Redesigning Primary Care for High-Risk Patients
The patient was a single male in his mid-30s who earned marginal wages in a physically demanding job and lived with several friends in a tiny and cramped apartment. Suffering from acute back pain, he went to the emergency room at Brigham and Women’s Hospital in Boston. There, clinicians discovered another health challenge: his blood pressure was dangerously high. After learning the patient had no primary care physician, the ER doctor referred him to Brigham and Women’s Advanced Primary Care Associates, which had earned a reputation for its performance in caring for high-risk patients.
Caroline Melia, the clinic’s case manager, recalled that the patient had been reluctant to make an appointment because he was unsure of what his health plan would cover. When he did come in, his list of health challenges grew longer. He had an endocrine problem and severe sleep apnea, which probably was worsening the blood pressure. The patient had carried a bag of various prescription bottles into the clinic and did not understand which of the drugs he should be taking. As it turned out, he had run out of the most critical drugs.
Over a period of a few months and several visits, Melia and some of her colleagues in the clinic worked with the patient. They helped him figure out his insurance and understand his medical conditions. The team also eliminated unnecessary pills, explained why the remaining prescriptions were crucial, developed a care plan that would work given the constraints in the patient’s life, and helped get his blood pressure under control.
It was the kind of case that made Stuart Pollack, MD, the clinic’s director, proud of his staff. In his view, this was what excellence in primary care was all about. He had endeavored to shape the clinic’s culture and operating routines to meet the needs of the highest-risk patients.
However, Pollack could only go so far in redesigning care because his budget was tied to fee-for-service reimbursement schedules. In 2011, Brigham and Women’s had opened the clinic with an eye towards the emerging world of accountable care; by 2016, several value-based contracts were in place. Nonetheless, in Pollack’s view, much of the organization was still locked in longstanding fee-for-service routines.
Pollack had an unusual perch from which to assess the advantages and disadvantages of various payment models. Over the course of his career, he’d experienced both capitation and fee-for-service.
After completing his medical training, he took a job with the Fallon Clinic (now Reliant Medical Group) in Massachusetts, which accepted payments only from the Fallon Community Health Plan. Fallon did not own a hospital but it had a close partnership with a nearby Catholic hospital. Altogether, it was a closed and fully integrated system, a highly rated one. For 10 years, Pollack doctored in this arrangement, under incentives to take great care of patients without wasting money.
These formative years shaped Pollack’s practice style. He enjoyed the intellectual challenge of guiding patients back to health with minimal intervention. It wasn’t simply a matter of frugality. He saw that every intervention in health care involved the possibility of both benefit and harm. In his view, volume-driven care tempted lazy thinking; it was an enticement to minimize or overlook the potential damage from an unnecessary imaging test or an avoidable hospital stay.
The clinic eventually decided to abandon capitation in favor of a multi-payer, fee-for-service revenue model. In Pollack’s view, it was a reasonable decision from a financial standpoint but a tremendous leap backwards from a clinical perspective. Having risen to chief of internal medicine, he found himself leading a group of reluctant physicians into a new world in which they had to code and bill every interaction with patients and were paid according to the number of patients they saw in the clinic each day instead of based on their patient panel size.
It was a multidimensional education. Pollack recalled:
I realized that the system is just fundamentally broken. It’s not the pieces—the doctors or the nurses or the patients. It’s what the system combines them into.
Pollack also saw that changing the payment model did not magically and automatically change the way clinicians behaved. He recalled, with no shortage of irony, how in his role as chief he had had to guide physicians who wanted to manage populations and deliver high-value care into thinking more about the nuances of coding, billing, and revenue maximization.
He’d been on the job for four years when a better opportunity came along.
Pollack’s ambition was to build a better model for primary care. In 2008, primary care redesign was a hot topic and the term “primary care medical home” was gaining currency. At a conference, Pollack happened to be seated near a primary care leader from Brigham and Women’s Hospital, a unit of Partners HealthCare. Before long, Pollack had accepted a new job that enabled him to spend significant time out of the clinic, thinking about and researching possibilities for care redesign.
