American industrialist and innovator Henry Ford (1863-1947) once quipped, "Obstacles are those frightful things you see when you take your eyes off your goal."
Donald Clark, M.D., not only enjoys his pediatric patients, he also includes them in the practice's risk-stratification process.
For tens of thousands of family physicians on the front lines of providing health care to Americans, improving practice efficiency is certainly a goal worthy of keeping top of mind. One way to do that is to identify patients at highest risk for hospitalization, ER visits and high-cost care, and then pour dedicated practice resources into the care of those patients.
Despite numerous obstacles that include the perils of traversing uncharted territory, the time and cost associated with shifting practice protocols, and uncertain payment for the substantial effort expended, some family physicians are making headway in this bold new world of risk-stratified care management.
Count Donald Clark, M.D., of Dayton, Ohio, among those physician pioneers.
Keeping High-risk Patients Healthy in Ohio
Clark serves as medical director for the family medicine faculty practice at Wright State University's Wright State Physicians Health Center, where he provides patient care and oversees a medical staff of 13 other family physicians and two nurse practitioners. He also is an assistant professor of family medicine at the university's Boonshoft School of Medicine.
- Risk-stratified care management is emerging as a way for practices to increase efficiency and lower costs by identifying sicker patients who are high health care utilizers and devoting extra practice resources to their care.
- Some physicians have found an AAFP risk-stratification framework, or algorithm, helpful in grouping patients into one of six risk levels.
- Medicare intends to pay physicians a chronic care-management fee beginning in January, and details are revealed in the recently released final 2015 Medicare physician fee schedule.
In an interview with AAFP News, Clark said his interest in risk stratification was first fostered by legislation(www.odh.ohio.gov) passed by the Ohio state legislature in 2010 that, among other things, aimed to test the patient-centered medical home (PCMH) model of care.
"That and our ensuing work with TransforMED (a wholly owned AAFP subsidiary) pushed us into the risk-stratification piece," said Clark. "One of the reasons to do risk stratification is to figure out who your highest-risk patients are so you can target specific interventions for them," he added.
Fast forward to September 2013, when the practice began an arduous six-month project of assigning each and every patient a health risk level based on a risk-stratified care management conceptual framework developed by the AAFP.
In fact, according to TransforMED's President and CEO Bruce Bagley, M.D., the framework, or algorithm, has proven itself worthy among many of the 336 practices involved in CMS' Comprehensive Primary Care (CPC) initiative. About half of those practices use the algorithm to risk-stratify their patients.
That means assigning each patient to a "resource use category" labeled low, moderate, high or extremely high. Within those four categories are six specific risk levels. When patients are identified as high risk, the level of health care services provided to them escalates. "We put more resources toward those patients, increase the number of support staff around them and give their physicians longer appointment times," said Clark.
Bagley -- who has trained colleagues on use of the algorithm and who led two sessions on population health at the AAFP's 2014 Assembly on Oct. 21-25 in Washington -- urged physicians also to consider those patients at risk of becoming high health care utilizers. They could benefit from guidance on self-managing a chronic condition or help navigating an often complex and fragmented health care system.
But back to Clark, who described a real clinic patient: a 64-year-old black male with diabetes, hypertension and peripheral vascular disease who also undergoes frequent dialysis.
Laura Tobin, A.P.N., a gerontological nurse practitioner with the Vanguard Medical Group, goes over medications with a homebound patient; many patients who receive home health services are designated as high risk.
Clark said when the man -- who has been designated as having a risk level of six, meaning he has complex or catastrophic health needs -- calls the practice, the front-desk staff person recognizes the patient by name and greets him cordially. And before the patient says another word, the call taker has a good idea about the level of services this patient will need.
Patients assigned risk levels of four, five or six automatically are slotted for 30-minute appointments, double that of lower-risk patients. "We want to be proactive," said Clark. And our high-risk patients notice and are appreciative of our efforts, he added.
