Dual-track medical homes, e-visits, retooled patient handoffs and more post-acute care are predicted provider trends for 2014, according to Steven Valentine, president of The Camden Group. HIN interviewed Valentine prior to his presentation during an October webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.
HIN: What is the physician practice going to look like in 2014? How has the primary care team evolved to meet the Triple Aim values inherent in the PCMH and accountable care models?
(Steven Valentine): We should expect to continue to see consolidation amongst the medical groups. The independent practice associations will begin to assimilate together because they need to put more money into their infrastructure. And many of the organizations have underperformed, in all honesty.
The primary care team is still critical. We've benefitted by keeping many primary care doctors around because they were negatively hurt with their net worth in the recession in 2008-2010. But it's slowly coming back and we’re starting to see those physicians thinking about retirement again. The reality is, we're never going to replace all of these primary care doctors as they wind down their practice. We need to do a better job of getting telehealth going and utilizing e-visits. We're seeing the health plans starting to pay for those e-visits, as well as having the consumer who uses them use a credit card and pay at that time, just like a visit.
We're going to have to look at different models. Obviously, the nurse practitioner is getting more involved with the primary care. And yes, they're still pursuing the Triple Aim. We know that quality scores, satisfaction scores and trying to manage cost per unit is still a critical focus of the triple aim moving forward with population health.
Lastly, with a PCMH in accountable care, while some of the pioneer accountable care organizations (ACOs) reduce themselves out of pioneer into the Medicare Shared Savings Program (MSSP), we still have a number of organizations and it's growing. The commercial ACOs have been very successful in California.
We fully expect accountable care to continue. We think the PCMH will evolve into two tracks. The first track is a primary care PCMH. The spinoff is a chronic care medical home that has the multidisciplinary team organized around a chronic disease. This is a model developed by CareMore years ago in Southern California and it's been expanded across the country. As I travel the country, I run into organizations that have set up these chronic care centers around the chronic disease.
HIN: Regarding the Pioneer ACO program, one of the top performers in the CMS pioneer program, Monarch HealthCare, told us that it's going to be working to engage specialists in care coordination roles in year two and year three. What's ahead for specialists in terms of quality and performance improvement as well as shouldering perhaps more care coordination duties, especially for Medicare patients?
(Steven Valentine): The specialists are going to be a critical piece to this whole solution. They have been a tremendous asset in the area of bundled payments, where you have the facility fee and physician fee combined into one payment. That works for both the Medicare as well as the commercial side. You're beginning to see more of the bundled payments within an ACO.
The ACO manages what we call 'frequency' in other words, the number of procedures to be done. Specialists are involved in satisfaction, quality scores, and resource consumption once the decision is made that the procedure needs to be done.
We expect the specialists to be involved with quality and performance. Everybody is putting in incentive programs to help drive higher quality, better performance, and a lower cost.
HIN: Hospitals have tightened the patient discharge process as a means of shoring up care transitions. But what other work needs to be done in terms of collaborations, perhaps with skilled nursing facilities (SNFs), long-term care and home health, for example, to improve patient handoffs and reduce hospital readmissions?
(Steven Valentine): Handoffs have probably been one of the areas where we've seen the most disappointment or underperformance within many ACOs. They have not effectively involved the hospitalists and the care/case managers who are typically embedded within the medical group that would oversee the patient throughout the care continuum. Or if it's a health system, emanate centralized care/case management function where they manage all of the transitions from pre-acute, acute to post-acute. We think this will get better. As the doctors are more at risk, they will get more engaged with the care/case managers to manage these transitions and handoffs.
We also know that, while not in 2014 but the trend will start, we'll see lower acute care utilization, pushing more patients to post-acute care. This means, in any given area, acute care hospitals will begin to convert excess capacity to post-acute care services like skilled nursing, long-term care, palliative care, hospice care, home care and rehab care. You will begin to see a closer proximity. The care managers will be able to work more effectively with the doctors and hospitals to manage the patient through the continuum, smooth out these transitions and have a better patient experience with better satisfaction scores at a lower cost.
Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry