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June 16, 2022
Multipayer Primary Care Network Primary Care Transformation The Center for Evidence-based Policy
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Evidence has been accumulating in support of the successful role primary care plays in health promotion, disease and death prevention, and more equitable distribution of health resources across populations. In Colorado, a group of health plans formed and self-funded the Multi-Payer Collaborative (MPC) in 2012, focused on transforming primary care and reforming health care payment in their state. With support from the Center for Evidence-based Policy, the MPC developed this Framework for Integration of Whole-Person Care (adapted from the work of Thomas Bodenheimer and colleagues). The Framework provides a roadmap for primary care practices as they seek to provide advanced levels of care, including the integration of behavioral and social health, and it prepares them to receive more advanced models of payment. The Framework also provides guidance for payer organizations migrating toward advanced payment models that pay for value delivered through integrated, comprehensive, whole-person, population-based approaches. The Framework has implications for supporting care transformation, financing and advanced payment methods, and public policy.
In 1978, the Institute of Medicine defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1 Since then, this definition has been used to position primary care as the foundation of the U.S. health system. It has also fueled models with four cornerstones (as in the work of Barbara Starfield and colleagues): first-contact care, continuity of care, comprehensive care, and coordinated care.2 More recently, the National Academies of Science, Engineering, and Medicine defined high-quality primary care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”3
Evidence has been accumulating in support of the successful role primary care plays in health promotion, disease and death prevention, and more equitable distribution of health resources across populations. Health systems built on high-functioning primary care have been shown to decrease racial and socioeconomic health disparities; decrease premature death; decrease death from pulmonary, cardiovascular, and heart diseases; decrease infant mortality; and decrease expenditures overall.4 Despite these data, in most U.S. states, primary care spending represents between 5% and 7% of overall health care expenditures, compared with an average of 14% in Western European countries.5
As a result, the Centers for Medicare & Medicaid Services (CMS) encouraged an increased focus on primary care and primary care payment, through initiatives such as the Comprehensive Primary Care Initiative (CPC), Comprehensive Primary Care Plus (CPC+), State Innovation Model (SIM) grants, and most recently Primary Care First.6,7 In 2021, the National Academies of Science, Engineering, and Medicine released a new report entitled Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Among other things, the report included payment models, use of interprofessional care teams, accountability, and improving quality as facilitators of high-functioning primary care.8
In 2014, Bodenheimer and colleagues published “The 10 Building Blocks of High-Performing Primary Care,” based on the seminal work of Starfield and colleagues,9 along with studies they conducted of model primary care practices and their experience helping practices transform to higher levels of functioning.10 These 10 “building blocks” include a foundation of four fundamentals (engaged practice leadership, data-driven improvement, empanelment, and team-based care) necessary to achieve the other six elements (patient-team partnership, population health management, continuity of care, access to care, comprehensiveness of care, and care coordination).11
Over the last decade the United States has experienced significant population changes. The country has continued to become more racially, ethnically, and economically diverse, with many ethnic minority groups doubling in population since 2010.12 The role that social determinants of health (e.g., housing, transportation) and social behaviors (such as alcohol and other drug use) play in achieving health outcomes is increasingly being recognized.13 Behavioral health and substance use disorder rates, and related deaths, are on the rise. The National Institute of Mental Health estimates that one in every five adults in the U.S. has a mental health disorder, with only half receiving treatment.14The Centers for Disease Control and Prevention estimates that one in every six children age two through eight has a mental, behavioral, or developmental disorder, and that one in every six adults had four or more adverse childhood experiences.15 According to the National Center for Drug Abuse Statistics, if alcohol and tobacco are included, 60% of Americans over the age of 12 currently use or abuse drugs.16 Deaths from drug overdoses have been rising at least 4% annually, with a current national rate of 21.6 deaths per 100,000 residents.18 Seven in 10 deaths are linked to opioid overdose.18 These changes challenge the conventions of a primary care delivery system that focuses on a transaction between one provider and one patient and is financed by a multipayer system in which a health plan pays a specified fee for the transaction.
The Colorado Multi-Payer Collaborative (MPC) was established in 2012 as a self-funded collaborative of payer organizations focused on transforming primary care and reforming health care payment in Colorado. The MPC brought together traditionally competing private and public health care organizations to share resources, coordinate quality efforts, and align payment approaches to achieve increased quality, improved outcomes, and controlled costs in the Colorado health care market. The MPC’s founding membership included Aetna, Anthem Blue Cross Blue Shield of Colorado, Cigna, Colorado Access, Colorado Choice Health Plans, Humana Inc., Rocky Mountain Health Plans, UnitedHealthcare, WellPoint, Health First Colorado (Medicaid), Teamsters Union Health Plan, a Taft-Hartley Trust, and CMS. Since its founding in 2012, MPC membership has changed over time as the marketplace evolved and mergers occurred, and by the end of 2021 the MPC consisted of five primarily national payer organizations. These payers were represented by dedicated Colorado-based leaders committed to improved primary care and payment in the market. While the number and configuration of participating payers changed over time, MPC members remained focused on their shared commitment to increased quality, improved efficiency, higher value, and continuous improvement. They worked together to diffuse innovative and successful strategies focused on system accountability, improved health outcomes and experiences for patients and providers, and decreased total cost of care.
