Posts Tagged ‘primary care’

Q&A: Florida Blue Applies PCMH Principle of Increased Access

October 24th, 2012 by Jessica Fornarotto

Providing six hours per week of after-hours coverage is a requirement of the Florida Blue patient-centered medical home (PCMH) so that members have complete access to their physicians no matter what time of day, says Barbara Haasis, R.N., CCRN, senior clinical lead of quality reward and recognition programs at Florida Blue.

During an interview prior to her presentation for a May 10, 2012 webinar on “The Patient-Centered Medical Home: Lessons from a Statewide Rollout”, Haasis discusses requirements for their PCMH pilot, the role of a nurse educator in the PCMH to disease management and future plans for embedding case managers in their practices.

HIN: Your organization is several months into a statewide rollout of a PCMH pilot with more than 1600 primary care providers participating. We realize it’s too early to discuss any hard outcomes, but one requirement for the practices that are participating in the pilot is the availability of at least six hours per week of after-hours coverage. Why did Florida Blue make that a requirement for participation in the medical home pilot?

(Barbara Haasis): Florida Blue chose to add that because we are following, by the letter, the principles of a PCMH, as described by organizations such as the American Academy of Family Physicians. And one of the principles is increased access. In today’s society, where almost everybody is a working adult, and our program is for commercial members under 65 only, we wanted to make sure that our members could see their physicians either before work, after work, or on the weekends, if it was not a medical emergency.

HIN: Are any Florida Blue case managers currently working inside participating practices, or are there any future plans to embed health plan case managers in the practices?

(Barbara Haasis): At this point, our case managers are still inside of Blue Cross Blue Shield. We have expedited the process of referring a patient to our case managers, and we are looking at doing a pilot with one of our vendors that works with chronic diseases, wellness education, etc. That is still in the discussion phase, though.

We’re planning to put together a small pilot of about four or five practices and to put a nurse in the office who is not a case manager but a practice coordinator. One of the roles of this nurse would be to identify patients to move into Blue Cross case management or one of our disease or wellness programs.

HIN: Could you describe the duties of the nurse educators in the medical home pilot, especially as they relate to patients with any of the pilot’s five focus health conditions, which are diabetes, COPD, coronary artery disease, asthma, and CHF?

(Barbara Haasis): Right now we have three nurse educators. They are each assigned to a specific practice so that they can establish a relationship with that practice. Part of the scorecards that we give to our physicians on a quarterly basis includes metrics that measure whether or not our diabetics have received their preventive screenings and their chronic disease management.

If a practice is having an issue with a specific disease entity, the nurses can offer them some suggestions on how they may be able to improve compliance. If there are issues with cost, we may be able to work on that with our case managers. The nurses have a relationship with the practice. Where the practice is having an issue with the patient, they can call their nurse educator and get assistance that way. They’re also aware of the external opportunities, such as the American Diabetes Association, that our practices can refer their patients to.

Infographic: Primary Care for the 21st Century

October 8th, 2012 by Melanie Matthews

Primary care in the United States is moving toward a new, team model of care centered around the patient and led by the primary care physician.

The aim of this model of care, the patient-centered medical home, is to increase the quality and cost-effectiveness of care. Learn more about the structure of this model of care, why it’s needed and what the healthcare system will need to support this model of care.

Primary Care in the 21st Century

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Video: 2012 Medical Home Starts Linked to Surge in Patient Satisfaction

August 9th, 2012 by Patricia Donovan

In a week when both Blue Cross Blue Shield of Michigan and CDPHP have considerably amped up their medical home game, a new video from the Healthcare Intelligence Network (HIN) documents a rise in patient satisfaction resulting from the construction of more medical homes.

In response to HIN’s sixth annual survey on the patient-centered medical home (PCMH) model, 52 percent of healthcare organizations who took the survey said they have established medical homes for their populations. This year’s survey results also reflected the highest levels of patient satisfaction to date in the survey’s six-year history, with 82 percent reporting a rise in patient satisfaction that they link to PCMH processes.

With patients at the center of the medical home care model, monitoring their satisfaction levels along with their health helps to paint a complete picture of PCMH success.

Earlier this week, Blue Cross Blue Shield of Michigan designated another 994 practices as medical homes, making it the country’s largest PCMH effort of its kind for the fourth consecutive year.

At the end of last month, CDPHP effectively doubled its medical home initiative when it added 70 practices to its Enhanced Primary Care effort.

Narrated by HIN COO and Executive VP Melanie Matthews, HIN’s sixth annual PCMH analysis delves into ACO activity planned by responding medical homes, health IT, PCMH team members, patient education and engagement strategies, and much more. Florida Blue’s Barbara Haasis also shares some details on the payor’s statewide rollout of a medical home program.

