Alabama FPs Help Make Patient Care Networks Function

State-based Program Relies on FPs, Coordinated Care to Reduce Downstream Costs

May 30, 2012 06:00 pm James Arvantes

Family physicians often are depicted as the bedrock of the nation's health care system, the leaders of patient-centered health care teams who deliver high-quality care at a lower cost. That description readily applies to the efforts of Alabama family physicians and members of the Alabama AFP who have played a pivotal role in developing, implementing and sustaining a series of independent, nonprofit patient-centered health networks that now provide coordinated care to about 90,000 Medicaid recipients in the eastern, western and northern parts of the state.

[Map-Care Networks for Alabama]

The Alabama Patient Care Networks program initially was implemented in three pilot areas: East Alabama (Lee, Chambers, Tallapoosa and Macon counties); West Alabama (Tuscaloosa, Fayette, Pickens, Greene, Hale and Bibb counties); and North Alabama (Madison and Limestone counties).

The Alabama Medicaid program created the Patient Care Networks program( last year, launching the first network in August, followed by two more in September. From the outset, Medicaid officials relied on primary care and family physician practices to serve as the basis of the networks. But the networks were purposefully designed to transcend the physician office alone by employing case managers, pharmacy directors and medical directors to work with the practices to supplement and coordinate care both inside and outside of a physician's office, thereby providing a continuum of care that reaches well into the surrounding communities.

"The physician's office is no longer the end-all and be-all of medicine," says family physician Julia Boothe, M.D., the clerkship director for family medicine in the Department of Family Medicine at the University of Alabama in Tuscaloosa. Boothe, who practices within the MedNet West Network in the western part of Alabama, adds, "The physician's office serves as the hub. But we have case managers going out into the field. We also have communication with the pharmacists and the medical directors through the network."

Early numbers from the Patient Care Networks program indicate that it is working. For example, the total cost of providing care to Medicaid patients in the network areas has decreased by 7.7 percent in the past six months compared to 0.6 percent in other parts of the state, say Medicaid officials. In addition, emergency room use in the network areas fell by 15 percent during the past six months compared to a 2 percent increase for the rest of the state.

"The networks are already having a huge impact," says FP Chelley Alexander, M.D., the medical director for the MedNet West Network.

Alexander, who also is chair of the family medicine department in the College of Community Health Sciences at the University of Alabama, predicts that, based on the early success of the program, the networks eventually will spread across the state.

Story Highlights

  • Members of the Alabama AFP are intimately involved in several nonprofit patient-centered networks that are providing coordinated health care to about 90,000 Medicaid recipients in three areas of the state.
  • The networks bring together physicians and other members of the health care team to supplement and coordinate care both inside and outside of the physician's office.
  • Early numbers indicate that the total cost of providing care to Medicaid patients in the network areas has decreased by 7.7 percent, compared to 0.6 percent in other parts of the state.

And that is the goal: to implement the program statewide, says Robert Moon, M.D., chief medical officer and deputy commissioner of health assistance for Alabama Medicaid.

"We currently have plans to go into the Mobile area in July, and then progressively roll it out throughout the state," says Moon.

Patient 1st

The Patient Care Networks program is based on an existing patient-centered medical home (PCMH) initiative within the Alabama Medicaid program known as Patient 1st. The program, which began several years ago, gives Medicaid beneficiaries access to medical homes. Patients either choose a primary care practice to be their medical home or Medicaid officials assign them to one.

An extension of the Patient 1st program, the networks operate as a "supportive circle" to supplement and enhance the care furnished by the PCMH, says Moon.

The Patient Care Networks program also is patterned on the Community Care of North Carolina( (CCNC) program, which relies on physician-led networks and PCMHs to deliver care to most of North Carolina's Medicaid beneficiaries. During the past several years, the CCNC program has generated more than a billion dollars in savings.

"We looked at a lot of different Medicaid programs across the country and tried to determine the best fit for Alabama," says Moon. "We decided that the North Carolina model was the best fit."

