Six Characteristics of High-Value Primary Care Practices

November 28, 2017 - High-value primary care practices that achieved exceptional care quality at reduced costs shared six attributes centered around risk-stratified care management, mindful specialist selections, and care coordination, a new study in the Annals of Family Medicine found.

“No one has ever studied this intersection of high-quality and low-cost health care at a national level for individual physician offices,” stated study author and Professor of Medicine at Stanford University Arnold Milstein, MD. “We’re hopeful that these studies will help American physicians and policymakers better understand what tangible changes in care-delivery practices will allow physicians to meet our national thirst for more with less.”

Milstein and his team at Stanford explored how some primary care practices deliver high-value care. The researchers used claims data from 2009 and 2011 to rank primary care practices based on annual healthcare spending per patient. They also assessed the practices based on 41 measures and conducted site visits to 12 high-value and four average-value practices.

The analysis revealed that 64 of over 6,500 primary care practices ranked in the top quintile for both spending and quality and another 102 ranked in the quintile above the mean.

These high-value primary care practices notably reduced healthcare spending significantly more than average-value sites. Practices in the high-value cohort spent 34 percent less.

The high-value cohorts particularly decreased spending on inpatient surgical services, outpatient hospital visits and ambulatory surgical services, and outpatient prescription medications. Spending differences between high- and average-value practices stemmed from differing rates of service utilization.

The practices also shared six statistically significant common characteristics. The attributes of high-value primary care practices were:

• Decision support for evidence-based medicine: care teams ensure patients receive evidence-based care and treatment, frequently making guideline-based reminders in the EHR to other providers, office managers regularly generate reports to identify care gaps, and physicians consciously avoid test orders not linked to change management

• Risk-stratified care management: each patient receives care based on his or her unique needs, with high-risk patients receiving monitoring and guidance from a care manager as well as longer office visits, frequent phone checks, and in some cases, home visits from clinicians

• Careful selection of specialists: clinicians use a narrow list of specialists with whom they trust to follow evidence-based guidelines and remain in contact as treatment plans develop

• Care coordination: care teams monitor patients outside of primary care visits and ensure patients complete specialist referrals, schedule timely follow-up after unexpected hospitalizations, and in some cases, track medication adherence

• Standing orders and protocols: practices create standing orders and protocols for uncomplicated acute illnesses and chronic disease management, as well as encourage non-clinician team members to use standardized workflows for patient care without requiring direct clinician intervention

• Balanced compensation: physician compensation based on value instead of just volume and compensation accounts for at least care quality, patient experience, resource use, or participation in practice-wide improvement activities

Researchers stated that the six attributes reflect the value of “care traffic control.” The characteristics demonstrated in the high-value primary care practices help patients with complex or chronic conditions and treatment plans navigate the healthcare system.

Traditionally, payers served as care traffic controllers by providing nurse care managers over the phone. But the study indicates that the primary care may be a better platform for care coordination.

Researchers also noted that decision support for evidence-based medicine and the development of standing protocols and orders act as tools to decrease cognitive burdens for physicians and their staff.

“They can help tame the overwhelming flow of outcome studies and clinical guidelines, the widening array of disease subtypes likely to grow quickly with planned national investments in precision medicine, and the complexity of treatment plans for aging populations,” the study stated.

Balanced compensation also revealed “the usefulness of echoing within a practice external efforts to reward value rather than volume.”

In addition to the statistically significant attributes, researchers found other common characteristics. The following are characteristics observed among high-value practices, but not statistically significant:

• Expanded care access

• Shared decision-making and advanced care planning

• Perception that patient complaints are just as valuable as compliments

• Comprehensive care

• Upshifted staff roles

• Shared work spaces

• Low overhead space an equipment

Researchers intend for the study’s findings to help physician office leaders to engage in care delivery and practice transformations that will help their physicians succeed under value-based reimbursement models, such as MACRA.

The Merit-Based Incentive Payment System (MIPS) will adjust annual physician Medicare reimbursement by as much as 9 percent starting in 2022 based on care quality and resource use. Eligible clinicians participating in MACRA’s other track, Advanced APMs, also have their revenue at risk based on their quality and cost performance.

Clinicians may be seeking practice transformation to support MACRA and other value-based arrangements. However, recent efforts, such as the patient-centered medical home, have yet to prove sustainable care quality improvements and lower spending, researchers stated.

“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 for non-Medicare as well as Medicare populations,” they wrote.

Using the six attributes of high-value primary care, eligible clinicians may be in a better position to improve care quality performance and resource use efficiency. “Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care,” the study stated.

“Meanwhile, physicians seeking to respond to payer incentives to improve value now may benefit from considering ‘care traffic control’ and other attributes of their primary care peers whom we found to rank favorably on performance measures typically used by payers,” they concluded.