Tracking down rural patients after they leave their primary care physician's office can be as difficult as counseling them to change their health habits. So family physician Julea Garner, M.D., gives her staff in Hardy, Ark., the same instructions for every patient regardless of his or her condition: "Make sure we have a current address and phone number."
Arkansas family physician Drew Dawson, M.D., examines a young patient who has come in for a well-child visit with her dad.
One of the basic tenets of primary care is keeping in touch with patients, and it's especially important in an era of payment reform that rewards continuity of care. But even in an age of smartphones, email and social media, maintaining that connection is not always easy for rural physicians. Patients may change phone numbers frequently or fill out office paperwork with a temporary address. It's just one of many complications that rural physicians wrestle with.
Because of Arkansas' extensive rural areas, the state is a testing ground for health payment reform projects. One that has attracted some primary care physicians is the Arkansas Health Care Payment Improvement Initiative,(www.paymentinitiative.org) which includes an episode-of-care component for acute conditions and a patient-centered medical home (PCMH) program(healthaffairs.org) to improve care coordination. Practices do not have to be recognized as PCMHs to participate.
An estimated two-thirds of all Medicaid providers in the state are enrolled in the program, which requires participating practices to have a minimum of 300 Medicaid patients to receive a per-member, per-month medical home support payment. Eligibility for shared savings requires at least 5,000 Medicaid patients -- a number that most practices cannot meet, so the state allows practices that have the same tax ID to pool their patients.
- Because of its extensive rural areas, Arkansas is a testing ground for several health payment reform projects.
- Three physicians shared their experiences and thoughts about one of the programs, the Arkansas Health Care Payment Initiative.
- An estimated two-thirds of all Medicaid providers in Arkansas are enrolled in the program.
Three physicians shared their experiences and thoughts about the state's initiative with AAFP News: two who are finishing their first year in the program and Garner, who recently applied to take part.
One year into the program, Lonnie Robinson, M.D., said he hopes the initiative succeeds, but he wonders whether the investment was worth it if his practice does not receive shared savings.
Overall, early returns for the program have been modest, Robinson explained, with net savings to the state's Medicaid program totaling $9 million in its first year. Still, he said, he remains optimistic
"That's a drop in the bucket (in terms of total cost), but it's certainly promising," Robinson said. "Current numbers are very early, but it's obviously better than continuing to see costs rise. The first year of the program is not typically when such programs see big returns in terms of cost savings because practices are still adjusting to the new paradigm and getting organized. The model has promise if it is given time to work."
Medicaid initiated the medical home program and pays $4 per member, per month. Blue Cross entered the program this year and pays $5 per member, per month.
"It is a potential new revenue stream that requires some changes, but it largely fits what we already do," said Robinson, who is one of eight primary care physicians in a practice based in Mountain Home.
To optimize his participation in the program, Robinson began delegating more tasks to staff. For example, he recently hired a scribe to handle electronic health record (EHR) data entry.
Lonnie Robinson, M.D., and staff nurse Sally Hambelton, R.N., review patient records at Robinson's Mountain Home, Ark., office. Robinson is participating in an Arkansas payment reform initiative.
"It frees me up to take care of patients instead of spending time pointing and clicking," he explained.
The Arkansas PCMH program involves selecting high-priority beneficiaries the practice sees twice a year and for whom the care team must develop detailed care plans. Medicaid assists by providing practices with a list of candidates based on claims data. Practices can then select the list as a default, or they may modify their selection based on what they know about their patients.
The program is not without its challenges, Robinson, acknowledged, with patient attribution proving to be particularly vexing. One of the program's performance measures requires the practice to follow up with a patient within 10 days after a hospital discharge. There is only one hospital in the area, so Robinson expected the practice's scores to be high. He discovered from reports that they were not.
One problem is that if a patient listed Robinson as his physician when applying for Medicaid -- despite, for example, not having visited the office for a decade -- the practice loses points if that patient fails to follow up after a hospital discharge. For that reason, patients who have moved or who are no longer considered active should not be counted for attribution purposes, said Robinson.
