Delivery of Care

On the front lines with primary care

Asking questions about how the COVID-19 pandemic will challenge the reconstruction of the primary care infrastructure in Rhode Island

Image courtesy of the CTC 2019 Annual Report

Barrington Pediatric Associates, with eight physicians and one nurse practitioner supported by a strong team of nurses, medical assistants, practice manager and a newly-added licensed mental health clinician. The practice joined PCMH Kids in 2017.

By Richard Asinof
Posted 6/1/20
An interview with Debra Hurwitz, the executive director of the Care Transformation Collaborative, an innovative, all-payer initiative that has created a unified program of primary health care in Rhode Island. She talks about how primary care practices are responding to the disruptions caused by the coronavirus pandemic.
Will R.I. Attorney General Peter Neronha investigate the reasons behind the low Medicaid reimbursements for pediatrics and primary care, which are see as a major contributing factor in health inequities in Rhode Island? Who will be responsible for developing protocols around interoperability of numerous competing telehealth texting platforms? What prompted what appeared to be a coordinated surge in unsolicited phone calls from physicians to check in on patients, and did they receive insurance reimbursements for those calls? Are primary care practices tracking the data related co-morbidities from patients who have survived COVID-19 but find themselves afflicted with kidney, heart problems and other conditions?
“The promise and peril of antibody testing for COVID-19,” written by Jennifer Abbasi published on May 19 in the Journal of the American Medical Association, offers a detailed look into the problems an misuse of antibody testing as a diagnostic tool. The problem, as identified by Elitza Theel, the director of the Mayo Clinic Infectious Disease Seriology Laboratory, is that people who have been infected with the virus don’t start producing antibodies – technically referred to as seroconvert – until 11 to 12 days after the onset of symptoms.
The problem, as one physician pointed out to ConvergenceRI, was this: If the immune system doesn’t make antibodies until after Day 10 of the infection, how can a test that relies on antibodies detect an infection during the first nine days while it is spreading?
Those apparent “deficiencies” have not prevented the Rhode Island Business Group on Health from sponsoring a COVID-19 webinar on Tuesday, June 2, which will include a discussion of COVID-19 testing and antibody testing and how they might be deployed in return-to-work strategies. Will the article published in JAMA be required reading for the participants? Good question.

PROVIDENCE – Most everything assumed to be “true” about the market-driven delivery of health care in the U.S., it seems, has been disrupted by the coronavirus pandemic. The Band-Aid has been ripped off and what is now visible for all to see is a festering wound. The rapid spread of the novel lethal virus has accelerated the decline of the advertised myth of health care as a sustainable business model, exposing huge gaps in the continuum of care.

Hospitals in Rhode Island are hemorrhaging millions of dollars each month. Last week, Lifespan, the state’s largest hospital system and largest private employer, reported it had lost $43.1 million in operating costs in the month of April alone. [Lifespan said it had received $36.6 million from the federal CARES Act to help offset those loses, and it had achieved a net income of $4.8 million in April, largely because of “improvements” in its investments in markets, despite the operational losses.] But the long-term prognosis, as a doctor might tell a patient, is grim.

Nursing homes in Rhode Island continue to be the place where a majority of fatalities from the coronavirus – as of May 30, more than 700 deaths and counting in the state – have been linked. Assumptions about providing a continuum of care for many of Rhode Island’s older, most vulnerable residents have been disrupted. With visitation now prohibited, residents of nursing homes find themselves living in isolation, still at great risk of falling victim to coronavirus.

The burdens of the coronavirus pandemic have fallen most heavily on the state’s residents of color, which should surprise no one. [See link below to ConvergenceRI story, “Connecting primary care to emergency care in a pandemic.”] Access to testing in communities such as Central Falls, where a high percentage of those who have been tested were positive, far higher than the state’s testing average, has remained problematic. Dr. Michael Fine, formerly of Blackstone Valley Community Health Care, was appointed last week to be the new “czar” of coronavirus health management in Pawtucket and Central Falls. But so much of what happens in Central Falls occurs off the radar screen of the media’s limited attention span. “In Central Falls, we have people dying in their homes,” Jonathan Acosta recently told podcaster Bill Bartholomew.

On the front lines with primary care providers

Primary care providers in Rhode Island have found themselves on the front lines of the coronavirus whirlwind, attempting to provide access to care, coordinate the scheduling of testing for the virus, adapt to a new telehealth modality when it comes to checking in with patients, and managing all the non-critical care that is a normal part of everyday life.

ConvergenceRI reached out to Debra Hurwitz, the executive director of the Care Transformation Collaborative, the all-payer organization that began as an innovative experiment under the direction of the R.I. Office of the Health Insurance Commissioner in 2008 and has grown to become the dominant force in primary care in Rhode Island, to capture her view of the future of primary care delivery in a world disrupted by the coronavirus pandemic.

