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Episode 26 – June 2021: National Healthcare Policy & Local Primary Care Access Improvement

June 2021

MaineHealth ACO president Jen Moore talks to federal policy expert Blair Childs about the Biden Administration’s health policy and funding priorities, including telehealth and value-based care. Also, Memorial Hospital CMO Matt Dunn, MD, reports on a successful effort to increase primary care access in the North Conway area.  

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organizations. An air-fried monthly podcast for health care providers. I'm Julie Grosvenor.

MIke: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO. In this episode, Matt Dunn, CMO at Memorial Hospital, tells us how he's expanding primary care access.

Julie: But first, we learn how national health policy developed in D.C. will likely affect the way we practice medicine right here at home.

Mike: And that's coming up right now. So let's dig right in.

Julie: Decisions in Washington can often seem remote and irrelevant to our day to day, but we're in a moment right now when policy and money coming from the federal level will likely have a real impact on how health care happens here at the local level.

Mike: So MaineHealth ACO president Jen Moore recently spoke to national health care policy expert Blair Childs about what to expect from D.C. in the months to come. Blair is senior vice president for public affairs at Premier, a leading health care improvement company that works closely with our ACO.

Julie: Let's take a listen.

Jen:
I know many of our practices are wondering how long reimbursement for telehealth will remain at par with in-person visits. What's your assessment on that?

Blair: Yeah, thanks, Jen. Great to be with everybody. Yeah, this is a really big topic in D.C. I mean, there's hearings being held every couple of weeks on this topic to try to understand this. The big issue in Congress comes down to this. The fear is that you're going to have, because we have a fee for service volume based service, people will go get get a telehealth service and a charge for that. And then the physician will say to come into the office so we can see you in person. So you pay twice for the same service. And that's the great hesitation. I think what's going to probably happen in the end is a couple of things. They will continue telehealth service at the current level for a period of time. It could be with some constraints on it, they'll continue it for a period of time to see what happens in terms of Medicare expenditures in particular. And obviously, the states are going to decide for themselves how they want to do this. But I have to talk about it from a Medicare vantage point, because that's what Congress has authority over. So I think they'll continue it for a short period of time, evaluate what's happening in terms of spending, evaluate how it all goes in general, and then they will make determinations how to continue it. And I think ultimately it's going to be, a lot of discretion will be given to see CMS to figure out how to expand this. And I think they will be extremely cautious because CMS is, their number one priority is protect the Medicare trust fund, which is the amount of money spent by Medicare. So they'll proceed with great caution. I do think, and this is what we've been strongly advocating for, is they need to just open up and continue the current telehealth reimbursement program, as is, for any organization that's in a risk based alternative payment model. So that's an ACO or a bundled payment program because you're already at risk. You need to think about how do you deliver care more effectively and efficiently. So those organizations are going to be very thoughtful about how they operate under their fixed budget when it comes to telehealth and all. But it's an incredible, it's potentially an incredible accelerator of lower cost, high quality care. And I would much rather see the physicians at MaineHealth and in your ACO making those decisions about how to use it versus the government.

Jen: Thinks there will be watching that closely. It's very important to our community, as you know, particularly given our rural nature. So there's been a movement underway for the last decade to move to value-based care. How do you see this playing out in the current administration?

Blair: This administration is going to be very focused on shifting from fee for service, which has demonstrated that it incents siloed care, uncoordinated care, a lack of focus on proactive care, because it's basically a sickness based system and this administration, and I would also argue the last administration, saw the need to move to value-based care and risk for providers overall. So they see the huge flaws in fee for service and they see value- based care as a solution. It also aligns with their health equity goals, because if you stop and think about how care is delivered in an alternate payment model where you're thinking about keeping people healthy and out of expensive settings of care, you will be more proactive in your care delivery. And the issue of equity is less. We see this in our ACOs. We see them perform that way all the time. This year, health care spending was projected to be 20 percent of GDP. It has actually stabilized over the last decade at about 18 percent of GDP. It's still a faster growing part of our economy than other parts, it's still a high growth and very good part of our economy to be in. But we have saved six hundred plus billion dollars over the last decade and I think the movement to value has been a major player in that. And this administration sees that as well. And as I mentioned earlier, they're sort of moving forward on the framework, the chassis of the ACA. And then I think they see that the value in value-based care moving from this micromanaging system where you don't get paid unless it's a covered service and that it's been quoted, documented properly and all the details and all the micromanaging to something that's less controlled and more provider driven. I think they believe strongly in that. And then I think we've also learned from the pandemic just how misaligned our system is. It's incredible when you think that the payers have made billions and billions and billions of dollars out of this pandemic while the providers have been doing all the work.

