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Tuesday Aug 30, 2016

Academy Offering Tools for Chronic Care Management

Most of you are aware that there is a large-scale and coordinated effort underway to change how care is provided and, just as importantly, how care is reimbursed. This effort was set in motion more than a decade ago through policy changes such as the establishment of the physician quality reporting initiative -- which is now known as the physician quality reporting system -- the push for electronic health records, and the failure of commercial disease management programs; among others.  

The AAFP, through sound leadership, read the tea leaves appropriately and began to promote delivery and payment models that would place a greater emphasis on the critical role primary care plays in our health care system. Through the Future of Family Medicine project(www.annfammed.org), the AAFP and six other national family medicine organizations promoted a vision for a health care system in which each patient would have an ongoing relationship with a primary care physician. In return, primary care physicians would provide care that was built on five Cs -- first contact, comprehensive, continuous, coordinated and connected. These fundamental elements of primary care were promoted by Barbara Starfield, M.D., but they also were the cornerstone of high-functioning health care systems around the world that exceeded the United States' performance on quality and costs.

To accomplish this goal, the AAFP began identifying, developing and promoting new delivery models, such as the patient centered medical home (PCMH), advanced functions such as electronic health records, and, most importantly, we began to promote the need for primary care physicians to be paid differently and better.  

A key aspect of the AAFP's payment policy was the implementation of a blended payment model whereby family physicians would be paid for direct patient care, but also for those services that are provided outside of the traditional face-to-face office visit.  This payment would ultimately become known as the care management fee.

Although the Patient Protection and Affordable Care Act contributed to the so-called value-over-volume movement, it was really two events that happened in the first quarter of 2015 that accelerated the pursuit of value-based payments. The first was an announcement by the Obama Administration that it would push to tie 30 percent of traditional fee-for-service Medicare payments to value-based payments by 2016 and 50 percent by 2018. The administration challenged commercial insurers and Medicaid programs to do the same. The second event was the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA), which codified value-based payment designs and put in motion a concerted effort to move away from the traditional fee-for-service construct as a means of compensating physicians for the care they provide. A central part of the MACRA reforms was placing a greater emphasis on the coordination of care across the health care spectrum.

The ability to manage the care of individual patients and populations of patients, especially those with one or more chronic health condition, has been identified as one of the most promising aspects of advanced primary care delivery models such as medical homes. Furthermore, effective care management by family physicians has proven to improve the quality of care for patients and reduce the per capita cost of health care. This has been proven in both public and private health care systems, as noted in the Patient Centered Primary Care Collaborative’s annual evidence report(www.pcpcc.org).

About five years ago, the AAFP started studying the concept of care management. What was it? What should it be? How much does it cost to provide care management services? How much should family physicians be paid for care management? How should these payments be risk-adjusted?  

We initially asked the Robert Graham Center to study care management programs and fees. Its report -- Blended Payment Models and Associated Care Management Fees(www.graham-center.org) -- identified some common care management functions across public and private health care systems and provided a solid foundation for our next project, a partnership with Discern Health(discernhealth.com) which aimed to further examine care management and identify three key findings:

  • What is care management?
  • What are the benefits of care management?
  • What is the value of care management to patients, physicians, and payers?

Discern Health recently provided the AAFP its findings in an issue brief titled Valuation of Care Management Performed by Primary Care Physicians.  Here is what Discern Health found with respect to the three questions above:

  • Numerous studies have identified reductions in total cost of care associated with patients who have received care management services organized by primary care physicians in a PCMH model. Research has found reductions, ranging from 4.4 percent to 11.2 percent for a particularly high-cost, frail, and elderly population.
  • When people receive high-quality care from primary care physicians, particularly for chronic conditions, they are less likely to experience rapid declines in their health that require costly treatment in a hospital.
  • A benefit of care management is an increase in the proportion of patients receiving high-quality, appropriate care.
  • Care management demonstrated a benefit for patient and staff experience of care, and staff reported lower emotional exhaustion scores on the Maslach Burnout Inventory Scale.

A final finding about per member per month (PMPM) fees is key, so I have included the full paragraph. It reads: "Studies have shown primary care physicians who invest in care management are creating significant value for the health care system through higher quality care at a lower total cost. On the whole, care management payments do not fully compensate physicians for the value they create. One of the best studies of the reduction in total costs of care (a benefit to health insurers) created by effective care management in a commercial population found a $16.73 PPPM reduction. This is considerably more than what insurers are paying for care management, which is $4.90 PPPM."

The AAFP sees care management as an important function of advanced primary care practices, so the Academy has developed an extensive set of resources to help you implement care management in your practices. We have prioritized the resources into the following categories:

  • care management;
  • risk-stratified care management; and
  • population health management.

In addition to these resources, the AAFP, as part of our collaboration with Discern Health, created a care management calculator (member log in required). This tool is designed to assess various factors that might influence care management costs and to provide an estimate of care management costs and savings based on: staffing hours, overhead, the chronic disease burden of the patient panel, the state where the practice is located, and revenue from care management billing or program funds. The calculator is Excel-based and organized in a stepwise process.

You can read more about the brief and the cost calculator in AAFP News.

Family Practice Management also has a number of good resources on care management, specifically the Medicare chronic care code.  

AAFP Welcomes New Director of Government Relations
On Sept. 12, Robert Hall, J.D., will join the AAFP as director of government relations. Hall, who most recently worked for the American Academy of Pediatrics, brings more than 20 years of experience to the AAFP. He will oversee the AAFP's vast government relations, advocacy, and political operations. In addition, he will work closely with the AAFP's Commission on Governmental Advocacy and will advise senior management and the Board of Directors on legislative and regulatory matters. 

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.