Collaborative adaptation

Monday, July 01, 2013 12:24 PM

Non-traditional Kaiser model in southern Colorado designed to meet needs of area physicians and patients

Kate Alfano, CMS contributing writer

When it comes to practice transformation, physicians are increasingly realizing that “business as usual” is no longer viable and that they must adapt a collaborative approach to medicine. Many private practicing physicians in southern Colorado are finding help from a perhaps unexpected ally, Kaiser Permanente. Kaiser has been in southern Colorado since 1997, but the model in the area encompassing El Paso, Pueblo, Fremont and Teller counties isn’t the typical fully integrated model seen in the Denver/Boulder area and in other parts of the nation.

“We operate down here primarily through a network model,” said Clinton R. (Rocky) White, MD, a practicing primary care physician and chief of outpatient network services for Kaiser Permanente, Southern Colorado. “We contract with fee-for-service physicians, just like a regular insurance company.”

In 2010, when Kaiser leadership noted disparities in quality between Denver/Boulder and southern Colorado, they embarked on a collaborative care model. “We were trying to take the best of the integrated system and think creatively about how to apply that in a fee-for-service network model to create more integration in care, create more connectivity and improve a few defined quality metrics,” White said.

Paying for value

That’s where the new pay-for-value initiative came in. Central to the collaborative care model, pay-for-value provides a stipend to physicians to help with population-based care and improve quality across nine quality measures, including five for diabetes, one for hypertension and three for prevention focusing on colorectal, breast and cervical cancer screening.

Though it may not sound different from other pay-for-performance programs, the twist to the Kaiser initiative is in its bottom-up approach. “First we went into each individual practice to see where they were at that time,” White said. “Each group is unique and all are individual. We told them where we see the future going and then asked what we could do to help them get there.”

The second part of the strategy focuses on working with the practices to improve performance on those metrics. Once baselines are determined across the nine metrics then the practices report quarterly on their metrics for diabetes and hypertension. The prevention bundle is pulled from claims data on a yearly basis. If the practices meet their goals, they get a bump on top of their fee-for-service payment.

The stipend, based on an attribution formula that makes up roughly 6-8 percent of the practice’s revenue from Kaiser, is intended to help support them as they invest in the various components of practice transformation, said Richard Spurlock, MD, MBA, medical director for Kaiser Permanente, Southern Colorado. “Most physicians don’t practice population medicine because they don’t have the tools and the resources to do that. They don’t have the EMRs, the registries or the nurse navigators to help them. We felt that once physicians we were contracted with in adult primary care understood that they could improve that care – measurably improve it – we knew they would work with us in a collaborative way.”

“Eventually, the pay-for-value program will evolve to include a set of value-based criteria in the categories of data connectivity, quality and service that encompass the values we feel these adult primary care practices should have,” Spurlock said. “We are approaching this as a long-term program, understanding that transformation takes time. We will continue to engage the practices and help them with the resources to be successful.”

The approach appears to be working. There are currently 24 primary care or multi-specialty groups involved in a pay-for-value contract, plus one pediatric group, three OB-GYN groups, and three cardiology groups. This translates to roughly 250 providers caring for 25,000 Kaiser Permanente members in southern Colorado.

David Hoover, MD, a pediatrician and board president of Mountain View Medical Group in Colorado Springs, said the model is favorable for the area. “El Paso County has a different personality than Denver/Boulder and this sort of model is more acceptable to the other physicians and patients than the integrated model would be.”

Providing support to achieve targets

Above simply providing bonuses, Kaiser also provides tangible staff support, outreach and registry functionality. Through Kaiser Permanente Care Connections, or KPCC, a team of nurses identifies gaps, provides a quarterly gap list to physicians and also reaches out to the patients themselves to encourage them to seek care. “If a provider has 500 Kaiser members and of those 75 are women over age 50, we give that list to them and say, ‘look – out of these women who are eligible for a mammogram, there are 20 who have not had theirs. Can you reach out to them and get them in for a physical?’” White said.

Kaiser also provides case and care management for complicated patients. Physicians in the pay-for-value initiative can refer the patients to the Kaiser Population and Prevention Services (PPS) team who then can reach out to the patient on a weekly basis to help with myriad issues, from compliance issues to helping to titrate their medications, under the physician’s orders.

“Not only are we giving them a target, we’re providing resources behind them to wraparound and support them to help them reach their target,” White said.

Additionally, Kaiser collaborates with HealthTeamWorks in southern Colorado to help physician practices make these transformations. White said that when they created the pay-for-value program, practices needed individualized help with things like their EHR or with population management. He would refer the practices to HealthTeamWorks who would provide an on-site quality improvement coach.

BJ Dempsey is one of these coaches. Under a three-year grant from the Colorado Health Foundation, she meets with practices twice a month, working on everything from basic skills to more sophisticated strategies. The HealthTeamWorks model is based on the principles of the patient-centered medical home and the seventh aspect is payment reform. “That’s the piece that’s been missing for most of the practices. Most in this area recognize the benefit and the need to provide patient-centered care, but without the payment reform aspect, frankly, they just can’t afford it,” said Dempsey.

That’s the nice part about the Kaiser Permanente program, Dempsey said. Under pay-for-value, the practices receive enough financial benefit to offset some of their costs so they can start the transformation process.

Ideal Family Healthcare in Manitou Springs has received assistance with data gathering and replacing some registry functionalities they were struggling with. “Without Kaiser’s lead we wouldn’t be getting as far as we have,” said Greg Sharp, MD.

“I think they have been rather unique in their involvement. I sure would like to see other payers take as active an approach as Kaiser has in their pay-for-value program. I see this cooperation between payer and provider as the future in terms of requiring more incentive change in the insurance marketplace and for providers to demonstrate they’re providing quality care.”

Seeing results

Since the program’s inception, the hemoglobin A1c screening rate has improved 13.1 percent; blood pressure control in their diabetics has improved 11.7 percent. The number of diabetics who have had an LDL screening has improved by 8 percent and the number of diabetics whose LDL is at target or below has improved by 14 percent. Diabetics with hemoglobin A1c less than 8, the hardest metric to move, has improved by 1.2 percent. And control of hypertension in the general population has improved by 12.6 percent.

“It’s a testament to several things: To the fact that the practices are beginning to understand population management and to the fact that I believe our support services are supporting them in doing that,” White said. “It’s also a testament to the fact that the smaller groups know their patients; they have a strong personal working relationship with them and it’s easier for them on that scale to see progress. We have some groups that are outperforming Denver/Boulder in some of these metrics – not in all metrics or in every group, but some.”

“What we like about Kaiser is that we’re moving in the same direction toward becoming a patient-centered medical home,” Hoover said. “We’re figuring out how they can help us provide better care for our patients, keep them out of the hospital, make sure they’re getting in for services they need. Physicians are great about providing one-on-one care. What we’re trying to learn to be good at is how to mange a population of patients.”