“Rhode Island has assigned a central role to primary care within the state’s strategy to improve population health and health equity, improve health care quality, and reduce costs,” Hurwitz said.

She continued: “Collaboration between primary care providers, payers, and the state is the hallmark of Rhode Island’s approach to construct a strong system of primary care that is capable of influencing these outcomes.”

According to Hurwitz, the novel coronavirus pandemic has exposed weaknesses in the primary care system and threatens to exacerbate longstanding pressures that could adversely impact Rhode Islanders’ health and well‐being.

The current crisis, Hurwitz said, “requires not only a reorientation of the health care system to further strengthen primary care, but also provides an opportunity to accelerate transformation efforts by increasing system resiliency to improve population health through the challenges ahead.”

Hurwitz offered a cautionary note about the challenge of reconstructing primary care in the aftermath of the pandemic. “Depending on the depth of the economic dislocation wrought by the pandemic and the speed with which primary care practices can adapt to the ‘new normal,’ the state may face the challenge of reconstructing primary care, with significant economic and health consequences.”

Here is the ConvergenceRI interview with Debra Hurwitz, the executive director of the Care Transformation Collaborative, which includes 128 primary care practices and 800 providers across adult and pediatric practices, two-thirds of the state’s primary care providers, serving approximately 695,000 Rhode Islanders who receive care through its patient-centered medical home model.

ConvergenceRI: How will telehealth change the way that patients interact with providers in a primary care practice? What other kinds of remote, mobile technology, such as texting and recording of blood pressure, will emerge as dominant practices?
HURWITZ:
Well there’s no question that COVID-19 forced the rapid implementation of telehealth as a mode of care delivery for primary care providers.

When the national state of emergency was declared, the R.I Office of the Health Insurance Commissioner quickly responded by mandating payment parity between face-to-face and telephonic visits.

To date, telehealth had not been widely utilized in Rhode Island. Telehealth can be an effective mode of care delivery for the right situations. COVID -19 forced primary care practices to immediately implement tools for telehealth so they could continue to care for their patients.

Traditional telemedicine visits include video capability, which allows the patient and primary care provider to see each other, which is important. However, during this COVID-19 crisis, providers found that they had to implement systems to support telemedicine.

What primary care doctors found is that many patients do not have access to Internet, smart phones and technology necessary for telemedicine visits. But, the vast majority of patients do have a telephone and can receive a call from their doctor.

A recent survey tells us that primary care providers have shifted their visits to 70 percent telehealth visits. We expect this to swing back some, because for many patients, a physical examination is required.

As we emerge from this crisis, we think that telemedicine and remote home monitoring will be a more frequent way that care is delivered. Of course, not all primary care visits can be done remotely; some physical assessments and treatments must be conducted in-person. Increasing use of home monitoring for things such as: weight, blood pressure, blood sugar, blood oxygen levels will become more common and make it easier for providers to monitor their patients key vital signs remotely. We are likely to see much more of this type of remote monitoring post COVID-19.

ConvergenceRI: In measuring population health outcomes, will empathy become an important metric as a way of predicting a higher range of engagement?
HURWITZ
: That is a good question. Increasing patient engagement is important and an area we need to continue to work on.

To date, we do an annual customer experience survey and several questions get at this issue – provider communication and office staff responsiveness. Rhode Island primary care providers score high on these measures, particularly our pediatric practices.

CTC practices have incentives in their contracts linked to how well they perform on these measures. But, with that said, we can do more.

Some practices have established patient advisory groups to help the practice increase patient satisfaction and experience of care. Some are implementing tools like Choosing Wisely, which encourages patients to discuss options with their doctor.

CTC and the R.I. Department of Health are working on a pilot with two teams that are participating in a Rhode Island Health Equity Challenge, looking at patients with diabetes in the context of COVID-19.

One of the first things teams were asked to do was identify a person with lived experience that could be part of the team. The second thing was to interview people with diabetes and understand from their perspectives what are their challenges and successes. This approach will help us understand what matters most as we seek to improve health outcomes and build community solutions.

ConvergenceRI: What are the opportunities for solo practitioners to set up shop, such as pediatricians, in under-served neighborhoods and communities?
HURWITZ:
Rhode Island needs to maintain and grow its primary care work force. Lower Medicaid payment rates are an equity issue in Rhode Island.

As an example, community pediatricians take care of children, 50 percent of whom are on Medicaid insurance. We are surrounded by states such as Massachusetts, Connecticut and New York that pay much higher Medicaid payment rates.

These factors make it difficult to attract and retain primary care providers. We need to look at how we can better support solo providers and other providers by looking at paying for care differently.

