physician incentive program associated with improved primary care practice cost and quality outcomes for high-need patients? The passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) of 2015-which aims to increasingly tie provider compensation to value of services delivered-creates particular urgency to better understand the specific context(s) under which existing pay-for-value programs positively impact patient care. We answered our research question in the context of a statewide, multi-pronged performance improvement program, which has been studied previously.24,27 We examined a range of cost, use, and quality outcomes for a panel of 1582 primary care practices that did and did not continuously participate in this pay-for-value program in order to assess various dimensions of performance. Our results inform ongoing efforts to use incentive programs to promote the evolution of primary care practices in ways that better meet the needs of high-need patients, and thereby improve overall health system performance.
 
"Our longitudinal analysis of more than 1500 primary care practices in Michigan over a 4-year period suggests that sustained participation in a pay-for-value program results in modest but meaningful improvements in care for high-need patients. Performance for practices participating in the PGIP pay-for-value program improved relative to nonparticipants in 3 domains. First, PGIP practices consistently and significantly outperformed control practices on 30- and 90- day readmissions. In 2013, compared with 2010, sustained PGIP participation resulted in a reduction of 25 readmissions per 1000 patients. Second, we found suggestive evidence that PGIP practices were able to reduce odds of incurring any ED utilization over time to a greater extent than control practices. Finally, we also found suggestive evidence that patients in PGIP practices saw significantly greater improvement over time in the quality of overall quality, as well as medication management quality (which could explain the increase in drug costs over time). However, total medicalŠsurgical cost was not reduced, likely because avoided use was for relatively rare events and was partially compensated for by increased drug spending. In addition, overall quality did not improve over time. Taken together, our results suggest that sustained participation may be an important factor in improving specific dimensions of care for high-need patients under a pay-for-value program.
 
In order to see the benefits of participation in a pay-for-value program for high-need patients, practices appear to need to engage with the program in a sustained way. The changes in primary care practices that are required to improve care for high-need patients- including significant changes in organizational culture, an emphasis on teamwork, and staff-level buy-in to new care processes- likely require pursuit over multiple years.19,35 Practices also need time to understand program expectations and develop and reinforce new behaviors and processes that support redesigned care. The rapid growth in the PCMH component of PGIP over the study period is likely a key contributor to observed changes in our outcome measures; however, we believe the additional PGIP programs beyond PCMH play a critical role in providing additional resources and incentives to support and sustain practice changes that lead to higher-quality care.
 
We observed heterogeneous effects of sustained PGIP participation across our outcomes that are mostly consistent with these expectations. Specifically, sustained participation was associated with reductions in readmissions, better control over any ED use, and improved quality. Changes in these measures likely result from changes that take time to implement but lie within the control of primary care practices. For example, high-need patients are likely to have a high volume of healthcare encounters with many different providers, both specialists and hospital-based clinicians. Providers need time to develop and implement new systems and workflows for managing patient transitions and the volume of information flowing in and out of their practice, such as regular medication reconciliation checks and active follow-up after hospital discharge. In contrast, we found no program effect on inpatient utilization or total medicalŠsurgical cost, which may reflect the fact that these 2 measures are less sensitive to changes that can be made by primary care practices. Significantly improving these outcomes, even among high-need patients who offer the greatest opportunity for gains, likely requires broader changes to the health system and to patient behavior-both of which are complex and require a long time frame to address. "
 
Policy Implications
 
As MACRA takes effect, provider payments will become increasingly tied to value through the Merit-Based Incentive Payment System and participation in alternative payment mechanisms (APMs), such as accountable care organizations, shared savings, or bundled payment initiatives. In early demonstrations, as well as currently operational new payment arrangements, these programs experience a lot of provider turnover.38
 
Although MACRA will compensate providers on an annual basis for APM participation, our findings about the benefits of sustained participation in these programs suggest that policy makers may want to consider conditional payments or additional incentives for providers who continuously participate in an initiative. In addition, the heterogeneous results across different outcome measures suggest that resources and support may be leveraged most effectively when targeted toward specific types of use that are more within practices' direct control.
 
CONCLUSIONS
 
Given the large investment in pay-for-value programs to date, and their growing prominence, our findings offer reassurance that these initiatives appear to be effective in accelerating performance improvement among primary care practices caring for high-need patients. Our findings specifically point to the importance of sustained participation, which likely helps practices establish new care processes to improve outcomes under their control-in particular, ED use and readmissions, which are more prevalent among high-need patients. However, moving the needle on outcomes like total spending likely requires broader solutions that involve new approaches to health system organization and patient behavior change.