Primary care has long been something of an outcast in the medical profession — and despite convincing outcomes and a validated assessment tool, checkered reimbursement has brought the Institute of Medicine’s Primary Care Model to the brink of demise.
But the accountable care movement, and some Medicare Advantage plans in particular, have breathed new life into primary care and offered new hope for the struggling Medicare system. At St. Louis-based Essence Healthcare, a 4.5-star Medicare Advantage plan, network primary care physicians’ deep experience in providing accountable care has spawned innovations that advance primary care and make progress toward the “Triple Aim Plus One” (outlined in C9 below). Their success is the result of five years of active practice transformation and continuous improvement in a risk-bearing environment.
The best practice experience from these front-line physicians can be summarized in the Accountable Delivery System Institute’s Accountable Primary Care Model. This model embraces the four pillars outlined in the Institute of Medicine/Starfield model and expands them for Nine C’s of Accountable Primary Care Delivery. They are:
C1: First contact means that care is initially sought from the Primary Care Physician/Clinician (PCP) when new health or medical needs arise. In a nationally representative sample of more than 20,000 episodes of care, when these events began with PCP visits, as distinguished from some other source of care in the system, costs were 53% lower. This cost differential persisted after controlling for ER visits, health status, socio-demographics, and other relevant variables.
C2: Comprehensive care. PCPs offer a wide range of services across the entire spectrum of needs, for all but the most uncommon problems. In accountable primary care, office visits for older patients are scheduled for 30 minutes to address explicit and implicit needs proactively. Longer visits also enable the compliant documentation and accurate diagnosis coding required for comprehensive health-risk assessments. These assessments enable data-driven collaborative population management, as well as appropriate risk-adjusted revenue assignment in Medicare Advantage, ACOs, and many Medicaid programs.
C3: Continuous, longitudinal (over time), person-focused care. Physicians and patients work together to reach mutual decisions in the context of long-standing relationships that transcend episodic care. Person-focused care includes preference awareness, setting priorities, discussing expectations, and engagement with family, as well as the usual personalized prevention, screening goals, and advance care planning.
C4: Coordinated care is widely praised but narrowly understood and practiced in the U.S. After World War II, the nation had about a dozen categories of health care professionals and a half-dozen types of specialists. Now we have more than 200 categories of health care professionals with over 100 specialties. While transitions from ERs, inpatient settings, and skilled nursing facilities are high-stakes opportunities, every referral to a specialist may be viewed as a type of care transition. Much of this coordination work can be rendered unnecessary by shifting care back to PCPs through C2 and C3.
C5: Credible, trusting relationships between PCPs and patients. As one PCP describes it: “Without credibility, we are nothing but referral clerks.” Credibility is one of the fruits of providing the first four C’s, but it can also be bolstered through effective, explicit communication about expectations. While about 90% of clinicians surveyed thought it was important to ask patients about their expectations, only about 15% reported having such discussions and felt adequately trained to handle expectations.
C6: Collaborative care is the product of nontraditional payer-PCP relationships. Dr. Berwick wrote that an integrator is necessary to facilitate the Triple Aim. The accountable care movement calls for blending the traditionally separate payer and provider roles in health care. The Collaborative Payer Model delivers pre-paid, risk-adjusted funding by way of the primary care doctor-patient relationship as it realigns interests, incentives, and reciprocal responsibilities. Clinical and claims data transparency from across the continuum of care enables a collaborative approach to population management that transcends organizational boundaries.
C7: Cost-effective care naturally results from C1 thru C6, but is enhanced through proactive, intentional PCP-led efforts, which can be empowered by educational programs, data, and clinical decision support from the payer. In addition to providing vital clinical claims data cost transparency, collaborative payers have the incentives and resources to sift through the medical literature to glean evidence-based, fiscally-responsible care consideration messages that can help PCPs bend the cost curve, and to deliver such messages as close to the point of care as practically possible. However, individualized decisions weighing tradeoffs and patient preferences can only be made by providers and patients together.
C8: Capacity expansion. Health care systems cannot provide the first seven C’s without expanding the capacity and productivity of PCPs. A wide variety of approaches — including team/pod-based care, e-visits, better information technology and sharing of data, and the use of non-physicians in appropriate situations — have shown promising results to narrow or even eliminate the PCP to future needs gap.
C9: Career satisfaction is gaining more recognition in recent years. In the U.S., 36% of PCPs are not satisfied with their careers — two to three times the rate of PCPs in western European countries. While Lumeris (prior to forming the Accountable Delivery System Institute) articulated the physician satisfaction “fourth aim” as “Triple Aim Plus One” in 2009, it has been independently acknowledged by other thought leaders. Career satisfaction is dependent on monetary as well as nonmonetary considerations such as meaning, control, and order. Managing both population and individual patients under the previous eight C’s has been shown in Essence Healthcare’s experience to facilitate dramatic improvement in this last of the nine C’s.
Collectively, the framework of the Nine C’s of Accountable Primary Care Delivery offers new hope for our beleaguered health care system, and for primary care in particular. As health entities across the country seek to learn from the innovative, risk-embracing PCPs who have been thriving under and producing substantial accountable care outcomes under the Accountable Delivery System Institute’s Accountable Primary Care Model, it is now being disseminated to other emerging full-risk health care markets.
Tom Doerr is a primary care physician with a part-time geriatrics practice in St. Louis and a cofounder of Essence Group Holdings Company, where he focuses on innovation. research. He is also a limited partner with Kleiner Perkins Caufield & Byers and a faculty member of the Accountable Delivery System Institute.