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At World Health Care Congress, Examining How Innovative Care Delivery Models are Disrupting Primary Care

April 13, 2016
by Rajiv Leventhal
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During the April 12 closing keynote at World Health Care Congress 2016, healthcare executives discussed the impact that new care delivery models will have on patient outcomes and the industry. 
The panel discussion at the Marriott Wardman Park Hotel in Washington, D.C., included: Rushika Fernandopulle, M.D., CEO of Iora Health, a healthcare services firm based in Cambridge, Mass.; Martin G. Kirstin, M.D., professor of medicine, division of gastroenterology and hepatology, University of New Mexico (Kistin is also currently a part of the replication team at the Extension for Community Healthcare Outcomes, ECHO, Institute at the University of New Mexico); and Ellen-Marie Whelan, Ph.D., chief population health officer, Center for Medicaid and CHIP Services (CMCS), and senior advisor, Center for Medicare and Medicaid Innovation (CMMI), Centers for Medicare & Medicaid Services (CMS), all gave different perspectives on how these innovative models are gaining scale nationally and globally. Below are excerpts of their panel discussion:           
Fernandopulle: We have been trying to build a fundamentally new model of primary care. The job that I think everyone wants us to do is improve people's health and keep them out of trouble. You have to build from the ground up, and we are focused on changing four things in general: you have to change the payment model; we won't make the difference if we don't. Then we have to change the care delivery model. Third, we need [to see] a difference in technology platforms, we need technology that is relational, and can manage populations, beyond the documental tasks that EMRs do currently. Culture change is the last thing, as you can be a good Level 3 patient-centered medical home and have a crappy culture. At Iora Health, our approach [has led to] a 40 percent drop in hospitalizations and a, 50 percent drop in ER visits. 
Whelan: When we transform the payer mix, we are hoping that changing payment does change care delivery. And we have to make sure that we have a workforce that could make that happen. We worked with folks to look at the role of the RN in primary care. What role might the RN have in a primary care delivery system? The baseline role of nurses, when we started, was that they provided a basic level of care, oftentimes in the home. So we were wondering what this looked like in a new care delivery model. With a bigger role of the RN, providers themselves felt happier [as studied by the American Board of Internal Medicine]. Nurses were helping in coaching and wellness training, and HEDIS [Healthcare Effectiveness Data and Information Set] measures were improved as result. Practices by and large were much happier. 
Kistin: ECHO was conceived and developed in New Mexico back in 2004, and it was designed to take care of one single problem, chronic hepatitis C. In those days, the treatment for hepatitis C was very toxic with severe side effects, and providers in New Mexico were not willing to treat patients for this condition. We had a specialty clinic, but the wait time was 10 months; if you were to get return visit, the wait was 18 months. Some patients drove 250 miles to get there as well. So our model uses video conferencing technology to train providers in underserving areas, and we set up virtual clinics in this initial model where providers would login to this clinic once a week for two hours. Providers and specialists would [confer] and then manage the case of the patient. Using this model, we have demonstrated that you can provide care as safe and effective as if they had access to this specialty clinic. And the providers loved it, they had a mentoring relationship with specialists, and relationships with other providers. It's important to recognize that this is a little different then telemedicine, as we don't treat patients directly, but give them support and tools. This model has been used around the world for 50 different chronic complex conditions. Our goal is to touch the lives of 1 billion people by 2025, and I think we can do it. 
Question [from moderator]: How are primary care physician shortages playing a role? 
Fernandopulle: I think we have a primary care shortage only if you think that  primary care doctors will do exactly what they're doing now. Part of the job is seeing people and making diagnoses and prescribing treatments. We have a physician who will have a whole team with him including a nurse and health coaches—each doctor has three health coaches, and when people fail protocol they go to the primary care practitioner. You give him or her downstream and upstream support to manage his or her population. The doctor can manage more people with a lot more help, and that's the idea behind [our model].
Whelan: As a clinician at CMS, we change payment to change the care delivery system. The payment change should allow for the improved care delivery model to be enhanced. Now you have an entire team as we are moving from fee-for-service [FFS] models towards focusing on the community members, care to be delivered in the home, and telehealth.  
Kistin: What we have discovered is that it's important to look at who is delivering care at every level and how those patients are being treated. We have had medically underserved areas traditionally, and there is little in the way of education, so we need to provide them with a better work/education balance by giving them mentors, people they could relate to. We believe strongly in having everyone working at the top of their licenses. We have a big training program for community health programs, as we think this is the key for managing chronic conditions.