Many solo providers demonstrate high customer experience and high clinical quality performance rates and yet are challenged with being able to stay in business. Particularly in pediatrics, it is getting more and more difficult to survive as a solo provider because of Medicaid payment rates. Solo practitioners are decreasing in numbers as doctors align with larger systems of care, which can provide infrastructure support.

ConvergenceRI: The conditions attached to being able to be tested for the coronavirus – authorization from a primary care provider, have exposed what seems to be a problematic situation regarding the assumptions around access to primary care.
Having health insurance, per se, does not translate into actually having a primary care provider, and further, access to seeing a primary care provider can be very difficult – it can takes months to schedule an appointment to be seen. How is CTC planning to address these apparent deficiencies?
HURWITZ:
All Rhode Island counties have a higher primary care physician rate than the nation, indicating a greater number of providers per person and potential for greater access to care.

While Rhode Island scores high nationally on people having a usual site of primary care, we know that there is still work to do. We believe that public education is needed about the value of having a primary care provider who knows you.

And post COVID-19, there is an opportunity to encourage individuals to identify a primary care provider.

Access is an issue with many practices having wait times for new patient appointments.

We have already mentioned the need to grow our primary care workforce; this would help with access.

We believe that implementing team based telehealth visits may also improve access to some extent. During COVID-19 many of the primary care providers accepted and treated patients who did not have a previous relationship with them.

ConvergenceRI: How is CTC planning to address the continuing problems with pre-authorization demands by health insurers?
HURWITZ:
CTC is initiating a special project requested by R. Health Insurance Commissioner Marie Ganim around prior authorization. We will be working with the health plans and the Rhode Island Medical Society to identify ways to define key principles of prior authorization, align across health plans what things should require prior authorization, and ways to improve and streamline processes to reduce administrative burden and barriers to care.

This project was stalled by COVID-19 but we anticipate re-starting that effort soon.

ConvergenceRI: How are CTC practices collaborating with peer recovery efforts around substance use disorder treatments?
HURWITZ:
Many of the federally qualified health centers have peer recovery specialists as a part of their care teams. The CTC Community Health Teams also have peer recovery specialists on the team. Peer recovery specialists are community health workers with a lived experience and are trained to assist others in their recovery journey. They have been a great addition to the Community Health Teams. CTC recently produced a video to showcase the impact between a peer specialist and a client.

[Editor’s Note: There is some discrepancy around the definition of what it means to be a peer recovery specialist. A “community health worker” is a Rhode Island certification and a “peer recovery specialist” is a Rhode Island/International certification. Currently, there are only seven people in Rhode Island who are dually certified, according to Ian Knowles, program director at RICARES. There is a distinct difference in the roles, according to Knowles. Community health workers are not “peers”; there are more certified community health workers than certified peer recovery specialists. The community health workers have a major role on the community health teams, while peer recovery specialists appear to be a subset. “Peer recovery specialists are utilized in behavioral health programs, but we’re not aware of a significant number utilized in primary care practices,” Knowles said.]

ConvergenceRI: Does the initial framework developed by the Rhode Island Foundation to serve as the basis for a long-term, statewide health plan need to be rewritten to deal with the realities of a post-pandemic world?
HURWITZ:
Good question. One thing we have learned from COVID-19 is that high rates of COVID-19 coincide almost exactly to poverty and areas of the state where health equity is a problem.

The Rhode Island Foundation vision for health very strongly promotes health equity. CTC is also piloting a Health Equity Challenge in Pawtucket and East Bay.

This project applies the “Pathway to Population Health Model” to these two communities and brings together community health teams, Health Equity Zones, Primary Care and a person with lived experience [in this case, diabetes].

We are working with Dr. Soma Shaha, president of WE in the World, a national expert in population health. We believe that this model with help us link clinical care to community resources and assist in identifying and addressing systemic community-based drivers of inequity and barriers to health.

ConvergenceRI: Is there an opportunity for CTC to play a leading role in developing a “housing prescription” program in Rhode Island, similar to what is being done in Massachusetts by the Boston Medical Center?
HURWITZ:
Our Community Health Teams work with some of the most vulnerable patients and housing is the number-one issue they deal with.

Finding affordable safe housing is a challenge because there is not enough of it. However, our Community Health Team evaluation has shown that of the patients that identify housing as an issue at intake, 56 percent were able to get this issue resolved at follow up [an average of 5 months later].

Some of our health plans are experimenting with housing solutions as a way to help patients and reduce unnecessary hospital utilization, e.g., emergency department use.

UnitedHealthcare recently presented to our board of directors an excellent model they are testing in other states. We hope to bring this model to Rhode Island. We believe there are multiple ways that CTC can promote housing security for vulnerable populations through our pilots.

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