CRANSTON – Despite the thick, early morning fog on Dec. 11, blurring the edges of certainty of buildings and streets and obscuring the boundaries between land, Narragansett Bay and the sky, the quarterly meeting of the Care Transformation Collaborative member practices, dubbed the Breakfast of Champions, proceeded on its scheduled course at the Rhode Island Shriners Imperial Room, with a clear sense of future direction and goals.

At the end of the two-hour meeting, the fog still persisted outside. Inside, however, the potential opportunity of a new low-cost alternative to measure and track patient engagement, “HowsYourHealth,” had become visible, resonating with many of the primary care practitioners in the room.

“I’m excited about this,” Dr. Edward McGookin, chief medical officer at Coastal Medical told ConvergenceRI, as he departed the gathering. “I’m going to see if we can implement it.”

As a result, a kind of transference occurred; the vision of new cost-containment strategies being implemented by regulators around the reform of delivery of primary care in Rhode Island became fogged up as a car windshield on a wintry day.

Transformers
More than 100 practitioners had filled the room, including many of the honchos from the primary care world in Rhode Island: Dr. G. Alan Kurose, president and CEO of Coastal Medical; Dr. Al Puerini, chairman of the board of Rhode Island Primary Care Physicians Corporation, now affiliated with Integra, Care New England’s accountable care organization; Christine Hansen, COO of Blackstone Valley Community Health Care; and McGookin, chief medical officer at Coastal Medical. Al Charbonneau, executive director of the Rhode Island Business Group on Health, the “voice” of Rhode Island business on health care, was also in attendance, sitting next to Kurose.

For the uninitiated, the Care Transformation Collaborative, née the R.I. Chronic Care Sustainability Initiative, has grown from an initial pilot begun in 2008 with five sites under the auspices of the R.I. Office of the Health Insurance Commissioner to now encompass 43 primary care practices with 73 total practice sites, delivering primary care to more than 320,000 adult Rhode Islanders through its team-based, patient-centered medical home model, or PCMH.

The expansion of the Collaborative has been funded in large part through the OHIC Affordability Standards, with an increased flow of money spent on medical costs by commercial insurers being directed toward primary care – now capped at about 10 percent of the total medical spend.

Future expansion
The goal is to expand the number of Rhode Islanders accessing care through the PCMH model to 500,000 – half of the state’s population.

The all-payer Collaborative, which includes Medicare, Medicaid and the four commercial insurers operating in Rhode Island – Blue Cross & Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island, UnitedHealthcare of New England, and Tufts Health Plan – will soon launch PCMH-Kids in January, targeting a small number pediatric practices.

In the broader context, the $20 million State Innovation Model plan focused on the transformation of the Rhode Island’s health services delivery system has made the PCMH model a lynchpin of its plans to better align and coordinate health care around primary care – and with it, to achieve a harmonization of metrics around quality of care and cost control.

To further its coordination of care, the Collaborative received a $600,000 grant on Dec. 1 from The Rhode Island Foundation to launch an integrated behavioral health program, with plans to add a behavioral health clinician to the primary care practice teams.

In addition, a pilot program will soon be launched to install a new case-management dashboard developed by the Rhode Island Quality Institute at up to 30 PCMH practices, targeting high-risk patients by sharing information regarding hospital use. The implementation of the dashboard is being funded in part through a $500,000 award from the Rhode Island Foundation.

Concerns around costs
The future navigational goals for the collaborative have been chosen and mapped: commercial health insurers are required to have 80 percent of their contracted primary care practices operating in a patient-center medical home by 2019, according to the standards set by the R.I. Office of the Health Insurance Commissioner.

At the same time, the Collaborative expects to move toward the goal of promoting payments for value over volume, aligning with the push away from fee for service and toward a continuum of accountable care.

Yet, despite the clarity in goals and the paths chosen to achieve them, there have been some nagging concerns raised about cost-containment and sustainability. [See link to ConvergenceRI story below.]

Dr. Kathleen Hittner, the R.I. Health Insurance Commissioner, and Dr. Gus Manocchia, the senior vice president and chief medical officer at Blue Cross & Shield of Rhode Island, both raised the question of cost containment at the Nov. 12 Care Transformation Collaborative “Learning Collaborative.”

“We haven’t demonstrated cost savings yet,” Hittner said.

“The great work that has been done so far has to go faster. Reducing costs has to go faster,” Manocchia said.

The burden of change
Much of the work – and the risk – to transform the practice of primary care have been placed on the providers themselves, a concern addressed head on by Dr. Pano Yeracaris, co-project director of the Care Transformation, at the beginning of the Dec. 11 session.

“Working hard is not the issue,” said Yeracaris. “It’s how we can make it easier,” he continued, bringing the joy of the work back into primary care.

Yeracaris pointed to a graph that he said Donald Berwick often used, charting effort over time, showing a bulge in the middle before a declining slope, saying: “[Electronic health records] haven’t made many lives easier.” Still, he continued with optimism about the potential of leveraging technology, “We are at the cusp of really big changes.”

Further, Yeracaris acknowledged that there was much more work to be done in changing the culture of primary care practice and focusing more on patient and family engagement.

Andrea Galgay, the director of ACO development at the R.I. Primary Care Physicians Corp., followed Yeracaris to the podium. Galgay, a member of OHIC’s Health Insurance Advisory Council, led the attendees in a quick response poll, using kahoot.it software.

