The Patient Centered Medical Home has the potential to become the central alternative “payment” model (APM). The objective of APM's, at the most evolved and sophisticated level, is to transition from “fee for service” to a population based, full provider risk financing model. The journey of “delivery” models to an incentivized payment model design is just beginning and the variety of delivery models cannot be expected to evolve at the same rate. The PCMH operating as a value based delivery model, will face barriers to value, as all organizations will, in grappling with new forays into the MACRA space. All agree health care is at a cusp of dynamic change, poised to aggressively move on cost linked to quality. Many processes have taken hold, on the ground, in all delivery models, and primarily related to automation of the health record. Over the last decade this necessary transition from paper to an automated and electronic record has not delivered on the promise of interoperability; nor does it serve as a foundation for clinical research or population health in a quantifiable and/or observational form. In short the automation has become a barrier to value. Other barriers have become apparent; from the business models of integrated provider networks, to the technical issues of patient centered care and precision medicine, where the single patient has become lost in the average of populations.
The Patient Centered Medical Home, alone in the organizational forms of the Alternative Payment Model, has a design that may have the greatest flexibility (pursuant to Federal regulations) in overcoming barriers to value. The source of this flexibility is the grounding of the mission of the PCMH at the patient level. Though the payment aspects are from benchmarks reflective of mini attributed populations, the primary care emphasis, by its nature, can be inclusive of all health care services at the patient level.
A reasonable task of the PCMH, particularly in the advanced APM status, is to tackle the objectives of MACRA for care coordination and collaboration. Regardless of how these objectives will ultimately be measured the PCMH can assume a role of developing the standards. To qualify for patient centering the patient's information must be captured in a medical record that is more than a tool to communicate codes to payors. It must also capture the trajectory of patient journeys through provider networks, targeting measures that reflect cost and efficiency objectives at each step.
A granular patient record that has readily accessible: patient history data, population metrics, evidence based population level statistics, and most importantly local information for the specific provider network, can serve as a decision support tool. This is the essence of patient centering, where the complexity and uncertainty of patient decisions are reflected in the record, allowing the patient to be unique in this era of information overload.
As complexity and need for coordination evolves from APM incentives, the demands on the patient record will change. The best use of the PCMH is to lead the evolution of patient centered care in the context of population health. As an organization, the PCMH can stand as a sphere of observation and influence, impacting patient journeys through the provider networks. This takes advantage of the PCMH's flexibility as a local organization of providers, leading the entire provider network (and attributed populations) to high level objectives that are relevant for all providers acting in a coordinated way.
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The PCMH can serve a novel role observing patient journeys through the perspective of provider groups and payors operating as networks. This perspective can facilitate care coordination and provider collaboration.
The logic of the patient encounter, when properly patient centered, derives supporting input information from populations as aggregates, and information specific for the circumstances of the patient. Presenting information at the inflection point (the transition from past to future) can be a unique hallmark of the Patient Centered Medical Home. To be a sphere of observation and influence, not just of patient encounters and individual journeys, but of many journeys of the patient groups, meaning patient centered logic must be aggregated as populations. Though much of the input into the logic of patient centered decisions is population based, the complexity and uncertainty at the patient level must factor into decisions. For patient centering, a filter is needed to curate very granular data for purposes of population review, which is very different. Thus the data aggregation can be for populations reflective of patient's outcomes such as for costs or journeys compared to providers and disease or measures of efficiency of journeys.
With the smaller populations of the PCMH, the need for statistical significance from large patient numbers changes to observational descriptors of groups of patients relevant for clinicians making patient centered decisions. These decisions do not diminish or override patient uniqueness from population averages.
This concept of preservation of patient uniqueness amidst metrics from averages of patient populations is uniquely suited for the PCMH as purveyors of observation and influence of small populations.
When the observational role of PCMH evolves from the current PCMH function of cost control through applying benchmarks, to specific specialties, to drawing in data from the entire spend of the patient centered network, the PCMH can influence the global spend. This follows from viewing the PCMH primary care focus in the sense of population health. Though spend, as attributed to providers, focuses on diagnoses, disease, as transactions of specialties, the larger more global view of cost focuses on networks. This minor change in perspective opens up moving from transactional based cost control, to the broader view of the entire attributed population with metrics developed from care coordination and provider collaboration.
Viewing providers as part of a network, either as formal groups or virtual ones, can have several beneficial effects. First each world of provider specialties can be aware of other worlds. The patient populations can drive the data links among providers who have different care objectives. The many narrow objectives of each specialty can be coordinated with broader objectives that provider share as members of networks. Cost containment can be more robust as a network function than as summations of transactions. Next, from awareness of provider worlds, semantics can be developed that allow standardized terms that link providers. These links can be quantified and thereby serve as metrics that will be the basis of PCMH observation of how the networks perform. Lastly, these metrics complete a loop back to the patient journey, completing the objective of influencing care delivery.
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At a high level the intent of the MACRA law is to implement the Alternative Models to foster the evolution of Fee for Service (FFS) to population based payment based on Value.
The Patient Centered Medical Home (PCMH) is ideally suited to play a major role in this evolution. The distinction of payment models from delivery models must be clear. Payment models are the force driving care redesign. As tightly structured entities, including ACOs, PCMH, CPC Plus, bundled payments and others, there is no reason they cannot change care delivery dynamically and quickly in response to the APM incentives. With fixed long term incentive structures each type of APM can evolve internally and as part of provider networks. Collaboration and coordination will be essential in this evolution of care redesign and compliance within the structure of the APM.
The MACRA law with its features of MIPS and accountable organizations has laid out objectives for each that can only be achieved with evolution in care delivery. These objectives for MIPS include a new category, improvement activities, advancing care information to replace meaningful use among other goals. For CPC Plus the objectives include care delivery redesign, multi-payor redesign and improvement in quality and efficiency of care. Payment elements will change with care management fees and performance based incentive payments.
An important element in goals for CPC plus care redesign includes reduction in unnecessary health care utilization. For the first time in MACRA compliance will include prevention of overuse, not just reduction in underuse. Addressing sticky issues such as potentially preventable ER visits, potentially preventable imaging, interventions, surgeries, etc… requires more than influencing transactions. A population based focus on aggregations of those transactions will show, for classifiable patient groups, comparisons of what was done to what was not done. This requires use of an old yet novel technology, counterfactual analysis.
The PCMH is ideally suited to set standards for counterfactual analysis, and in fact is the only organization of health care networks that can do this.
Healthcare in 3 Dimensions is a system to optimize and assess the delivery of healthcare using counterfactual analysis of care paths, managing costs without sacrificing the individuality of the patient.
Robert Ripley MD, will be presenting the “Pyramid of Value” at the 2017 PCMH Congress, November 3rd & 4th.
Video introducing Healthcare in 3 Dimensions has been released. Learn more about this exiting technology.
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