Payment & Delivery Models

Testing new value-based health care and payment models: One program's success

As physicians await the final rule on the Medicare Access and CHIP Reauthorization Act (MACRA), specialty societies across the country are getting a head start in testing out possibilities for alternative payment models (APM) to shift the health care system toward value-based care and payment. One practice at the University of Colorado recently showed that a new model could reduce frequent emergency department (ED) visits by roughly 40 percent.

How the pilot program reduced ED visits

In 2012, the Metro Community Provider Network (MCPN) in Colorado was selected as a site partner to test the replicability of a pilot program funded by the Center for Medicare and Medicaid Innovation (CMMI) to decrease overuse of emergency and inpatient services by patients who frequently visit the ED.

Jennifer Wiler, MD, an emergency medicine physician and associate professor and vice-chair of the Department of Emergency Medicine at the University of Colorado, helped create and facilitate the program at MCPN, which they called Bridges to Care. The program is a multidisciplinary team of health coaches, community health workers, care coordinators, behavior health specialists and a primary care physician, she said.

The goal was to “provide services to enrolled patients for two months to educate and empower them to become independent and make better choices about health care navigation and utilization,” Dr. Wiler said.

From 2012 to 2015, the Bridges to Care program enrolled almost 600 patients through partnerships with community health organizations, such as federally qualified health centers (FQHC) and a community advocacy organization called Together Colorado. The program included patients who had three or more ED visits or two or more hospital admissions within six months.

“This program and the services that were provided for home-based care created a financial incentive for emergency care providers and hospitals to partner with community programs,” Dr. Wiler said.

Uniquely, the program included mental health patients. “Typically, high-utilizer programs exclude substance abuse and mental health primary or comorbid diagnoses, and we included those diagnoses,” she said.

“We found that touching a patient when they’re in acute crisis increases the potential of a successful intervention,” Dr. Wiler said. “If we saw a [patient] in the ED and we tried to call them the next day to enroll them in the program, it was not as successful as having someone talk to them in the middle of the night when they were there for their visit.”

Community case workers were on site, embedded in the ED to enroll eligible patients in the program. “We picked our high-volume times, which could go up until midnight,” she said. “The community case worker then had access to the EHR infrastructure in the clinic to make appointments and follow-ups with the clinic notes and also had access to our hospital system information."

“Our program intervention was to make an initial assessment of the patient through home visits,” she said. “At least two home visits were provided to the patients after they were enrolled” to determine their specific needs and reasons for frequent visits to the ED.

Some of these reasons included social determinants of health. “The No. 1 barrier to accessing care for our patients was a transportation issue,” she said. “The community organizers helped to navigate immigration issues if they existed, transportation, cultural acclimation and education issues.” The program helped patients decide how to leverage available and appropriate community resources.

The results of the program show its success. “Overall, there was nearly a 50 percent reduction in ED utilization and a 42 percent reduction in utilization for patients with chronic pain,” she said.

“We saw a 45 percent reduction in visits related to ambulatory sensitive conditions,” she said. Patients also self-reported an increase in their number of healthy days and a decrease in their number of unhealthy mental health days.

“The total site cost [for the Bridges to Care program] was $1.2 million,” she said, “and our total program savings was $13.5 million.” That breaks down to about $23,000 of savings per participating patient.

“We’re excited about our results,” Dr. Wiler said. “[But] it’s a challenge because grants don’t create sustainability.”

Pivoting to an APM

The American College of Emergency Physicians (ACEP) has convened a task force that is looking at opportunities for emergency medicine to participate in potential APMs. “The program that I specifically participated in is being discussed as a potential APM or to inform APMs in development,” Dr. Wiler said.

As vice-chair of an AMA workgroup on emerging payment issues, she recently presented the program and its results to leading experts in payment reform at the National Value-based Payment and Pay for Performance Summit in San Francisco.

“Right now there’s not a financial incentive for us to work together,” she said. “There’s resources in our state, a per-member, per-month case management payment that’s being provided by Medicaid for care coordination, but currently it’s insufficient to support the services that we implemented and does not recognize the value contribution of the hospital or emergency physician.”

It’s important that physicians get involved with their specialty societies now to create programs and develop physician-focused APMs that work for their patients as the health care system transitions to MACRA.

“What’s challenging is there will be similarities but important differences in each practice and community across the country," Dr. Wiler said. "But there’s a real potential to decrease ED utilization and avoidable costs.”

Dr. Wiler said payment models need to be easy to implement and meaningful, and they should create alignment among stakeholders. “But they have to allow for customization based on the needs of the community,” she said.

To help physicians and specialty societies in the effort to create these payment models, the AMA worked with Harold Miller to develop the “Guide to physician-focused APMs.”

For more information about APMs