A retrospective on primary care models and learnings from a variety of industry vantage points — Part One

We all have heard that healthcare transformation is difficult; I’ve written this blog to convey what I’ve learned about primary care reinvention from a variety of roles over the years. I’ve been afforded perspectives through the lens of health plan, investor, provider, and patient. This blog is presented in two parts, and after reading both, you’ll have some insight into how Curai is applying these learnings to create a terrific primary care experience for our patients.

In his latest blog post, Neal talked about my experience on the business side of primary care reinvention; it’s true, I’ve been at it for over a decade. I’m a healthcare services lifer with nearly 25 years of experience, and I’m sticking with it despite the piles of industry barriers; it’s slow-moving, risk-averse, bureaucratic, and wrought with misaligned financial incentives. For me though, the mission is incomplete. Our end destination ought to be an economically viable way for all Americans, regardless of job or insurance status, to have access to high-quality primary care. Primary care would include proactive management of preventive, urgent, and longitudinal care needs. It would consist of everything one needs short of medical emergencies, hospitalizations, and specialty care, including pediatrics, obstetrics and gynecology, mental health, vision and dental care. Despite the best efforts of many besides me, we have a long way to go. I want to share what I have learned over the years through various seats around the table — health plan, investor, provider, patient. From my new seat as Chief Business Officer at Curai, I’ll be partnering with our clinical, product and technology teams, as well as external collaborators, to bring this experience to bear on our mission to provide the world’s best healthcare to everyone.

2008–2012 Learnings from the health plan perspective

In 2008, I had the great fortune of developing programs for a regional BlueCross BlueShield health plan that increased provider reimbursement for medical care when improved patient outcomes were demonstrated. Our team was accountable to create, test, and evolve care and reimbursement models that rewarded providers and encouraged program spread when we found success. Below are highlights from three programs from this time, each of which were seeking to instantiate Barbara Starfield’s famous four Cardinal Cs of great Primary Care: “first Contact accessibility, Coordination, Comprehensiveness, and Continuity”.

1. The Intensive Outpatient Care Program (“IOCP”)

Program Details: This program dedicated an employed Nurse Care Manager (“RN”) as a single-point of contact for each panel of 200 poly-chronic patients (people with multiple chronic conditions; typically obesity, diabetes, and depression, plus one other condition). The RN was staffed in primary care clinics where patients had at least one visit in the prior 18 months. RNs were accountable to coordinate patient’s longitudinal care and preventive visits, facilitate medication reconciliation, and drive completion of activities that were evidence-based indicators of top quality care management (mainly via HEDIS measures). Payment in addition to fee-for-service was a care management monthly fee per enrolled patient, which covered salary and training for the RN. You can read more about the IOCP here.

Key Takeaways and Program Learnings

• Deliver ROI for your sponsors by nailing all aspects of longitudinal care. We can save significant bottom line dollars for our business customers when polychronic patients have optimal support. IOCP delivered ROI: the program saved sponsors 9–20% of total medical care costs, was spread regionally in the Pacific Northwest, nationally through a CMMI (Center for Medicare and Medicaid Innovation) demonstration project, and many newco’s have spawned from the idea of a medical home for the “sickest of the sick”.
• To garner engagement, PCPs should issue invitations to their patients inviting them to join specific programs. Initial patient engagement worked best when it was MD-led. Patients were most likely to opt into the program when invited by the MD directly (during IOCP it was via phone call), even if thereafter interactions were mainly with the RN.
• Non-MD members of the team are imperative to help patients improve their health trajectory. The RN was the hero at the center of the program. Well-trained and empathetic nurses not only were effective coordinators of care for patients, they made patients feel more comfortable and willing to follow their regimens.
• Aim novel tech towards enabling the patients to develop the relationship with their care team. The IOCP found success with very little use of technology. Example? I remember part of our training course was teaching nurses how to sort their panel of patients in Microsoft Excel.