About 18 months later, Brigham and Women’s, which was interested in further expanding its presence in primary care, spotted an attractive real estate opportunity. Anticipating a shift to value-based care, the leadership team wanted to turn the building into a leading-edge primary care operation. Pollack joined a small committee that drew up preliminary designs and soon negotiated his way to running the clinic himself.
He was most interested in building a clinic to serve high-risk patients. Loosely defined, these were patients who had multiple medical conditions, often including a mental health challenge. They also lived chaotic lives, with some combination of low income, difficult employment, and unstable living or family situations. Generally, such circumstances rendered attending to health a low priority for these patients. In addition, they had limited access to primary care and had trouble navigating the health-care labyrinth.
The existing system made the least sense for these patients, in Pollack’s view. This was also the segment of the population where there was the greatest opportunity for improvement.
Given the choice, Pollack might have chosen to build a clinic that served these patients exclusively. Instead, Advanced Primary Care Associates served about 2,000 patients who fit into this category out of a total patient panel of roughly 8,000. Although the high-risk group accounted for only about 25 percent of the patient panel, Pollack estimated this group represented roughly half of the clinic’s workload. The other 6,000 patients fell into three categories: Brigham and Women’s employees, patients of a nearby concierge practice that had closed when the physician leading the practice had retired, and residents of the neighborhood in which the clinic was located. Pollack’s goal was to design a facility that could serve all patients well while delivering particularly outstanding results for the high-risk subset.
On the surface, operations within Advanced Primary Care Associates are straightforward. There are three teams whose primary role is to see patients each day—not just the high-risk patients, but all patients. These teams include one full-time equivalent MD, typically staffed by a few providers who spend only a fraction of their time in the clinic (as is commonly the case in academic medicine), as well as a full-time PA, an LPN, and two medical assistants.
If this were the entire staff, there would be little reason to imagine high-risk patients would do better here than anywhere else, but there is more. Several additional staff spend all of their time—or nearly all of it—with high-risk patients. Each of the three teams includes a licensed social worker, and a case coordinator (Caroline Melia), a nutritionist, and a pharmacist work with all three teams.
In Pollack’s view, Melia had ideal experience for her work, having worked with high-risk patients throughout her career. After completing her nursing training, she had worked for several years in the Boston Health Care for the Homeless Program. She enjoyed caring for the most complicated patients and had become familiar with a variety of Boston-area programs and resources that she could draw upon to assist them. Furthermore, she was skilled in helping patients with their insurance plans.
Beyond staff with the requisite skills, serving high-risk patients requires time, availability, and teamwork. At the most basic level, teamwork implies routine face-to-face conversations among the staff. If the three teams had schedules that kept them running full speed from patient to patient all day long (as the incentives of fee-for-service medicine compel), it would be difficult for the MDs, PAs, LPNs, and MAs within the clinic to ever have more than a fleeting exchange with the staff fully dedicated to serving the high-risk patients.
Therefore, Pollack kept his teams scheduled at about three-quarters of a typical primary care pace. This created sufficient slack in the schedule to permit ad hoc meetings focused on a particular patient, often with the patient in the room. In fact, such meetings were a regular part of the clinic’s daily rhythm. The team endeavored to employ techniques such as motivational interviewing to ensure that care plans were realistic and that patients would succeed in following them.
At the end of each meeting, the team documented responsibilities for follow-up actions. It was not always possible for every clinician to stay in the room for the entire conversation but, in Melia’s view, everyone was familiar enough with each other’s work that they could assign responsibilities and follow up with each other as needed later in the day. Pollack and Melia both believed that willingness to drop what you were doing to join a conversation about a high-risk patient was a crucial element of the clinic’s culture. Everyone pitched in when necessary.
The administrative team in the clinic worked to schedule back-to-back appointments for patients wherever possible. The slack in the schedule made it feasible for a “warm handoff” among clinicians between appointments; that is, the clinicians had time to speak face to face and share observations and recommendations about the patient. For example, high-risk patients often had multiple prescriptions, so an appointment with the pharmacist typically was scheduled before the appointment with the physician. The pharmacists discussed recommendations for changes to the medication regimen with the physician prior to the physician entering the room with the patient, enabling the physician to focus on the exam and the conversation.