If you prefer to read an executive summary of the survey results, download it here. A more detailed analysis is available in the HIN bookstore.

Medication Adherence Gets Boost from CMS Innovation Advisors

August 1st, 2012 by Jessica Fornarotto

“Payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources,” says Dr. Janice Pringle, director of the program evaluation research unit at the University of Pittsburgh School of Pharmacy. This is just one of many lessons Dr. Pringle learned after being selected for the Centers for Medicare and Medicaid Services Innovation Advisors Program.

During an interview with HIN’s executive vice president and chief operating officer, Melanie Matthews, Dr. Pringle discussed why she applied for the Innovation Advisors Program, the medication adherence intervention she developed with Highmark and Rite Aid, other initiatives supporting medication adherence, and much more.

HIN: What prompted you to apply for the Innovation Advisors Program?

(Dr. Janice Pringle): I have always been interested in innovations and I teach a course on healthcare innovations at the University of Pittsburgh. I also have been involved in a program where we took some strategies that are used in behavioral health and applied them in community pharmacy services, and we looked to see if that had an impact. I considered that an interesting innovation. And I have to emphasize that I did this with my collaborators: Highmark, which is a commercial payor and is now Gateway, a Medicaid payor; and Rite Aid Corporation and CECity have all been part of this particular program. We’re funded through the Pharmacy Quality Alliance (PQA).

HIN: What have you learned thus far?

(Dr. Janice Pringle): We’ve learned a lot. First of all, we’ve learned that pharmacists want to have a greater impact on their patients, so when you’re giving them the opportunity to do so, they rise to the occasion. We’ve also found that community pharmacy organizations such as Rite Aid are interested in supporting this. We also know that the payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources. We know that CECity, which provides some platforms to help us scale things, is a very important and necessary partner.

Finally, the PQA is important because they provide us with the national contacts. We’ve learned that the implementation barriers can be attenuated; we can get over them. Where there’s a will there’s a way. Even though pharmacists are very busy in community pharmacy settings, they can learn to have meaningful discussions with patients about their adherence and learn to fit it into their work. We’ve also learned that once they see this, they can continue to do it even more.

Our preliminary results have demonstrated to us, when we compare the medication adherence rate for the medication classes we’ve studied, that the pharmacy is better involved. 118 pharmacies improved medication adherence for the patients who received services there, compared to the pharmacies that we used as controls that were not using this intervention. What’s really key is that this effect seems to improve or increase over time, which shows us that the pharmacist gets better and better at it as they go forward. We’ve studied these data over a 12-month, or in some cases, a 13-month period. That’s everything that we’ve learned and we’re excited to see if we can continue to push this forward, and maybe change the conversation about the importance of community pharmacy in the healthcare arena and landscape.

HIN: What role do you believe medication adherence will play in the recommendations developed by the Innovation Advisor program?

(Dr. Janice Pringle): Medication adherence is definitely an important issue for many of my advisors. They’re programmed by looking at adherence, and it came up multiple times whether we were looking at transitions of care, palliative care issues, whether it was looking at issues of integrating and doing models using primary care, and so forth. Medication adherence has definitely come up. I would imagine, especially given we know that Dr. Will Shrank is a member of Brigham & Women’s Hospital Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics and his expertise is in medication adherence, it’s an important issue for them, and also for CMS in general and the innovation center.

HIN: Of the innovators selected to participate, what other types of initiatives support medication adherence? How do these programs complement or differ from yours?

(Dr. Janice Pringle): There was much interest in the issue of medication adherence, specifically some of what we were doing in our program and how they could apply it to their models. For most of the models that I heard about, the vast majority seem to have an interest in how they can improve medication adherence because they understood that this was an issue for them in improving health — or their “three-part aim” as they call it, which is improving health, improving care and reducing cost.

HIN: Can you briefly describe the intervention you’ve developed with Highmark and Rite Aid to improve medication adherence rates?

(Dr. Janice Pringle): The intervention involves screening, brief intervention (SBI) of patients for medication adherence issues. This way, you can place them in a risk profile. You use any screen that has validity in that purpose. You can sort your patients based on prior data and information. You can also do a universal screen where you ask them questions when they come in, but you want to bring up those patients that seem to be at greater risk than others. You can then apply a brief intervention, which is a two to five minute conversation that is based on motivational interviewing principles that address the issues of how we can help you improve your medication adherence. This is called a facilitative manner — you’re trying to have the patient and the pharmacist work together to address that issue.

HIN: When you spoke with us in May 2011, you were evaluating the preliminary results for the community pharmacist’s intervention. Can you share what results the program has achieved to date?

