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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
June 25, 2020
Multipayer Primary Care Network Primary Care Transformation Telehealth Primary Care Investment COVID-19
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By Sarah Klein and Martha Hostetter
When Maryland launched its advanced primary care program in 2019 to improve population health outcomes and reduce unnecessary hospital use, no one anticipated it would prove as useful as it has in helping practices adapt to COVID-19.
The Maryland Primary Care Program, which is jointly managed by the state and the Center for Medicare and Medicaid Innovation, provides funding as well as technical assistance to practices working to expand access to primary care and behavioral health services, identify patients’ unmet social needs, and coordinate care among specialists, among other improvements. (Read a companion issue brief for a look at key program components.)
Primary care clinicians who voluntarily joined the program serve roughly half of the state’s residents. They receive quarterly payments to provide care management services to those covered by the traditional Medicare program, as well as care management fees and a share of the savings they achieve for providing these services to patients covered by the state’s largest commercial insurer, CareFirst Blue Cross Blue Shield. The care management payments from Medicare range from $6 to $100 per beneficiary per month; these funds are in addition to whatever fee-for-service or capitated payments practices receive. During the pandemic, these payments have provided a lifeline to some practices, helping them avoid layoffs as visits declined.
Just as important, the Maryland Primary Care Program has created an infrastructure for state leaders to communicate about their pandemic response and offer clinicians tools to help patients most at risk from COVID-19—enabling clear guidance and coordinated responses during a time when conditions have been changing rapidly. “We didn’t contemplate having a viral pandemic when we planned the program,” says Howard Haft, MD, who was deputy secretary for Maryland’s public health services during the program’s planning process and is currently its executive director. “But it turns out we have in place the important pieces to help us respond.”
With information and rules evolving during the pandemic, the Maryland Primary Care Program has created a channel through which state public health leaders can offer immediate guidance to primary care clinicians. Multiple times a week, Haft and colleagues hold webinars on topics ranging from how to apply for small business loans to how to pivot to telehealth and the implications of new state and federal waivers on reimbursement for virtual care and other services.
The webinars have also kept the practices up to date on the status of the epidemic in Maryland and how they can use data to identify and reach out to vulnerable patients. Some of the earliest webinars focused on how the state had adapted the dashboards of its health information exchange, known as CRISP (Chesapeake Regional Information System for our Patients), to track COVID-19 cases and streamline testing. Providers can use the system to help them identify who should be tested, order tests, and track results. Over the past months, the webinars have kept the practices informed of the state’s evolving priorities for testing and its contact tracing program.
The state has asked primary care providers to follow up on positive and negative lab tests ordered by contact tracers for their patients and accept unassigned patients who have tested positive. Practices will also identify patients for testing, which could trigger contact tracing.
The webinars have also offered a way to inform clinicians about a new risk-stratification tool, the “COVID Vulnerability Index,” created to identify people at greatest risk of experiencing COVID-19 complications. It was adapted from a tool practices in the program were already using to identify which of their patients were at high risk of an avoidable hospitalization or emergency department visit and allocate care management resources accordingly. The new index—created in just a few weeks by the data analytics firm Socially Determined in partnership with CRISP and CareFirst—combines social, demographic, and claims data from Medicare, Medicaid, and commercial payers to produce risk scores based not just on a person’s age and medical conditions but also their particular circumstances, such as whether they live in low-income neighborhoods or high-density housing and/or in areas that have poor air quality or high crime rates. Haft encouraged practices to use it to identify and reach out to patients: “Tell your patients, ‘I can take care of you, don’t go out, I can do telemedicine.’ Otherwise, your high-risk patients could wind up sick, in the hospital, on ventilators, or dead.”
The state has also leveraged its network of 24 care transformation organizations (CTOs), independent organizations created as part of the Primary Care Program to offer practices resources and technical assistance. The practices aren’t required to partner with CTOs but most do, sharing portions of their care management fees to purchase data analytics and the services of CTOs’ care management staff, including nurses, pharmacists, and social workers. The CTOs thus create economies of scale benefitting smaller practices that would otherwise be unable to hire care management staff.
Many of the CTOs, by virtue of their hospital affiliations, serve as natural bridges between primary care practices and hospitals and have helped spread the word about state initiatives. “When COVID-19 started there was information coming from everywhere,” says Christian Gomes, director of operations for the Frederick Integrated Healthcare Network, a CTO affiliated with Frederick Memorial Hospital, an hour northwest of Washington, DC. “Having a source of truth from the state about the current status of everything has been really helpful for our practices.”
To help practices shift to telehealth, the state partnered with the Maryland State Medical Society to obtain 200 to 300 HIPAA-compliant telehealth licenses, which they gave to participating practices free of charge initially and then provided to small practices through grants. Some CTOs have also purchased other licenses for other telehealth platforms for their practices.