Like CCNC, physician practices within the Alabama networks are paid on a fee-for-service basis, but they also receive a per-member, per-month care coordination fee. Unlike the CCNC program, however, practices within the Alabama networks also have an opportunity to receive a share of any savings generated by the program, according to Moon.

Family Physician Involvement

One of the most striking features of the Alabama Patient Care Networks program is the level of family physician involvement. Moon, a family physician, is considered the Medicaid official most responsible for overseeing the development and implementation of the network concept in the state. Bob Mullins, M.D., another family physician and the former Medicaid director, worked alongside Moon in pushing the concept forward.

According to Moon, family physicians make up the largest percentage of PCMHs in the patient-centered networks.

"Family physicians are a critical part of the function of our networks," says Moon. "They are a key piece in the sense of being the hub for patient care, and they are really helping to drive the quality and cost performance of our system."

Facts About the Alabama AFP

Chapter EVP: Jeff Arrington
Number of chapter members: 1,425
Date chapter was chartered: 1949
Location of chapter headquarters: Montgomery, Ala.
2012 annual meeting/scientific conference date/location: June 21-24, Sandestin Golf and Beach Resort, Destin, Fla.

Building the Program

The structure of the networks themselves has enabled disparate members of the health care team to work together to provide a high level of coordinated care that accomplishes the simultaneous goals of higher quality, greater patient access and lower costs.

The state Medicaid program pays each network a per-member, per-month fee that ranges from $3 to $5, depending on the eligibility category of the Medicaid recipient. "One category is the aged, blind and disabled, which is the higher payment," says Moon. "For the other categories, the networks receive $3 per month, per patient."

The payments to the networks average about $100,000 per month, and the networks use the funds to hire case managers, medical directors and pharmacy directors, according to Moon. The medical directors are responsible for overseeing the functions of the network, and, every two months, the network medical directors pull together the primary care physicians within the networks to discuss patient care and the performance of the physicians.

"At the meetings, they discuss data trends in the network and what can be learned from the best-performing physicians," says Moon. The interaction is not punitive, he stresses. "It is meant to make the ones who have done well shine and share what they have learned."

As the medical director of the MedNet West Network, Alexander runs the bimonthly meetings. She notes that "physicians often don't get meaningful feedback on the care they provide." But the network can rectify that. For example, the MedNet West Network has started providing physicians with data on their asthma patients. The data focus on how many patients end up in the emergency room as a result of their asthma.

"You should have seen the physicians' faces when they got the list of those patients," says Alexander. "It is the sharing of data that is important."

The case managers are another key component, serving as a critical bridge between the network practices and the patients.

"The case manager really becomes embedded in a practice, and they get to know a certain set of patients and a certain set of physicians very well," says Alexander.

In this role, the case managers can reinforce what the physicians are saying and prescribing by meeting with patients in their home environments. The case managers can go and find out why patients don't adhere to their medication regimen, for example, or why they continue to miss medical appointments.

"We've had a lot of cases where our case managers will find patients who have been going to the emergency room two or three times a week for years, and no one has been able to stop it," says Alexander. "Once the case managers get involved, they find out there is something else deeper involved. The patient may not have air conditioning in their home, or they may not have enough to eat. There is some kind of underlying problem, and the care manager fixes that problem and the patient no longer has to go to the emergency room."

The network pharmacy managers also play an important role by looking at prescribing patterns that exist within their respective networks to determine whether there are problems with drug interactions or whether physicians are prescribing inappropriately.

Alexander describes the networks as a wrap-around form of care. "We are not just looking at the patient at a moment in time in our offices," she says. "We are looking at the patient's whole life in terms of family and community in a bigger way to impact their health."

That role dovetails beautifully with the mission of family physicians, she notes.

"Family physicians have the ability to form relationships with people of all different types, demographics and ages," says Alexander. "So, when you start to put together these teams in the community where you are trying to improve health, family physicians have the ability to relate to different organizations and bring them to the table. That is the key to making this all happen."