(Dr. Janice Pringle): With the pharmacies that were involved in the intervention, we looked at the patients that came to those pharmacies and looked at their formulary claims data. We found that their adherence significantly improved and continued to improve over time, so there was an acceleration of an effect over time. For the 13 months or so that we examined the data, compared to the control pharmacies that were fairly similar in many different ways, we examined the similarities to the intervention pharmacies on the same medication classes and the same adherence measures.

HIN: What did you learn in year one of the intervention and how have you modified the intervention based on these findings?

(Dr. Janice Pringle): One of the things that we’ve learned is that you have to keep in touch with the pharmacists consistently to make them aware, if they’re applying this innovation, that this is an innovation that has importance. Pharmacists have many competing requirements; immunizations, different tasks that come through in a community pharmacy chain. We keep in regular monthly contact with the pharmacists to determine what issues or concerns they may have or limitations. We want to get the issues addressed as quickly as possible. We also keep track of where they stand in the innovation process. That’s one thing that I think is important.

The second is, Rite Aid has reported this whole program and that’s key. Rite Aid put some very talented people in charge, such as Jesse McCullough, who is the clinical services manager for Rite Aid, and Rick Mohall, the director of clinical services at Rite Aid. They cleared the way for this to become an initiative for the pharmacies where we’re implementing so that it would continue to be priority. And they changed how they are evaluating the pharmacists.

There are raises also related to the pharmacy, but not just the pharmacist’s performance. The pharmacies are being evaluated as a unit. We found that one pharmacist could be on board, another may be less on board, and they could cancel each other out as they move forward. If you’re now evaluating the pharmacy as opposed to the pharmacists, that changes the conversation.

HIN: Do you have plans to expand the program to include other pharmacy chains?

(Dr. Janice Pringle): Yes. PQA and CECity have been working on the second phase of this, which is called Equipp. They are targeting the entire state of Pennsylvania, looking at some other pharmacy chains and other payors. They also have been talking to some other states. Dr. David Nau, PQA’s senior director of research and performance measurement, has been involved with CE City and is moving this forward to the other states, especially Pennsylvania.

HIN: Are the pharmacists receiving any higher payment for their services?

(Dr. Janice Pringle): Rite Aid has many programs that they’re using to provide incentives to their pharmacists, or to make up the way in which they’re reimbursed. Some of them relate to this study and some do not. What I’m about to say is one aspect of the many ways in which the pharmacists’ salaries were determined. I’m not privy to all of them.

I do know that Rite Aid has, as of January of this year, decided to look at ways that the entire pharmacy is performing, and adherence is one way to be able to look at that. There are other things that they’re looking at as well, but this was partially in response to our study and in response to other things, too, that indicated that it’s good to have the pharmacy be one unit in terms of how the pharmacy takes on innovation, or approaches ways in which we can be considered productive.

We will also be looking at, with Highmark, ways in which we can provide additional pay for performance, or value-based purchasing strategies for the pharmacist. We’ll be testing and developing some models for our colleagues. I wouldn’t expect those to be moved into the field until some time in 2013.

HIN: The community pharmacists can have a measurable impact on medication adherence, according to the results of your program. After the pharmacists, where should organizations concentrate their efforts to boost medication adherence? What should be done within the primary care practice?

(Dr. Janice Pringle): For our next step, we should bring physicians and pharmacists together. The same strategies we’ve used with the pharmacists can be used in the physician’s business. What could be interesting is having the physicians and pharmacists together with an understanding of common quality metrics, such as what CECity provides and what PQA has suggested regarding the measurement. This way, you can keep track of what’s going on with the patients between the physician’s practice and the pharmacy practice.

I think it would change the whole conversation of how we’re receiving medications in our community — if pharmacists are working in collaboration with physicians and physicians are learning the same skills. We could greatly enhance medication adherence and we could change the health of our communities. Again, it’s a matter of will to do that.

Are Payment Tides Turning for Primary Care?

July 16th, 2012 by Patricia Donovan
Primary Care Pay

Value-Based Payments

Several indicators this month point to more dollars flowing into primary care offices, either in the form of higher provider salaries, increased reimbursement, or both. And new market data finds physicians leading the majority of accountable care organizations (ACO).

A study released last week by Medical Group Management Association found that median pay for primary care physicians (PCPs) grew 5 percent last year to $212,840, capping a five-year increase of 16.7 percent from 2007 to 2011. While an actual PCP paycheck pales next to a specialist’s, of note is MGMA’s finding that PCP compensation grew at a faster rate than specialist pay over the last five years.

The reimbursement stage is being set for patient-centered care delivery models like the patient-centered medical home and the ACO that put a premium on care coordination, with many payors offering a combination of traditional fee for service (FFS) payment topped off with a care coordination fee, with possibly a little shared savings thrown in to sweeten the payment pot.