The MPC was organized with guidance, facilitation, and support from the Center for Evidence-based Policy, based at Oregon Health & Science University in Portland, Oregon. Originally established in response to requirements of the federal CPC initiative, which was designed to strengthen primary care through a core set of comprehensive primary care functions and population-based payments, the MPC built momentum over time and also participated in CPC+ (a successor of CPC), as well as the Colorado SIM initiative. In addition to their aligned participation in these reform initiatives, participating payers advanced their own shared efforts to transform the quality, payment, cost, and outcomes of primary care in the state. The MPC decided not to participate in CMS’ most recent model to advance primary care, Primary Care First, although one individual payer is participating in the model.
Central to all the transformation efforts of the MPC was the development of a shared Framework for Integration of Whole-Person Care as a transformation and measurement roadmap for primary care practices and payers alike. The Framework, including the process used to develop it, created a common understanding among disparate payer organizations of the core components of advanced primary care, primary care payment, and the transformation needed for both payers and providers to achieve it.
The Framework for Integration of Whole-Person Care was adapted from the work of Bodenheimer and colleagues.19 The Framework’s goal is to communicate commonalities among MPC member plans in three key areas:
1) The journey necessary to achieve more advanced, integrated levels of primary care delivery; 2) Key milestones along the journey; and 3) Example transformation activities that occur at payer organizations.
By design, the Framework does not represent a specific payment model or initiative, nor does it guarantee participation in any payment program by any MPC member plan. Instead, it provides a roadmap for primary care practices as they seek to provide advanced levels of care that account for the challenges of current populations, including the integration of behavioral and social health, and prepares them to receive more advanced models of payment. The Framework also provides a roadmap for payer organizations as they migrate toward advanced payment models that pay for value delivered through integrated, comprehensive, whole-person, population-based approaches.
Over the course of four years, members of the Colorado MPC documented their shared lessons related to the coordination of health care and social supports (including behavioral health). They held two to four work sessions each year for payers, primary and specialty care providers, and other stakeholders to discuss challenges and objectives and to establish common definitions related to the transition toward integrated, whole person primary care in the state. Drawing on “The 10 Building Blocks of High-Performing Primary Care”20 and feedback from providers and other stakeholders, members of the MPC developed the Framework for Integration of Whole-Person Care (Figure 1).
MPC members also worked with the Practice Innovation Program at the University of Colorado Anschutz Medical Campus (CU) to ensure that the identified Framework goals and milestones were available to and consistent with efforts across the state to support the transformation of primary care. The Practice Innovation Program at CU coordinates the Colorado Health Extension System, which convenes and coordinates Practice Transformation Organizations (PTOs) across Colorado. Using regional health connectors, practice facilitators, and clinical health information technology advisors, the PTOs supported by the Practice Innovation Program provide on-site practice support, guide learning networks, and spread transformation best practices.
“The 10 Building Blocks of High-Performing Primary Care” by Bodenheimer and colleagues was intended as a simple way for practices to conceptualize quality care. The MPC’s Framework used these building blocks as a foundation, but suggested new dimensions to reflect recent population, care, and market changes, adding nuance to the straightforward approach taken by Bodenheimer and colleagues.21 (See Figure 1.) The Framework also adds substantial depth by identifying common payer goals, measures, and metrics to gauge the transition to integrated, whole-person models of primary care.
Figure 1: Framework for Integration of Whole-Person Care
Based on the experience of MPC member payers and a broad range of stakeholders over four years, the Framework for Integration of Whole-Person Care suggests the addition of four dimensions to the important work of Bodenheimer and colleagues:
1) The integration of behavioral health and social supports in each building block;
2) The addition of the “locus of provider coordination”;
3) The inclusion of payer functions; and
4) The organization of payer functions into “levels of collaboration.”
1. Integration of Behavioral and Social Supports
The Framework calls for behavioral and social supports to be included in the definition of care at each building block. National and international organizations estimate that health care accounts for only 10%-20% of health outcomes.22,23 It has further been estimated that up to 75% of primary care visits include components related to behavioral health.24 These estimates are borne out in the experience of MPC member plans, and, as a result, behavioral health and social supports were included in MPC definitions, goals, and measures at each step in the Framework, aiming for a final goal of full integration of behavioral health and primary care. This dimension is included in the definition of each building block and reflected in the transformation goals and milestones (see Table 1).
