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The American Journal of Accountable Care March 2019
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J. Mac McCullough, PhD, MPH; Natasha Coult, MS; Michael Genau, MS; Ajay Raikhelkar, MS; Kailey Love, MBA, MS; and William Riley, PhD
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Improvement of Outpatient Quality Metrics in a Limited-Resource Setting
Carolina dos Santos, BA; Torkom Garabedian, MD; Maria D. Hunt, LPN; Schawan Kunupakaphun, MS; and Pracha Eamranond, MD, MPH
Effective Population Health Care Delivery Under Medicare’s Merit-based Incentive Payment System: Realigning Accountability With Capability
Adam S. Wilk, PhD; and Sanjula Jain, PhD
Making Sense of Changes in Healthcare: Lessons From the AcademyHealth National Health Policy Conference
Jaime Rosenberg

Improvement of Outpatient Quality Metrics in a Limited-Resource Setting

Carolina dos Santos, BA; Torkom Garabedian, MD; Maria D. Hunt, LPN; Schawan Kunupakaphun, MS; and Pracha Eamranond, MD, MPH
This study presents an example of a population health initiative in a limited-resource primary care setting that led to significant improvements in preventive care quality metrics in the context of major insurance payers.

Objectives: Healthcare systems are increasingly focused on improving outpatient quality metrics to achieve better clinical outcomes. In this study, we aim to explore a model in an outpatient setting to achieve high-quality care in the context of risk-based contracts with major payers.

Study Design: We used data from a population health initiative conducted in a primary care setting.

Methods: In a primary care practice, a member of a healthcare network based in Massachusetts and southern New Hampshire, a population health initiative was implemented to improve screening rates for breast cancer, cervical cancer, and colorectal cancer and to improve control of hypertension and diabetes. This intervention consisted of a team-based initiative involving population health managers, a licensed practical nurse, medical assistants, and primary care providers, who identified gaps in these quality measures from 2015 to 2017.

Results: Screening rates for breast cancer showed significant improvement, from 88% in 2015 to 97% in 2017 (P <.01). Cervical and colorectal cancer screening rates improved from below network compliance rates to surpass network performance. Control of hypertension also showed significant improvement (P = .05). Control of diabetes was not associated with significant improvement (P = .20).

Conclusions: The exhibited trends indicate that within the confines of limited resources in a local community setting, it is possible to improve delivery of quality care, leading to significant improvements compared with a larger network with more resources, without increasing systemic costs.

The American Journal of Accountable Care. 2019;7(1):4-9
Healthcare cost in the United States has been steadily increasing due to America’s aging population and the burden of chronic diseases.1 The staggering costs incurred to address our population’s healthcare needs cannot be sustained over the coming decades without an overhaul in healthcare fund disbursement. A possible solution implemented by many healthcare organizations across the United States has been the adoption of global spending contracts. One mechanism to help improve quality, while controlling costs, has been the adoption of accountable care organizations (ACOs). In an ACO, a global budget is established by insurance payers, encouraging provider groups to work together to keep spending below a set target in order to take advantage of shared savings. Provider groups also assume risk for excessive spending, further promoting careful allocation of funds.2

The potential benefits of risk-based contracts have led healthcare providers to shift their focus away from the provision of supply-driven healthcare, centered around the profitability of services dispensed, and toward the delivery of value-based care. This system focuses on outcomes achieved per healthcare dollar spent, aiming to reduce costs while improving care. This system is beneficial for all stakeholders involved, including patients, who receive better care, as demonstrated by improved quality outcome metrics in healthcare systems that have already adopted this model.3

Massachusetts pioneered the adoption of alternative payment models by entering into risk-based contracts with insurance payers, such as Blue Cross Blue Shield (BCBS) and Tufts Health Plan, as early as 2009 and participating in the Pioneer ACOs under Medicare. Years of data collection have shown that healthcare providers that participate in global contracts reduce spending growth and increase quality improvements compared with providers that do not participate in the contracts. According to a 2015 report, 90% of BCBS Massachusetts–covered specialists participated in the global contract.4 Effective March 2018, 17 healthcare organizations across Massachusetts entered into an ACO arrangement with the state’s Medicaid payer, MassHealth,5 demonstrating the state’s pioneering leadership in the arena of healthcare reform.

