Clinicians Collaborating to Advance Value-Based Payment

Paul Casale_resized“We want patients to be able to call with questions and see their doctor in a timely way.”

CAMH spoke with Paul N. Casale, MD, MPH, FACC, from the American College of Cardiology and NewYork Quality Care to learn about implementing to alternative payment models (APMs). Dr. Casale is a member of the Board of Trustees for the American College of Cardiology and Executive Director for NewYork Quality Care, the accountable care organization for New York-Presbyterian, Columbia, and Weill Cornell Medicine. He is a member of the LAN’s Primary Care Payment Model Work Group. The American College of Cardiology is also a LAN Committed Partner.

NewYork Quality Care started in January of 2015 and is comprised of three world-class institutions committed to providing the highest quality care for patients. As leading academic institutions, the ratio of specialists to primary care physicians is higher than might be found in many accountable care organizations (ACOs), which creates challenges as you develop programs for care management and care coordination. In addition to the ACO, two of medical schools that make up the ACO have signed onto the Oncology Care Model, and the third institution, a hospital, is in the mandatory region for the Comprehensive Care for Joint Replacement (CJR) bundle. So there’s quite a bit going on, not just in the ACO, but also with the engagement of specialists around episodic, bundled care. In that context, one of the lessons learned is the importance of building data analytics capabilities and infrastructure within the clinical practices to ensure that patient care is well-coordinated across the three institutions.

New York-Presbyterian recently started an initiative in telehealth and the ACO is looking to leverage this along with technologies within the electronic health records, such as e-consults, to enhance communication between patients and their physicians and between primary care physicians and specialists. Telehealth can help patients build a stronger connection with their primary care physicians. In the past, we had patients who bypassed their primary care physicians to go to the emergency room (ER) or a specialist. We want patients to be able to call with questions and see their doctor in a timely way.

One of the first telehealth initiatives by the hospital has been a telepsychiatry program in an effort to broaden patient access to behavioral health services. Another area the hospital is using telehealth is in the ER. For example, patients may have a virtual visit with an ER physician to provide advice on whether coming to the ER is needed or if seeing their primary physician in their office is a better alternative. The ER physicians are also using telehealth for follow-up after a patient is seen in the ER to enhance communication and coordination with patients as they transition back to their primary care physicians for further care.

Cardiac patients, such as those with heart failure, have multiple co-morbidities requiring the expertise of a variety of specialists along with their primary care physicians. These payment models enhance our efforts to build infrastructure to improve care coordination among the care team and strengthen the care management team. Currently, we have an analytics team on staff to help identify high risk patients. They work closely with our care management team which coordinates the additional services needed for these complex patients. Population-based payments support team-based care to improve outcomes for cardiovascular patients.

A big challenge is investment in infrastructure. Building information technology (IT) infrastructure is expensive, but important in order to be successful in APMs. Physicians understand the value of building infrastructure, whether it’s care coordination, data systems, analytics, or other technology, but where does the money come from when reimbursement is based solely on fee-for-service (FFS)? Building an infrastructure may require tremendous upfront costs.

An opportunity for physicians in implementing APMs is to leverage this infrastructure to improve the quality of care, lower costs, and improve outcomes for patients.

There are opportunities to provide FFS payments for services that will be helpful in an APM environment, such as payment for telehealth and other methods of virtual communication with patients. For example, when a patient comes to a doctor’s office for a relatively minor complaint, a physician could instead help that patient without a face-to-face visit. Some payers are starting to recognize the value and pay for this type of service. FFS payment for e-consultation is another opportunity to enhance the coordination of care between primary care physicians and specialists within an APM. In addition, the LAN’s Primary Care Payment Model Work Group can be a resource. I see the Work Group’s efforts as an important opportunity to think about ways for better integration of primary care and specialty care – not just with improving coordination, but payment too.

Use your data to understand your patient population. For large organizations like NewYork Quality Care, we have the advantage of having analytics expertise. Smaller systems may need to identify a partner to assist them with data analytics, but it is important to understand where patients seek care and which patients most frequently seek care. Care management needs to be a priority. Often, this is an area of focus for patients in the hospital, but it is just as important for patients seen in the ambulatory setting. Developing those capabilities is an early critical step for an ACO. Engage physicians participating in an ACO and leverage the capabilities of all members of the care team to improve the quality of care for patients. Finally, it’s critically important to engage patients, since one of the challenges is that many patients do not know they are in an ACO or understand the benefits of an ACO in improving the quality of care provided to them.