She then discussed how new OHIC accountability standards and cost containment strategies that will be applied to the PCMH model practices. These include: developing and managing a high-risk patient registry; delivery of case management services to high-risk patients; and referral of patients to specialists who provide value-based care.

What the patient says
Then Dr. John Wasson, developer of the “HowsYourHealth” patient assessment tool, stepped to the podium an hour into the gathering and began his 17-slide presentation, talking about the importance of measuring a patient’s confidence in managing his or her health as the key benchmark in primary care.

Wasson, an emeritus professor of Community and Family Medicine at Dartmouth Medical School, began practicing medicine in 1971, with a focus on geriatrics.

Wasson said his interest in promoting HowsYourHealth was altruistic; he receives no money from the use of the software.

But money – and how it was spent – was a big selling point for HowsYourHealth, according to Wasson. He contrasted the costs the HowsYourHealth tool with PCMH requirements, which he dubbed: “WheresYourMoney.”

To initiate the HowsYourHealth software, there is no charge for an individual practice or a minimal charge for a statewide organization, compared to an estimated $50,000 per MD cost to meet PCMH requirements, according to Wasson. Similarly, the cost to maintain HowsYourHealth software is negligible, compared to the estimated cost of $100,000 per MD cost to meet PCMH requirements.

Beyond promoting HowsYourHealth as a very low-cost, patient- and practice-serving alternative, Wasson also challenged the audience to do more than serve as a voice at the table, removed from decision-making. Instead, Wasson urged the primary care providers to function more like a research & development team, posing questions and testing the value proposition.

“You should be asking the questions, and not just be the voice at the table,” Wasson urged. He likened the current situation of primary care to manufacturing an automobile designed to meet the needs of the corporation – but one that doesn’t work for the drivers.

When an audience member asked if HowsYourHealth was interoperable with Epic software, Wasson responded: “That’s a great R&D question,” urging the questioner to ask how to make that happen.

Wasson cited the findings from the 2015 MayoClinic proceedings, which found there were a 60 percent rate for burnout and 40 percent rate of satisfaction with work/life balance, indicators that there was a perception of need for different results with the PCMH and the path for change.

Wasson also challenged the current thinking around cost-containment strategies now being deployed in Rhode Island to target the high-risk users of health care, saying that there was no real evidence to support the success of such models through randomized control trials.

Wasson challenged the validity of the statistical analysis of high-risk administrative data, compared to what he saw as the distinct advantages of calculating risk based on patient reports in his software.

“It’s called regression to the mean,” Wasson explained, explaining what he saw as the problem of using administrative data to create a registry of high-risk patients. “If you target the outliers, a large number of them will then move closer to the average.”

Peer-to-peer
In a brief interview with ConvergenceRI after his presentation, Wasson explained that he doesn’t often make presentations to groups. “The bottom line is always about relationships and communication. I don’t have any ongoing relationship with this group,” he said. “Because we all know that these types of talks don’t accomplish much. But, what works better is when someone in the back of the room says: ‘I’m doing this, and it’s simple to do, and then it’s peer-to-peer.”

Indeed, that’s exactly what happened when a primary care physician stood up, saying she used HowsYourHealth, and found that its key advantage was that she now walked into the appointment with the patient knowing in advance the patient’s concern and condition, rather than only figuring that out at the end of the session.

When asked how he would suggest redesigning the current initiatives around targeting high-risk patients in Rhode Island, Wasson explained: “It’s pretty straightforward, in one sense. The biggest problem is with analyzing the data, when people talk about return-on-investment. They’re kidding themselves. Because they need to have the treatment control group, if there’s something else going on, as comparison.”

“Here is, off the top of my head, what I would suggest doing,” Wasson elaborated. “Starting in January, say you have x number of practices that signed up to be mental health ‘enlightened.’

For the sake of argument, he continued, “Let’s say there are 20 of these ‘enlightened’ practices. I would say: Let’s start with 10 practices, and leave the other 10 to do another thing.”

With the 10 practices where implementation of this care management [strategy] was delayed, Wasson suggested that these practices would use the HowsYourHealth tool and “leverage the heck out of it.”

Then, results from the patients would be evaluated, six months to a year later, comparing the cost effectiveness of the two approaches over time, in a randomized comparison.

“Is it perfect? No,” he said. “It would certainly move you ahead, because you have a cross comparison, and you’re building the clinicians’ awareness of patient confidence as a key measure [of health] – plus whatever else you feel like are minimal major outcome measures.”

In response to a question that asked about the trend of consolidation of health care and the restructuring of primary care from a corporate perspective, with retail clinics, urgent care and freestanding emergency facilities capturing a greater share of what once considered primary care, Wasson replied: “The fundamental question you’ve asked is, what is disrupting the whole medical model. Technology is part of it, and that’s what we’re talking about here.”

The modern generation, he continued, “doesn’t value continuity as much – particularly for the stuff that CVS Health and what those emergency departments are going to [treat].

Indeed, Walmart and CVS and everyone else are going to become more and more an intermediary for primary care – or supplant it for those who are healthy enough to do it.

And, Wasson continued, “They probably should. Most of the stuff that comes through the door shouldn’t have come through the door, anyhow.”

“If you go back 50 years, most people didn’t visit doctors for sore throats,” he said, saying that in this country, cases of rheumatic fever were rare occurrences.

“The bottom line is that primary care is becoming more and more chronic care management,” Wasson said. “And, that’s what we’re talking about here.”