A few years ago, Larry Ratcliff, M.D., a solo family physician practicing in Farmersville, Ohio, realized his normally positive spirit had been dampened by the crushing volume of his work. After 35-plus years taking care of patients, he needed a change.
Interacting directly with patients is what the majority of family physicians went into medicine to do. Maintaining the joy of practice, however, can bring challenges -- and opportunities -- for some.
"I was jaded," Ratcliff told AAFP News. "Basically I got tired of trying to see how many patients I could cram into a day. I was looking for a different and new way of practicing medicine."
The actions he took at that point changed his attitude and his practice.
Ratcliff, a longtime champion of the patient-centered medical home, applied for and was accepted into the original Comprehensive Primary Care (CPC) initiative rolled out in 2012 by the CMS Center for Medicare and Medicaid Innovation (CMMI).
"This afforded me an opportunity to transform my practice. Even though I'm actually seeing more patients, I enjoy my practice a lot more now," said Ratcliff.
Ratcliff puts his patient panel size at about 3,000. His staff members include a nurse practitioner, a registered nurse, a medical assistant, a care coordinator and two front-office employees.
- A family physician in rural Ohio detailed his positive experiences with CMS' Comprehensive Primary Care (CPC) initiative.
- Larry Ratcliff, M.D., says the initiative has improved patient care and brought joy back to the practice of medicine.
- He urged his family physician colleagues to apply for future CPC Plus programs without hesitation.
He also relies on the support of a much larger group of 15 affiliated medical practices that serve greater Dayton, Ohio. Ratcliff is medical director for that group, the Providence Medical Group.
Ratcliff said the practices embrace continuous process improvement and learn from one another in regular group meetings.
For example, statistics show that one practice excels in the care of patients with hypertension. That success leads other practice leaders to ask questions such as, "How is your office doing that?" "What can I do better?"
In effect, "You're looking at your practice, reaching out and learning new ideas," said Ratcliff. "Five years ago, I thought I had the best practice on the planet -- and I found out I didn't."
What Changed, and Who Benefits?
The most profound change in Ratcliff's practice came with the addition of a care coordinator. This full-time clinician spends a lot of time managing patients outside the practice. It's important work that no one in the practice ever had time to tackle, said Ratcliff.
The care coordinator manages patient care with outside agencies, makes sure patients get to their office appointments and ensures that the primary care office is kept in the loop on all aspects of patient care.
"I have follow-up on all of my diabetic patients on a regular basis, and my hypertensive patients are coming in and seeing the care coordinator -- and getting extra education and extra care. This is about extending our care beyond the confines of just our offices," said Ratcliff.
From a budgeting standpoint, the position is paid for by a CMMI grant and by insurers who pay a care management fee that ranges from $2 to $40 per patient per month.
The practices in the Providence Medical Group also have access to a full-time pharmacist who works with patients with complicated medical needs and assists when patients undergo transitions of care.
When it comes to results seen during the past four years, Ratcliff is quick to point out that practices have seen marked decreases in utilization, hospital admissions and readmissions and ER visits.
"This is good for patients; they love the new way we approach them," said Ratcliff. Physicians and insurance companies are happy, too.
But Ratcliff and his group aren't finished yet. All of the practices in the Providence Medical Group applied a few months ago to participate in the CPC Plus initiative; they'll learn their status in coming weeks.
It's an exciting time for sure. "I should be thinking about retiring," said the 66-year-old Ratcliff. "But instead, I'm thinking about the joy of continuing in practice."
New CMS Opportunities Announced
Ratcliff's positive experience with the CPC initiative is timely in light of CMS' recent announcement about new opportunities for health care professionals to join advanced alternative payment models (APMs) developed by CMS' CMMI.
According to an Oct. 25 press release,(www.cms.gov) participants in these new models could earn incentive payments as part of the Quality Payment Program, which was developed to implement the Medicare Access and CHIP Reauthorization Act (MACRA).
"Every day, the CMS Innovation Center is improving the future of Medicare by testing innovative care models across the country," said CMS Acting Administrator Andy Slavitt. Thanks to MACRA, "clinicians have more opportunities and motivation to join these evidence-based approaches, which aim to improve care quality while creating cost savings," he added.
CMS expects to reopen applications for new practices and payers in the Comprehensive Primary Care Plus(innovation.cms.gov) (CPC+) model and will increase slots in the Next Generation Accountable Care Organization(innovation.cms.gov) (ACO) model for the 2018 performance year.
Specifically, as part of the Quality Payment Program in 2017, clinicians could potentially earn a 5 percent incentive payment through participation in an advanced APM, such as one of the following examples:
- the Comprehensive End-Stage Renal Disease Care Model,
- Medicare Shared Savings Program ACOs -- tracks two and three,
- the Next Generation ACO Model and
- the Oncology Care Model.
CMS expects the list of participation and incentive payment possibilities to continue to grow in 2018. In the release, CMMI Director Patrick Conway, M.D., noted that by 2018, 25 percent of clinicians in the Quality Payment Program are expected to "earn incentive payments by being a part of these advance models."
Ratcliff urged his physician colleagues to join the tsunami of change without trepidation.
"This is a process and not an event," said Ratcliff. "The innovation center understands that this process takes time, but continues to move forward with its goal to implement value-based payment.
"As for my practice," he added, "we're glad that we were chosen to go down the CPC path and do not want to go back.
"The CPC+ program is open to all primary care, and I encourage all family physicians to apply. It is not a test but a learning opportunity. You will learn so much about your practice, your patients and your community," said Ratcliff.
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