The Accountable Primary Care Model: Beyond Medical Home 2.0

The new Accountable Primary Care Model delivers Triple Aim-like outcomes. This model is empirical, measurable, programmatic, scalable, and transplantable.
Published Online: December 12, 2014
Thomas D. Doerr, MD; Herbert B. Olson, FSA; and Deborah C. Zimmerman, MD
ABSTRACT
Objective: To test a novel model of primary care designed to improve healthcare outcomes.

Methods: We used literature searches, data analytics, and interviews with high-performing physicians to create the Accountable Primary Care Model. We enhanced the “4 Cs” Primary Care Model (first contact; comprehensive care; continuous care; coordinated care) with the addition of 5 more Cs: physician credibility, collaborative learning, cost-effectiveness, capacity expansion, and career satisfaction. Then, using a retrospective quasi-experimental design, we compared 3 years of outcomes data from members in a Medicare Advantage plan in a virtually integrated delivery system with relevant benchmarks, including matched patients in fee-for-service Medicare.

Results: The Medicare Advantage health plan averaged 29,556 members with costs that were 58.93% of those in fee-for-service Medicare. Spending was shifted when appropriate from inpatient to outpatient settings and from specialists to primary care physicians. After allocating $80 per member per month for primary care costs, the health plan had medical cost ratios from 2010 to 2012 averaging 72.7% before surplus distribution. Member benefits were the best in the market, evidenced by the average maximum out-of-pocket expense limit of $1875. The next best plans averaged $2800. The health plan was rated 4.5 stars each year by CMS for quality, patient experience, access to care, and care process metrics. Of the primary care physicians surveyed, 90.2% would probably or definitely recommend this plan to another physician. About 91.4% of specialists surveyed were satisfied or very satisfied with this plan.

Conclusions: The Accountable Primary Care Model offers improved clinical outcomes, cost, and patient satisfaction—the Triple Aim formulated by the Institute for Healthcare Improvement—along with the additional aim of physician satisfaction. It is the Triple Aim Plus One.
Introduction

Volume-based reimbursement has limited the deployment of the Institute of Medicine/Starfield’s Primary Care Model (including the 4 Cs: first contact; comprehensive care; continuous care; coordinated care)1,2 despite its better healthcare outcomes at lower costs and validation of an assessment tool.3 Emerging evidence from controlled trials of the Patient Centered Medical Home (PCMH) model 3 to 5 years post implementation shows that it has produced little, if any, savings in the total cost of care. For example, Friedberg et al published a controlled trial 3 years after implementation of the PCMH for 39,559 patients in a multi-payer environment and found no total cost savings.4 Analysis of the retrospective study by Flottemesch et al reveals that a 10% increase in the Patient Practice Connections Readiness Survey (a proxy for medical home-ness) correlates with a 0.35% reduction in total annual costs of care for 58,391 patients with diabetes during years 3 through 5 post implementation.5 Wang et al found no significant changes in total medical costs during the third year post implementation of the PCMH in 1891 patients with diabetes.6 Furthermore, none of these studies includes the cost of supporting the PCMH, estimated to be $148,347 to $163,347 annually per primary care physician (PCP).7

Development of the APC Model

To enable physician transformation to accountability, Lumeris developed the Accountable Primary Care (APC) Model. Lumeris is a company that designs, builds, operates, measures, and optimizes value-based care models. This model embraces the 4 columns (Cs), or pillars, that support the Institute of Medicine/Starfield Primary Care Model,2 and contributes 5 additional Cs. The goal of this model is to foster the Institute for Healthcare Improvement’s Triple Aim of improved clinical outcomes, cost, and patient satisfaction, along with the additional aim of physician satisfaction—it is the Triple Aim Plus One.

The APC Model is built on the Lumeris data analytics department’s multivariate regression analysis of relationships between 23 hypothesized variables and the medical cost ratio to discover critical success factors. We also contracted with the Olin School of Business at Washington University in St. Louis for an independent discovery of critical success factors. They utilized multivariate regression analysis to identify the 13 most important independent variables that impacted cost/revenue ratios at the PCP level. They then used forecast error variance decomposition of 2010 data to validate the model they generated from 2009 data. In addition, in 2012, the primary author of this manuscript interviewed 10 high-performing PCPs and hospitalists with more than 200 years of collective experience in diverse settings such as medical groups, independent practice associations, and a physician-hospital organization. The high-performing physicians were identified based on Lumeris internal data analytics focusing on population health quality metrics, patient satisfaction, and costs of care. During the same time period, this author performed Google Scholar searches of the grey and medical literature about topics and synonyms related to the 9Cs. He then searched the references in, and the articles citing, each study, as appropriate. After obtaining full text copies of the 1377 articles that passed initial screening, he reviewed each, analyzed the key findings, and integrated them into coherent themes. All of this information informed the development of the APC model as we utilized qualitative interpretative analyses to discover larger meaning and theory.