Sixty-one percent of respondents to the sixth annual HIN 2012 Patient-Centered Medical Home survey reported they operate under an FFS plus care coordination fee model.

And earlier this month, CMS proposed payment increases for family physicians of approximately 7 percent and for other practitioners providing primary care services of between 3 and 5 percent. As it has in other initiatives resulting from healthcare reform, the proposed rule offers additional financial incentives for care coordinated during critical transitions in care, such as when a patient is discharged from the hospital:

For 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.

Dr. Carrie Nelson, medical director of special projects for Advocate Physician Partners (APP), lauds CMS’s proposal. “It’s a long time coming that that kind of recognition has translated into reimbursement for primary care physicians,” notes Dr. Nelson, a family physician herself. “I know first-hand the amount of work that goes into making sure your patients aren’t falling through the cracks and getting the care they need in an efficient manner, especially after a hospitalization or major clinical situation.”

However, it’s critical that those dollars given to primary care for care coordination actually go toward that function, Dr. Nelson cautioned, and that quality measures are established in parallel with this funding. “There’s a risk that these funds could be seen as ‘new money,’ she said. “I think primary care feels undervalued and underpaid, and there is some validity to that. But at the same time, reimbursement for care coordination may not translate into actual care coordination unless there are some quality measures associated with that in order to make sure that the dollars go toward the purpose for which they were intended.”

With eight years of clinical integration (CI) under its belt, involving more than 4,000 physicians and 10 hospitals, APP can speak from experience. Its nationally recognized CI effort has achieved record performance in almost all measured areas, resulting in improved patient outcomes and significant cost savings. The CI program laid the groundwork for a value-based payment contract between APP and Blue Cross Blue Shield of Illinois. Dr. Nelson will share lessons learned from contract implementation during a July 18, 2012 webinar, Bending the Cost Curve with a Commercial Value-Based Payment Contract.

Diets, Doctors and Obesity: Heavier Weight for Primary Care

June 27th, 2012 by Patricia Donovan

It’s only Wednesday, but it’s already been a weighty week for obesity.

On Tuesday, the U.S. Preventive Services Task Force recommended that primary care doctors screen adult patients for obesity. The task force further suggested that healthcare professionals offer or refer obese persons to a comprehensive weight loss and behavior management program with 12 to 26 sessions in the first year.

But what type of weight loss program is optimal, and what’s the most effective diet to follow? Separate studies appearing in the current issue of the Journal of the American Medical Association (JAMA) offer some guidance for physicians in these areas.

Researchers in the first study, in search of effective but resource-efficient weight loss treatments, compared a standard behavioral weight loss intervention (SBWI) with a stepped-care weight loss intervention (STEP). The JAMA article notes that stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches.

All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every three months for the STEP group in response to observed weight loss as it related to weight loss goals.

In addition to determining the mean change in weight over 18 months, the study also measured additional outcomes including resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake and cost of the program.

Researchers concluded that among overweight and obese adults, the use of SBWI resulted in a greater mean weight loss than STEP over 18 months, but that compared with SBWI, STEP resulted in clinically meaningful weight loss that cost less to implement.

But let’s back up a minute to that low-calorie diet both groups followed. The second published study found that not all calories — and low-calorie diets — are created equally. Researchers at the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital studied the effects of three diets, each of which contained the same number of calories:

  • Low-fat, which is typically recommended by the U.S. government and American Heart Association, aims to reduce overall fat intake.
  • Low-carbohydrate, modeled after the Atkins diet, reduces almost all carbohydrate intake.
  • Low-glycemic, which aims to keep blood sugar levels steady by choosing natural foods and high-quality protein, carbohydrates and fats.

Even though all three diets consisted of the same amount of calories, researchers determined that the low-glycemic diet came out on top: aside from helping to stabilize metabolism even after weight loss, existing research suggests that low-glycemic diets help people feel fuller longer and experience improved sense of well-being, as well as improved mental and physical performance.

You can learn more about this research in Thriving, the Boston Children’s Hospital pediatric health blog.

For Americans identified as overweight or obese and for the healthcare providers assigned to treat them, there are no easy solutions. I leave you with these thoughts from George A. Bray, MD, excerpted from his editorial on these obesity studies that appears in the same JAMA issue:

Obesity is one of the most important and most frustrating health problems that physicians treat, and the studies in this issue of JAMA provide valuable information for clinicians who treat obese patients. It may be possible to have a more individualized approach to weight loss, rather than a one-size-fits-all approach. The most efficient treatment approach incorporates periodic reassessments and adjustment of the weight loss regimen based on a patient’s success at any given time. Although the exact relationship between dietary composition and weight maintenance remains unclear, calorie restriction is more important than diet composition in administering weight loss regimens.