Clark said that even though his practice was not part of the CPC initiative -- and thus did not experience an infusion of extra resources -- the practice decided the changes "would help move us forward toward becoming a PCMH practice."
The next big step is examining practice data for hard evidence that shows risk stratification is improving patient outcomes and lowering costs. Clark is looking forward to bringing a nurse care coordinator onboard to manage the highest-risk patients.
Medicare to Pay for CCM Services in 2015
CMS indicated in the final 2014 Medicare physician fee schedule its intent to pay physicians for the provision of chronic care management (CCM) services. Indeed, the proposed 2015 schedule(www.federalregister.gov) fleshed out more details about payment for CCM services.
For instance, CMS proposed payment of about $42 a month for the provision of CCM services provided to Medicare patients with two or more chronic conditions that are expected to last at least 12 months and that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline, or until the patient's death.
When the proposed rule was first released, the AAFP suggested changes(1 page PDF) be made to it and expressed concerns about the agency's fee-for-service approach. The Academy urged CMS to instead create a risk-adjusted per-patient, per-month care management fee.
At publication time, the final 2015 fee schedule rule had just been released, and AAFP staff will review it to determine the full effects of this provision on family physicians.
"Hopefully, as the PCMH model advances and is supported not only by individual payers but by state and federal support, this kind of care management will be implemented across the board," said Clark. With future payment for care management services still uncertain, Clark declared himself "guardedly optimistic" about the future.
Positive Patient Impact in New Jersey
Risk stratification also is getting play in Verona, New Jersey, under the tutelage of family physician Thomas McCarrick, M.D.
McCarrick serves as both the chief medical officer and the chief medical informatics officer for Vanguard Medical Group, a primary care group with six sites, about 35 physicians and some 48,000 patients.
He said in an interview that his organization's journey with risk-stratified care began in 2010 with a Horizon Blue Cross Blue Shield pilot project that expanded into a PCMH program.
"As part of that transformational process, we began to think more about where the costs were expended within the practice -- in terms of the patient population -- and how we were going to manage those costs," said McCarrick.
The practice discovered that just 5 percent to 10 percent of its patients accounted for 30 percent to 50 percent of the total cost of care.
"We're trying to teach our doctors how to think about risk," said McCarrick. He said he tells physicians that if they are seeing 25 patients a day, probably at least one or two are high risk. And he engages physicians in the risk conversation by having them consider each patient's risk of landing in the hospital or the ER in the next six months.
"At every single visit, we ask the clinicians to assign a risk score to every single patient, so it's a continual process rather than just once a year," said McCarrick.
McCarrick pointed out that payment for this kind of care management lags behind the effort expended. He pointed to specific initiatives within certain insurance companies but added, "Not every payer is involved. So when you try to do this across the practices, it turns out that you have really very little care-coordination dollars to expend on your population, and that makes it much more difficult."
"In most practices, even though 5 percent to 10 percent of patients are high risk, there are only resources available to take care of 1 percent to 2 percent of those. The trick is making sure that you really are finding the patients you want to spend those resources on," said McCarrick.
An important part of the process is constantly assessing which activities and interventions will improve outcomes for particular patients, according to McCarrick. "It's hard to measure -- it's hard for a practice to see how its activities are impacting the utilization rates of these patients," he said. "If you were able to avoid a hospitalization or an ER visit, that's not really measured, because it didn't happen."
Still, his overall assessment of the risk-stratification method was upbeat.
"Anecdotally, we hear in the practice about how we did some interventions and those patients didn't have to go to the hospital or ER. Our team here feels positive about the work they're doing because their subjective impression in dealing with the patients is that they're having a positive impact," said McCarrick.
Like Clark, McCarrick is waiting for the payment model to adjust to a care-management system.
"We have five nurse care coordinators across six sites now and we have substantial resources within the practice, but there is also a cost associated with this. We've been able to make this work with the additional (CPC initiative) payments we've received," said McCarrick.
However, other payers need to step up, or there's a "serious risk" that care-management programs like this will fall apart after the CPC initiative is completed, he said.
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