Annals of Family Medicine Research

Use Field-tested Tactics to Improve Care, Reduce Costs

November 27, 2017 03:16 pm Sheri Porter
[cost value chart with three push pins]

How do some primary care practices excel at delivering high-quality care to their patients? What sets these physicians' strategies apart from those of their talented, hardworking peers?

Researchers set out to explore that question, and their work is highlighted in an article published(www.annfammed.org) in the November/December issue of Annals of Family Medicine titled "Exploring Attributes of High-Value Primary Care."

Authors noted that CMS got the attention of U.S. physicians when it introduced Medicare's Merit-based Incentive Payment System (MIPS), which will "adjust annual physician payment by as much as 9 percent in 2022, based primarily on measures of quality and efficient resource use."

Story Highlights
  • Results of a research study published in the November/December Annals of Family Medicine highlight 13 attributes frequently found in high-value primary care practices.
  • The findings are timely because Medicare's Merit-based Incentive Payment System will adjust annual physician payment by as much as 9 percent in 2022 based primarily on quality measures and efficient use of resources.
  • The top six attributes are described as decision support for evidence-based medicine, risk-stratified care management, judicious selection of subspecialists, coordinated care, standing orders and protocols, and balanced compensation.  

They also pointed out that ongoing programs aimed at helping physicians improve care quality and lower spending have failed to show consistent, across-the-board progress in these areas.

"This lack of improvement may be due to the absence of evidence on what physicians can do to attain both low per capita spending and favorable quality scores," wrote the authors. 

Thus, they set out to look at a small national sample of primary care practice sites to "reveal attributes of primary care delivery associated with high value."

After developing a ranking process for quality that was based on 41 measures, researchers visited 12 high-value primary care office sites and four average-value sites between May 2013 and June 2014.

Site visits lasted eight hours and were conduced by a primary care physician experienced in practice assessment and a nonphysician qualitative researcher. Visiting teams conducted interviews including "open-ended questions aimed at identifying attributes that interviewees felt might account for their practice site ranking favorably."

Key Findings

Authors called out six of 13 attributes that reached the predetermined point of statistical significance and distinguished high-value practices from average-value practices; those attributes are

  • decision support for evidence-based medicine,
  • risk-stratified care management,
  • judicious selection of subspecialists for patient referrals,
  • coordinated care,
  • standing orders and protocols, and
  • balanced compensation.

Researchers noted that the six attributes cohere around three themes.

"Risk-stratified care management, careful selection of specialists and coordination of care reflect physician recognition of the need for 'care traffic control' to help patients with complex conditions or treatment plans navigate the hazardous streets of a fragmented U.S. health care system," they wrote.

Authors pointed out that for decades, payers attempted -- unsuccessfully -- to coordinate patient care "in isolation from primary care sites" via telephone mediation by nurse case managers. Those failed efforts suggest that primary care "represents an advantaged platform for care coordination," they said.

Researchers noted that the availability of decision support for evidence-based medicine and the creation of standing orders and protocols served to "ease cognitive burden" for physicians and staff by helping "tame the overwhelming flow of outcome studies and clinical guidelines, the widening array of disease subtypes … and the complexity of treatment plans for aging populations."

Furthermore, the sixth attribute, balanced compensation, "signals the usefulness of echoing within a practice external efforts to reward value rather than volume."

The other attributes seen more frequently in high-value practices relative to average-value practices were identified as

  • expanded access including same-day appointments, walk-in availability and extended evening and weekend hours;
  • shared decision-making and advance care planning;
  • patient feedback -- positive and negative;
  • comprehensive primary care where physicians practice within the full scope of their expertise;
  • upshifted staff roles that allow physicians to devote more time to the most complex patients;
  • shared work spaces where care teams can communicate face-to-face; and
  • low practice overhead costs for office space and equipment.

On the cost side, authors noted that annual spending between the two cohorts differed mainly in the areas of inpatient surgical services, outpatient hospital visits, ambulatory surgery centers and outpatient prescriptions.

Author Q&A

Designated first author and research project lead Melora Simon holds a master's degree in health services management from Columbia University in New York. She currently serves as the director of adult demonstration projects at Health Plan of San Mateo in California, where she tests and scales care delivery models to reduce health care spending and improve quality for vulnerable populations.

Simon responded to some questions about the research team's findings for AAFP News.

Q. Why is this study important at this point in time?

A. On the eve of year two of the Quality Payment Program, with full implementation only a year away, clinicians and their teams need feasible, tangible approaches to improve quality and reduce cost. Where better to look than at practices that are performing well on these dimensions to learn from their field-tested tactics.

Q. Why should family physicians pay particular attention to these findings?

A. Family physicians are uniquely equipped to deliver comprehensive care; they manage complex patients and handle minor procedures such as IUD insertion, suturing or joint injections rather than referring care out to specialists.

In addition, many family physicians work in smaller practices, similar to those characterized in our study, and can nimbly adopt new approaches.

Q. Did any unexpected findings come to light?

A. We were surprised that health information technology did not play a more prominent role. If we were to repeat the study in a few years, we would expect to see that it does indeed matter how people are using health IT.

Q. What's the most important point you want family physicians to take away from this study?

A. Patient care "traffic control," defined as the active surveillance of and support for patients' needs between visits, is possible with a team-based approach.

Q. Where should the research go next?

A. We need to test the adoption of these tangible changes at a larger scale to see the impact that they have on quality and cost.

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