The program tracks several performance targets, such as the percentage of beneficiaries who receive a hemoglobin A1c test at least once a year and the proportion of patients with congestive heart failure who are prescribed beta blockers. Because of the limited time the practice has participated in the program, however, Robinson said it has been difficult to determine whether the practice has qualified for shared savings. Medicaid will make a final determination by October.
Faced with that uncertainty, Robinson asked Medicaid officials whether the practice would receive shared savings if it lowers costs but comes up a few points short in meeting some performance targets. The state responded that practices are not expected to excel in every area and will not be downgraded for not doing so.
That's good news, according to Robinson.
"It could be a great thing for the state," he said. "If the system is perceived as fair, the number of participants will go up. If the financial incentives are seen as unobtainable, many practices may choose to withdraw or stay on the sidelines. For now, we feel it has been a good program for both patients and providers."
Working With EHRs
Garner, a former president of the Arkansas AFP and current chapter delegate to the AAFP Congress of Delegates, recently applied to participate in the initiative and will begin reporting in January.
Long an advocate for a comprehensive approach to care that showcases high-quality primary care, Garner said she supports that key concept behind the Medicaid initiative. Still, she added, the documentation requirements and ongoing technology hiccups could be problematic.
For example, with a practice panel that includes 700 Medicaid patients, Garner thinks combining practices to reach the 5,000-patient threshold needed to qualify for possible shared savings could pose problems because the practices will be graded as a group, not individually.
"If I improve and they don't, I don't get shared savings," she explained.
Another concern for Garner is the expectation that participating practices use their EHRs in coordination with those of other facilities as if they were all part of an integrated network -- when in reality, they are not.
As her family physician peers have previously noted, EHRs are often not well-suited to recording population health metrics. In Garner's case, staff members may speak with patients about smoking and mammograms -- as required for reporting -- only to discover that those data are not captured in the EHR. Similarly, foot exams for patients with diabetes, another requirement, are not reflected in the record.
Although Garner can certainly see the value in tracking these health factors in her patients, she is hesitant to invest in the expensive software upgrades needed to bring her EHR into compliance with the state's reporting protocols.
"The concept of team-based care and caring for patients is embedded in family medicine," she explained. "The tracking and giving information to a payer instead of patients is not what we have been about."
The Patient's Role
Connecting with patients is a big issue for Drew Dawson, M.D., who struggles to maintain contact with patients who either have no phone number or sometimes turn their mobile phones off. And attempts to reach patients by mail often result in a "return to sender" response because they've given office staff a temporary address.
The lack of reliable contact information makes chronic care management a tough task, he said, but he has a solution in mind.
"We're probably big enough for a care coordinator," said Dawson, who is based in Pocahontas, Ark. "We need someone who can figure out how to reach them."
Fortunately, the practice is using EHRs to ensure that patients who are due for a colonoscopy, an immunization or other preventive services are closely monitored. As a result, patients with chronic conditions such as diabetes are receiving more attention and suffer fewer ill effects from their disease.
But even though technology may help physicians stay up-to-date with care management, it cannot influence patient behavior. Dawson recalled instances in which he wrote out medication instructions and then asked the patient whether the instructions were clear. Sometimes, he said, the patient would say yes and leave the office, only to call back later to say he forgot the instructions or lost the paper altogether. Other times, a patient would fail to learn to use an insulin pump properly while professing that she could handle the process.
With greater accountability for patient care resting with the physician, Dawson hopes patients will take a more active role in their health.
"We used to joke that you need to pay an individual to drive to a patient's house to put a pill in their mouth," he quipped. "For some patients that may be cost-effective, but you are shifting the patient's responsibility to somebody else."
Yet despite the drawbacks and uncertainties, Dawson is in the process of reapplying to participate in the medical home initiative.
"In the long term, if we see that it moves the cost curve in the desired direction and saves money, there is no major downside," he said.