Jen: Thank you, Blair. That was incredibly helpful and informative.

Mike: Well, it's time for The Sizzle, the segment where we highlight the good work of ACO participants this month. Our producer Paul Santomenna speaks to Matt Dunn, CMO at Memorial Hospital in North Conway, about his efforts to expand primary care access in his community.

Paul: So, Matt, at Memorial, you've launched this effort to improve access to primary care. Can you talk about when you started that and what kind of problems you were trying to solve?

Matt: Yeah, absolutely. We really started this in the summer of 2019. There was a leadership transition here and one of the things we heard early on was that there was not enough access in our primary care practice. We heard this from our providers. We heard this pretty strongly from our community. We could see it in our metrics that things like our third next available appointment time wwas very long compared to industry standards and even within our own system, it impacted the work environment. Our providers were feeling like they weren't able to see their patients when they needed to. Even some of the longer visits, like annual wellness visits and annual physicals were pushed out six and seven months and this made for, I think, a very challenging environment. At the same time, I think the needs in health care in terms of collecting information for things like ACO payer programs, quality metrics, has grown over the years and many of those were collected at the time of the visit which made the visits challenging, as well as the kind of continual challenge of clinical staffing, so MA and support staff. We know this is a challenge in our system. It's a challenge everywhere nationally. And you add all three of those together and it made for a pretty challenging environment. One of the things early on with the provider group in particular was really to listen to their needs and one of them actually threw out expanding our hours and, historically in my career, that's always been challenging. And you say, well, what do you mean by expanding hours? And they said, well, we're only open 8 to 4 Monday through Friday and our area has a very low unemployment rate. So that means if anyone has a job, which is most of our community, they have to take time off to come. And that's not very popular. So that started the seed. We started to look at models and over the course of a few months of planning, we went from Monday through Friday, 9 to 4, so we had really thirty five open clinic hours, we expanded that to 53 hours a week by going to 10 hour days as well as opening both Saturday and Sunday for a four hour stretch. The first three weekends that we opened for scheduling were all full by the end of the first day and our schedules were completely full till 6 p.m. within the first couple of days, we booked out that quickly. It's had a pretty significant impact, I think, on providers being able to see their patients. We also at the same time started to look at other operations like a rooming process where we were collecting information, health maintenance activities, in an effort to give providers more time with their patients. We started to pull some of those activities out of the visit itself. And we're doing direct outreach to patients. We developed something called the Patient Outreach Center. So that has also given the providers more time in their day and the staff to be able to have direct patient contact. What we've seen as a downstream effect of this is A, our community has definitely noticed. They're thrilled to be able to come in after work. And in calendar year 2020, we saw a 20 percent growth in our overall primary care panel size, which was tremendous. It's really unprecedented growth. And we're currently adding 20 to 30 new patients per week still. So at the same time that this was very successful, the downstream effects is that it's been very successful and and we're growing, which is a good problem to have. It's forcing us to think and be more creative, engage our team more and hire more. And I've hired by the end of this year, I'll have five more primary care providers, staff who are completely full. We did make this flexible. So there are some of the providers that said, "hey, I would really much rather work just four days a week" and figure that out. And one of our physicians has enjoyed the weekend so much that she wants to work one every month. So she's taking the bulk of them compared to some of the other providers. So, we've been also somewhat flexible in terms of how people are scheduled and providers that are working four days a week aren't going to go to 4 10 hour days. So, how do you account for that variation? That's also allowed us because of the flexibility in scheduling to actually better utilize our space, our practice and our clinical staff, because wwe can balance the schedule better.

Paul: Just one final question, which is how do you think this could work in other communities? I mean, you obviously tailored this to the needs of that particular community there. Can the same kind of thing work elsewhere?

Matt: Absolutely. I don't think I mentioned this at the beginning, but on top of listening to our team here, we did conduct some community outreach and talked to a bunch of stakeholders in the community to really hear the pain points and be honest about them instead of avoiding them. So I think we all try to do the best we can to listen to the community. And sometimes the more you reach out, the better. And we heard an awful lot about some of the pain points that have existed here. And there still are, there's a bunch. And I think you listen to those to be honest about them and you understand what you can and cannot affect. And I think that level of engagement with your community as well as your team, like I mentioned, this was a decision by all of us. This didn't come from me, didn't come from our president, didn't come from our chief nursing officer. This came from our primary care practice with us to support and guide and help create this access.

Julie: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our Web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at Bacon@mainehealth.org. That's Bacon@mainehealth.org.

Mike: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next month.

Julie: See you next month.