ACO performance is measured through several quality measures that capture a variety of metrics, such as patient coordination, safety, and preventive health services uptake.6 Quality outcome metric guidelines are provided by the insurers as part of the risk-based contract model. Quality bonuses can be awarded to organizations based on reported performance data that are related to processes, quality, and patient satisfaction.2

Preventive care is an important aspect of alternative payment models and, partnered with population health initiatives, can be a powerful way to drive down costs while promoting better care.7 This focus is especially crucial in populations of racial/ethnic minorities, non-English speakers, and low-income individuals, who are less likely to be included in preventive care efforts but can benefit greatly from necessary screenings. The greatest benefit is seen when healthcare providers implement patient navigation efforts that are designed to promote inclusion.8

Despite defined guidelines on how to measure quality outcomes, there is insufficient knowledge on how to build strategic initiatives within healthcare organizations in order to meet these goals, especially in a limited-resource setting.9 The collection of quality outcome data can require specialized infrastructure, including automated reporting systems and dedicated population health personnel.10 Relying on practice physicians alone to deliver adequate preventive care is not always feasible, mostly due to time constraints. Prior research findings estimate that it would take 7.4 hours per working day for a physician to provide all recommended preventive care screenings to patients.11 To ensure administration and reporting of preventive care in a primary care setting, many healthcare providers have adopted a team-based approach, with delegation of tasks to multiple members of the practice. Incorporating medical assistants (MAs) and licensed practical nurses (LPNs) into the quality outcome workflow has been shown to be beneficial and can be a less costly way to improve workflow without expensive organizational overhauls.12 We sought to determine whether a team-based approach would improve preventive quality metrics under an alternative payment model in a resource-constrained community practice model.


Study Population

This study started as a population health initiative in a community health center, aiming to improve compliance with preventive health measures based on the best practice guidelines accepted by 3 major commercial payers. Compliance data were collected from 1 point in time midyear each year to assess which preventive outcomes should be the focus of the clinic’s efforts for the remaining half of the year. The patient population studied was made up of patients coming to Community Medical Associates (CMA) who were covered by 1 of the following 3 major commercial insurance plans: Harvard Pilgrim, BCBS, and Tufts Health Plan.

CMA is a patient- and family-centered medical practice serving the population of the Merrimack Valley region and southern New Hampshire. It is part of a broad healthcare organization network, which includes many hospitals and outpatient practices in Massachusetts. Starting in 2015, a population health initiative was implemented in the CMA primary care practice to improve screening rates for breast cancer, cervical cancer, and colorectal cancer (CRC) and to improve control of hypertension and diabetes. This intervention included a team-based approach with population health managers, an LPN, MAs, and primary care providers identifying gaps in quality outcomes and systematically following up on outpatient outcomes from 2015 to 2017.


The study period spanned from 2015 to 2017. The studied measures for compliance rate were screenings for breast cancer, cervical cancer, and CRC and control of hypertension and diabetes. Blood pressure guidelines were measurements of less than 140/90 mm Hg in the population aged 18 to 59 years, as well as in the population with diabetes and less than 150/90 mm Hg in the population aged 60 to 85 years. Overall diabetes control was defined as the percentage of patients with glycated hemoglobin (A1C) of 9.0% or less. Of note, the same standards of care were applied for the entire patient population at CMA, including the Medicare beneficiaries, but this study included only members of the previously mentioned 3 commercial insurance plans, given that the focus during the study period from the network perspective included only commercial payers.

Data collection for the outcome measures was done through claims-based search and complemented by data found within electronic health records (EHRs).

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