2. Patient-Centered Medical Homes (“PCMH”)

Program Details: The vernacular for a PCMH today is “Care Team”. In a PCMH setting, the primary care entity dedicates multidisciplinary teams to manage a group of patients. This environment is designed to make optimal use of the skill set of each person on the team, starting with moving low acuity and rote activities off of the physician task list to other team members. Payment in addition to fee-for-service was an enhanced monthly fee for every health plan member that was part of a PCMH. Our health plan also covered some provider costs of tools and training to become a PCMH.

Key Takeaways and Program Learnings

• Be equipped to recognize and proactively address patient mental health concerns; screen for depression and anxiety in symptomatic patients. PCMHs must serve mental health needs as part of primary care. PCMHs who had a behavioral health specialist as part of the team could unlock positive health change for people. These team members were available “down the hall” to talk to a patient who screened high on PHQ-9 depression screening questions and helped them get the support they required for their mental health issues.
• Start with an “Intake Visit”. PCMHs earned patient trust and were able to address more health issues when they started new patient relationships with an “Intake Visit”. These were often 45 minutes or more with the MD and care team.
• Adopt tools and training for equipping patients to self-manage in time. Patient outcomes were better when care teams deployed tools and training that helped them meet patients where they are; for example the Patient Activation Measure (PAM). Success with such tools is measured by moving the patient mindset along a continuum of readiness to change.

3. Accountable Care Organizations (ACOs)

Program Details: ACOs include doctors, clinics, and hospitals who take on medical care responsibility for a population and have financial incentives that reward performance when good outcomes are achieved for that population. PCMH or IOCP programs could be embedded ACO care models. We worked to implement ACOs with commercial populations (not Seniors, not Medicaid programs). Payment in addition to fee-for-service was a cut of healthcare cost savings administered on semi-annual basis after reviews of provider performance vs expectations (“upside only”). In addition, we sponsored technologies that sorted patient data in order to prioritize patient care needs and the health plan used advanced analytic tools to evaluate MD and clinic performance. ACO demonstration projects nationally, for the most part, didn’t perform as all had hoped, particularly with the commercial population. Much of what I witnessed in the trenches was that the adoption curve for providers was very steep and new requirements were often cumbersome vs long standing workflows.

Program Learnings:

“Do not put each foot in a different boat” Chinese Proverb

• The primary care team commitment level makes or breaks any new primary care model or program. Too many primary care providers found themselves part of ACOs but continued to be compensated by their management for seeing high volumes of patients rather than taking care of each patient’s holistic needs.
• Without HMO experience, ACO workflow requirements were too foreign for primary care teams. Most commercial providers had only practiced in PPO environments and could not adapt to criteria that rewarded them for activities like closing the loop on specialist visits or verifying that hospitalizations went well. Large healthcare systems are now able to do much of this using technology systems that rose up in time to support ACOs and financial risk contracts.
• Providers can’t have a foot in two boats and expect to reach their destination. As a regional Blue health plan, we had the largest volume of any payer, yet often this was only 25% of a physician’s patient base. This was not enough volume to influence physician practice behavior change in meaningful ways. While we offered more reimbursement, we required new processes that only applied to a portion of the patients.

Key Takeaways: Curai has a strong advantage over traditional provider systems seeking to transform from within; our purpose built technologies, practice workflows, and reimbursement models naturally align with providing the best care for patients.

In 2012 I took a new role on Cambia’s healthcare strategic investment team (now called Echo Health Ventures). My hope was to use the terrific learnings I gained through experimentation with new care models to give an unfair advantage to startups who aimed to push the industry forward. In addition, I believed that novel technologies could help bring Starfield’s vision to life in ways she may not have imagined! Kevin Grumbach, editorial board member of the Annals of Family Medicine said this well:

“In this era of dynamic primary care transformation and redesign, Starfield’s 4 Cs retain an enduring integrity and relevance; what is innovative these days is the means to deliver the core functions of primary care, not the functions themselves.”

Stay tuned for part two of this blog, where we’ll dig into learnings as investor, provider, and patient from 2012 through today. It’s such a privilege to apply these learnings to business strategy at Curai, where we are harmonizing our mission, care functions and technology for the benefit of our patients.