Episode 35 – March 2022: Toward a New Primary Care Payment Model

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, a paleo-friendly 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.

Julie: For our Meaty Topic this month, Dr. Rob Chamberlin, joins Mike to evaluate the first year of the Primary Care First program in Maine.

Mike: Yep, there is a lot to digest here, so let's sharpen our canines and get right to it.

Meaty Topic...

Julie: A little over a year ago, more than two dozen practices participating in the ACO joined an experimental reimbursement program from Medicare called Primary Care First. It was Medicare's first major foray into capitated payment for primary care. The idea was to reduce reliance on fee-for-service payments and support team-based care. The ACO's CMO, Rob Chamberlin, helped enroll Maine practices, and our own Mike Clark was a participant. So now Rob will be joining Mike to discuss how this experiment has turned out so far. Welcome.

Rob: It's great to be here Julie, thanks so much for the introduction.

Mike: Thanks for joining us, Rob. And first off, if you could, would you set the groundwork for us? What is Primary Care First?

Rob: So, Primary Care First is a program that Medicare has initiated to pay primary care practices in a different way. So if a practice is enrolled in this program, instead of getting paid in what we call fee-for-service, meaning every time you see a patient, then you send a bill in and you get paid, what Primary Care First does is they pay the practice every month to take care of the patients, regardless of whether the patients come in, and then when they do come in, you get a smaller fee for when the patients come in.

Mike: Great, so you saw the potential in this program, and you've been an enthusiastic supporter of this in the system, what potential did you see when you first looked at the PCF proposal?

Rob: Yeah, it's a mix of the potential in this and also the flaws in fee-for-service payments. So the problem with fee-for-service payments is, as you know well, Mike, is you have to see a patient in person or maybe through video, has to be a physician or an APP, and that's the only way you can get paid. And so you have to build your system around a fee-for-service payment model that requires the patients to see us in person or through video. The potential when you can move to what we call this is called a population-based payment model is when that money comes into the practice, you can decide how to allocate that money across your care team any way you want. So there's this quote from Millbank, which is an organization that does a lot of research around this. And they say the benefit of population-based payments is you don't have to worry about who provides what kind of care in what venue. So it no longer has to be Mike Clark with an in-person visit to check someone's blood pressure. Now it could be a nurse at Mike Clark's office who does a phone call follow-up to a patient who's at home and is checking their blood pressure at home. And that could be the care delivery model or part of the care delivery model.

Mike: Yeah, that makes so much sense, to sort of redesign or this really could form the foundation for redesigning how we think about primary care delivery. So, you know, we've crossed the one-year mark starting the second year of this program. How would you assess the success of the program here in Maine?

Rob: I'll share with you the perspective from the ACO and from where I sit as a provider here within MaineHealth and Mike, I'd love to hear your thoughts because I know you're involved in this as well. When we entered this program, it was very much to build some momentum towards changing the payment model for primary care. And so in that sense, the program has been very successful, and I think that Medicare's hope was that this would catalyze some further transformation with other payers. And so we have seen that Maine Care now has a program that's come out is called Primary Care Plus, which they are looking to evolve to resemble Primary Care First. We've been in discussion with some commercial payers about these types of population-based payments for primary care. So in terms of jumpstarting the conversations with multiple payers towards a new payment model for primary care, this has been very successful. The other ways we can think about the successes is how much it has led to transformation at the practice level. And one of the difficulties is if you're getting, you know, a monthly payment for every patient and then you can decide, well, this allows my nurses to provide more care or a health coach, and I don't need the person to come in to see me. That's great. But if that's for only 15 or 20% of your patients, then it's limiting because the other 85% of your patients are still getting paid in fee-for-service.

Mike: Right.

Rob: And so, I would say that the full potential of this transformation from fee-for-service to population-based payments is limited until we get to a critical number of our patients for whom we are getting reimbursed in this model. And the study suggests that's around 50%. So we're working hard to get there. But I would say that the full potential can't be unleashed until we get to that point.

Mike: Yeah, that makes complete sense because really, what you're talking about is not just a change in the payment system, but it's a change in the care delivery model. But inevitably our care delivery models are built around the reimbursement paradigm. So this is a big shift.

Rob: Yeah, I'm curious like, how would you answer that question of assessing the success of this program for your practice.