Although Melia preferred to avoid any formally defined leadership role, she was a de facto team captain in conversations focused on care coordination and care planning for high-risk patients. As part of her role, she also spent significant time educating patients on appropriately using the clinic versus the hospital (emphasizing that the clinic was dedicated to being available for them) and training home caregivers on the needs of the patients they tended.
Melia also proactively monitored the panel of high-risk patients and responded quickly if she noted one had missed an appointment or been admitted to the hospital or the emergency room. Knowing that transitions in care were frequent trouble spots and that hospitals often discharged the most challenging patients prematurely, Melia paid particular attention as patients moved from hospital to home, for example, or moved into or out of a rehabilitation center. The clinic built close relationships with the rehabilitation centers and home health agencies that its patients used most frequently. Slack in the clinic schedule again played a crucial role here. The clinic was committed to scheduling lengthy appointments with patients within three days of discharge.
While Pollack was proud of the clinic and its staff, he would have preferred to engineer a much more aggressive redesign of primary care. Brigham and Women’s was caught in a nebulous gray area between fee-for-service medicine and accountable care, and Pollack had somewhat limited freedom. On the one hand, he felt fortunate to have some degree of flexibility; because the senior leaders at Brigham and Women’s were committed to transitioning to accountable care, Pollack’s budget targets provided for a generous level of acceptable losses under strict fee-for-service accounting. On the other hand, because his budget was still tied to fee-for-service mathematics, any further hiring or any redeployment of the revenue-generating staff was next to impossible to justify, regardless of the benefit to patients or the system.
In Pollack’s ideal, Advanced Primary Care Associates would staff additional nurses, behavioral health specialists, health coaches, and community health workers. Furthermore, the clinic schedule would not revolve around physician appointments. In fact, as patients would more often see other providers, doctors would need to see only about five patients per four-hour block. Physicians would have fluid schedules and they would be perceived as just one member of the care team—the one that happened to have the deepest medical training. They would be regarded as the experts on rare diseases and complex care plans, and they would allocate their attention based on where their unique knowledge was most essential.
None of this was possible, however, so long as the clinic’s budget was subject to fee-for-service math. The staff members who focused on the clinic’s high-risk patients were predominantly unbillable, and doctors had to see patients to earn revenue. Pollack expressed his frustration:
There is no more suffocating constraint on the imagination of the physician innovator than the RVU.
Pollack anticipated that the transition to accountable care eventually would compel Brigham and Women’s to adopt a more sophisticated analysis of the financial impact of primary care operations. Even under existing fee-for-service contracting, Pollack’s clinic delivered value that was not accounted for. His clinic received no financial credit for downstream referrals nor for keeping poorly insured and uninsured patients (those on whom the hospital would lose money) healthy enough stay out of the hospital. Under accountable care, Pollack’s clinic would sensibly be credited for keeping any patient healthy and out of the hospital. Unfortunately, the accounting systems and processes necessary for such analyses were not yet in place.
The patient, a woman in her late 50s, used a wheelchair. She was a half-paralyzed stroke victim who also struggled with poorly controlled diabetes. She lived alone; her ex-husband was an addict. She was in pain and occasionally overused pain medications.
Nonetheless, and to Pollack’s great satisfaction, she had been admitted to the hospital only twice over a four-year period. Both admissions were quite necessary because of sudden fluid buildup in her lungs.
When the patient was seen in the ER a third time, it was because of a significant weakening of her “good” side. Despite the fact that she was having trouble moving at all, she did not want to be admitted.
Upon receiving the news, Melia and the clinic team, knowing the patient had little family support, sprang into action to develop a workable care plan outside of the hospital. The patient was going to need a lot of help. It took several hours of work, but Melia found a good skilled nursing facility with available space, spoke with insurers, and even arranged transportation.
Pollack estimated that the team scrambled to make such arrangements on behalf of patients at least twice a month. For him, it was a point of pride.