The APC Model (The 9 Cs)

The APC Model has 4 levels. Level 0 is no PCP engagement, or the absence of accountability; PCPs are paid one-off for piecework. Levels 1, 2, and 3 represent low, medium, and high PCP engagement, respectively. Organizations may progress through these levels sequentially. Some organizations will have aspects of more than 1 level of the model implemented at the same time. Each level is implemented through a playbook that includes granular and specific actions for 8 different actors—the types being: administrator; analyst; care manager; chief medical officer; office staff (registered nurse, medical assistant); primary care physician/ nurse practitioner/physician assistant; population health manager; and regional medical director—and roles in the healthcare system by day, week, month, and quarter.

C1: First contact refers to the patient’s initial entry point into the healthcare system. When new health or medical needs arise, it is usually optimal for the first contact to be with the PCP. In a nationally representative sample of more than 20,000 episodes of care, episodes that began with PCP visits, as opposed to some other source of care in the system, were ultimately 53% less costly. Controlling for emergency department (ED) visits, health status, sociodemographics, and other relevant variables did not materially change this cost differential.8

C2: Comprehensive care means PCPs offer a large range of services across the spectrum of patient care needs, for all but the most uncommon problems. With the APC Model, office visits for older or more complex patients are usually scheduled for 30 minutes to proactively address both manifest and latent issues. Longer visits also enable compliant documentation and accurate diagnosis coding for comprehensive health risk status assessments. These assessments enable claims-enhanced, data-driven collaborative population management, as well as appropriate risk-adjusted revenue assignment in Medicare Advantage (MA) and many accountable care organizations, Medicaid, and state insurance exchange programs.

C3: Continuous, longitudinal, person-focused care means that PCPs and patients work together in the context of longstanding relationships to reach mutual decisions that transcend episodic care. Accountable PCPs tend to follow their patients across care settings as they attend to their care in hospitals, nursing homes, and hospices. Person-focused care includes discussing expectations, discerning preferences, setting priorities, and engaging with family, as well as the usual personalized prevention, screening, and advance care planning.

C4: Coordinated care is widely admired but narrowly understood and practiced in the United States. Transitions to and from EDs, inpatient facilities, and skilled nursing facilities are obvious high-stakes care coordination opportunities. Half of Medicare beneficiaries have 5 or more chronic conditions.9 And every referral to a specialist—with accompanying requirements for information transfers, medication reconciliations, and adjustments to the patient’s overall care plan— may be viewed as a type of care transition. Accountable PCPs, those practicing at the top of their professional training and providing comprehensive primary care, decrease the number of care coordination events as they enhance patient convenience.

C5: Credible primary care earns patients’ trust in the PCP’s competence, beneficence, and professionalism. The strategic significance of this high level of trust is manifest as patients are willing to place confidence in PCP recommendations that may run contrary to their expectations or apparent wishes. Credibility is needed to counter the prevailing currents of Internet-driven consumerism and supply-sensitive care, which tend to undermine PCPs’ authority as they promote patient-specific and individually designed care agendas. PCPs earn credibility with patients primarily by providing the first 4 Cs, but also by honoring patients’ perspectives with active listening and respectful explanations, and by their professionalism in providing excellent customer service.10

One accountable PCP said that without credibility, physicians are nothing but referral clerks. Patients who do not trust their PCPs often want their care from specialists, even for health problems within the realm of primary care.

C6: Collaborative learning requires cooperation across institutional roles, organizational boundaries, and care settings. Both PCPs and the integrators11 of the healthcare system (often the payer or hospital) make important contributions. Payers contribute clinical and claims data transparency aggregated from across the continuum of care. Clinicians perform the work of augmenting this shared, actionable longitudinal information with their own patient data. Clinicians' knowledge of their patients is complementary to payers'. It is more nuanced (as it includes patients' current preferences) but incomplete in its breadth. The system integrator typically funds the analytics, while clinicians engage with the resulting rules-based clinical decision support messages. These 2 parties also take accountability for various tasks and responsibilities in collaborative population management, built on a foundation of collaborative learning and trust.12

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