Mike: We definitely approached it with some fear and trepidation, not knowing what the bottom line impact would be for us, and as a small practice, that's a big deal. But I was drawn to the model. I really do believe that the future for robust and stable primary care delivery is a change in the payment model to a population-based payment or perspective payment. So, I was intrigued by it, and I really do see it as the direction we need to go. So I jumped in with both feet. One of my favorite refrains is under the traditional fee-for-service model. My best work. You know, some of my most important work is completely un-billable and un-reimbursable, you know, that extra phone call, that extra work you do, the phone call to a specialist, the sort of behind the scenes work you do to really ensure the patient gets the care that they need. So, unless they're in front of you doing a billable office visit, the pressure is constantly on you to not do those things. And any reimbursement model that pushes us to not do the right thing, you know, has problems, as you said. So I jumped on this. We did some modeling in our practice to try to do a, you know, a pro forma of what we expected the reimbursement to be. You know, sort of estimating the average number of office visits per year, per patient, within this population. You know, looking backwards and then kind of modeling it out based on the monthly perspective or the quarterly, but you know, the prospective payments together with what we expected to collect in the reduced office visit fees. Medicare did carve out procedural visits. Some of the other CPT codes don't fall under the bundle of the prospective payments. So, we pulled some of those out and when we ran the math it looked like we would at least break even and possibly even see an increase in reimbursement under the model. And, as we ran the numbers after the first year, indeed we did. We did see what, we believe we saw an increase compared to what we would have collected. There's other factors too, being, you know, the pandemic ongoing, some people not coming into the office for care. There may be other factors afoot, but overall we do believe that it actually helped us as a small practice in the bottom line. So I'm holding out great hope for this as that first step towards a better payment system.

Rob: Yeah, I think you feel much more acutely than some of our employed physicians, that the financial side and the stabilization of payments, especially in the context of a pandemic, and, you know, down the road in the context of changing care delivery models, is just so critical. I'd be curious if this were to expand, if other payers would realize that this is really a win-win because, for the payers, it's not necessary that they have to pay more in this program for us to realize the benefits of the flexibility from a population-based payment model. So of course, we all would support, and the studies would show, that if they did invest more in primary care, they'd more than make up for that with better access and lower costs overall. But if more payers were able to move towards this kind of payment model, how do you see that impacting the care delivery system in your own private practice?

Mike: I think if we could sort of uncouple reimbursement from the fee-for-service paradigm, it would really free us up to look at what, you know, what staffing model, what would make sense to be successful in that. And I think it could allow us to move towards a more patient-centered staffing model. I think it would take a shift. I mean, it would take some really rethinking because we're just so used to delivering care in a fee-for-service model. But I could see it really opening up the door to more of a team-based care, and also building the care delivery around the patient, what they want, what their needs are. If they want to come in for an office visit, you know, we can do that. If they're like, "No, I'm stable, I really don't see the purpose for coming into the office," and, you know, we get the data that we need or they get the follow-up labs that are necessary, you know, it just creates a lot more flexibility. And I think we could almost, at least in primary care, I think we can almost rethink what primary care looks like. And that's really exciting. I think it's the opportunity for primary care providers to step off the hamster wheel and really think, OK, my job is to take care of a population of patients, not just to power through as many office visits as I can for this day. And that's an exciting opportunity, and I think we'll need some help, you know, to rethink that. We're going to need the expertise of people who have spent some time working on a different care delivery model to help us retool. But I think the opportunity for real satisfaction in our practices, in primary care, and for patient satisfaction is super high. And like you said, I think the numbers would predict that costs overall for patient care, you know, could go down, so.

Rob: Yeah, I agree. One of those, I'll just highlight one of the things you mentioned about the satisfaction of our care teams and our PCPs. I remember when I was helping to lead primary care at Maine Medical Partners and we designed a new care model, but to fund the care model, it all came down to how many more visits will the PCP have to fund the other care team members or to fund the time that an APP could be used to support the whole panel. And that limitation was really discouraging. And I think it takes away the autonomy of a PCP, to think about how to optimize the care for their patients. When you're told, at the end of the day, the only thing we're going to pay you for is that in-patient visit, but then please also redesign the care you're delivering, it feels very limiting and it feels like you don't have the autonomy you need. Because, if you decide that the best care for your patient is a phone call follow-up because there's no reason for them to come into the office, like you said, now you're trying to squeeze that in because you're not going to get paid for it or you're having the patient come in because it's the only way that you can support the operations of your practice. So the opportunity for population-based payments to increase the autonomy of our care teams to deliver, to design systems around what's best for the patients, I think could be really transformative.

Mike: Yeah. Well, I appreciate Rob, your vision and leadership for our ACO and for our system, and really being on the lead edge of innovative population-based payment, and for the work I know you're doing with other payers. I really appreciate that.

Rob: Thanks, Mike. And likewise, I appreciate you being an independent PCP who is willing to do all the hard work, to do the analysis, and to jump into a new model to really be a leader and model that for others who are in a similar situation. So thanks for your leadership as well.

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, as always, 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!