2. Locus of Provider Coordination
In today’s health care market, MPC members suggest that the activities related to some building blocks are more likely or appropriate to be satisfied at the clinic office level (e.g., empanelment, team-based care, engaged leadership), while others may be more efficiently achieved by a network or system of clinics (e.g., population management, continuity of care linked to behavioral and social supports, comprehensive care coordination). Full integration as described by the Framework is best achieved at a community level. This dimension is represented along the right-hand side of the Framework.
3. Payer Functions
Many models of primary care transformation include descriptions of core functions of advanced primary care. Few, however, include a description of what payers can do to support these core functions. Recognizing the symbiotic relationship of transformation between providers and payers, the Framework identifies core functions payers may undertake to support the transformation of primary care into advanced, whole-person care models. This dimension is represented by bullets in the Framework.
4. Levels of Payer Collaboration
The Framework organizes core payer functions that support practice transformation into three “levels of collaboration” based on the optimal manner in which payers should interact with one another in fulfilling their core functions.
In addition to the four dimensions described previously, MPC members identified goals and milestones to measure the transition to each of the building blocks, focused on the delivery of whole-person care that includes the integration of behavioral health. This substantive and unprecedented work was designed to serve as a shared expression by payers about the journey necessary to achieve advanced, integrated levels of primary care delivery and to specify a common set of measurable milestones that could be used by practices and payers alike.
Along with guidance for providers and payers engaging in advanced payment models, there are additional opportunities to deploy the Framework to advance efforts. These opportunities lie in three areas: care transformation, financing and advanced payment methods, and public policy.
The authors acknowledge and applaud the work of the members of the Colorado MPC for the development of the Framework. In particular, the following individuals provided substantial input and direction:
1 Institute of Medicine. A Manpower Policy for Primary Health Care. Washington, DC: National Academy of Sciences; 1978. 2 Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998. 3 National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press; 2021. doi:10.17226/25983 4 Perrin JM. Detailing the primary care imperative — remembering Barbara Starfield. Milbank Q. 2020;98(2):235-238. doi:10.1111/1468-0009.12460 5 Cohen J. Primary care is integral to improving U.S. healthcare, but is falling further behind. Forbes Magazine. September 6, 2019. https://www.forbes.com/sites/joshuacohen/2019/09/16/primary-care-is-integral-to-improvingu-s-healthcare-but-is-falling-further-behind/. 6 Ibid. 7 Landon BE. A step toward protecting payments for primary care. N Engl J Med. 2019;380(6):507-510. doi:10.1056/NEJMp1810848 8 National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press; 2021. doi:10.17226/25983 9 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457- 502. doi:10.1111/j.1468-0009.2005.00409.x 10 Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166-171. doi:10.1370/afm.1616 11 Ibid. 12 U.S. Census Bureau. “America Counts: Stories Behind the Numbers/ 2020 U.S. Population More Racially, Ethnically Diverse Than in 2010.” https://www.census.gov/library/stories/2021/08/2020-united-states-population-more-racially-ethnically-diverse-than-2010.html. Accessed June 1, 2022. 13 National Academies of Science, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington, DC: National Academies Press; 2019. doi:10.17226/25467 14 National Institute of Mental Health. “Mental Health Information Statistics.” https://www.nimh.nih.gov/health/statistics/mental-illness. Accessed June 1, 2022. 15 Centers for Disease Control and Prevention. “Data and Statistics on Children’s Mental Health.” https://www.cdc.gov/ childrensmentalhealth/data.html. Accessed June 1, 2022. 16 National Center for Drug Abuse Statistics. “Drug Abuse Statistics.” https://drugabusestatistics.org/. Accessed June 1, 2022. 17 Ibid. 18 Ibid. 19 Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166-171. doi:10.1370/afm.1616 20 Ibid. 21 Ibid. 22 Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129-135. doi:10.1016/j.amepre.2015.08.024 23 Magnan S. Social Determinants of Health 101 for Health Care: Five Plus Five. NAM Perspectives. Washington, DC: National Academy of Medicine; 2017. doi:10.31478/201710c 24 Robinson PJ, Reiter JT. Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York: Springer; 2007. 25 Robert Wood Johnson Foundation Commission to Build a Healthier America. Time to Act: Investing in the Health of Our Children and Communities. Princeton, NJ: Robert Wood Johnson Foundation; 2014. http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 26 Health Care Payment Learning & Action Network. The LAN Healthcare Resiliency Framework. 2020. https://hcp-lan. org/workproducts/LAN-Healthcare-Resiliency-Framework-Overview.pdf
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