Physicians working with Frederick Integrated Healthcare Network’s care managers have joined video visits with patients. “Whether it’s a COVID-19 case or something else, I think it gives the beneficiaries some peace of mind when they see their doctor’s familiar face on the other end of the camera,” Gomes says.
At Mace Medical, a primary care practice with two clinics in the Baltimore suburbs, volume has dropped by half, even after switching to mostly virtual visits in mid-March. Rather than furlough employees, Mace’s leaders asked staff who had less work to do triaging patient calls to reach out to them at home. “You’d be surprised by how many people said, ‘Thank you for calling. I’ve been having chest pains,’” says Chukwuma Ebo, MD, Mace Medical’s chief operating officer.
Mace Medical’s leaders, who partnered with 10 other Baltimore-area independent primary care practices to form a CTO, made several other modifications in response to the pandemic after talking with peers. They designated one of their two clinics as a place to treat patients who needed to be seen in person for complaints other than shortness of breath or other upper-respiratory problems and the other as a site to offer coronavirus tests and treat those with COVID-19. Many of Mace Medical’s patients work in health care, manufacturing, transportation, or other jobs that don’t allow them to work from home and thus are at heightened risk of infection—and so far 20 percent of those tested have contracted the virus. Once COVID-19 patients are identified, they are seen by a physician and if, well enough, sent home to self-quarantine with thermometers and pulse oximeters. Mace Medical’s care managers then call them regularly to check their temperatures and oxygen levels.
Before the pandemic, approximately 120 practices—including Mace Medical—had integrated Screening, Brief Intervention, and Referral to Treatment (SBIRT) services to help those with substance use disorders. Many had adopted the collaborative care model, in which primary care clinicians, care managers, and mental health consultants work together, often through virtual platforms, to oversee patients’ behavioral health care. Mace Medical’s approach to collaborative care involves a partnership with Mindoula, a behavioral health company that offers virtual visits with psychologists, social workers, and psychiatrists. This has proven particularly useful during the pandemic as demand for services to cope with depression, substance use disorder, and anxiety has grown. “It’s a stressful period for everyone,” Ebo says.
One thing that hasn’t changed is Mace Medical’s commitment to seeing patients wherever and whenever they are needed. Mace Medical clinicians continue to round in the hospital, even on COVID-19 units, provide telehealth visits to nursing home patients, and visit homebound patients. The only difference is that they now do so on a rotation, with one clinician at a time working in each location then taking off for a spell to allow for quarantining, if necessary. During a recent home visit, one of Mace Medical’s nurse practitioners realized her patient was severely anemic and needed to be hospitalized. “Dr. Haft used a phrase that stuck with me,” says Ebo. “We don’t want to win the battle but lose the war. We might defeat COVID-19 but conditions like diabetes, heart disease, and COPD are not going anywhere, nor are mental health issues and substance use disorders.”
It remains to be seen whether or to what extent the pandemic has jeopardized practices’ ability to meet the three main requirements of participation in the Maryland Primary Care Program: reaching quality targets, reducing avoidable hospital events, and achieving all of the elements of advanced primary care within three years. It’s also not clear whether all primary care practices will be able to sustain their businesses if patients continue to avoid seeking care.
At Mace Medical, Ebo says the care management payments have been “a lifesaver” in recent months, enabling the clinic to retain all full-time staff, albeit with clinicians taking one day each week of unpaid time off.
Still, Haft and other state leaders are concerned that for some clinics the pandemic will cause them to shut down: “I worry about the viability of small and medium-sized practices, in particular.” More than one-quarter of primary care practices across the United States that have been surveyed on a weekly basis report they have skipped or deferred paying clinicians due to declines in visits following COVID-19. Haft plans to advocate for additional grants and loans, but even with those, he worries some practices may have difficulty staying afloat. Maryland’s hospitals may have more cushion because they receive global budgets.
The program expanded from its first to second year. To sustain primary care practices and stabilize the program, it may help to bring patients enrolled in Medicaid managed care plans into the fold in the future years; already, about half of Maryland’s beneficiaries covered by both Medicare and Medicaid are enrolled. “In general, I’m supportive of all-payer reforms, because it helps clinical practices to have a consistent set of expectations and incentives,” says Joshua Sharfstein, MD, vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health.
Sharfstein says the state may also want to leverage its partnerships with physicians to reach consensus on the policy and payment changes that should remain in place to ensure access to care even after COVID-19 retreats. This may be particularly important for ensuring access to behavioral health services. “Behavioral health just became more important than it was yesterday,” says Chad Perman, MPP, the state’s Primary Care Program director. “We think practices will be able to offer a lot of support for behavioral health care and that will be a real strength of the program.”
In Baltimore, Ebo remains optimistic that the Maryland Primary Care Program, and perhaps lessons learned from the pandemic, are steering his state in the right direction: “Primary care should form the foundation of any country’s health care system. Period.”
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