1/ COVID19 has put primary care in jeopardy

Working under fear of getting sick and bringing it home to families, docs and nurses are getting burned out

Visit volumes are down and staff are being laid off

I want to share some GOOD news today that offers hope..from a health plan

2/ Let's start with this fundamental truth

Fee-for-service is a terrible way to pay for primary care

What should be longitudinal, patient-based, relationship-oriented becomes transactional

"Productivity"=shorter and shorter visits

Profit=feeding procedures & local monopolies

3/ For decades, primary care docs have put their head down and somehow made it work

As @JMichaelMcW points out poignantly, professionalism is a powerful force

But we create moral injury if our duty to patients and the duty to our organization/employer are at odds every day

4/ Independent practice owners could set their own culture and didn't have to "feed the machine"

But FFS rewards market power in plan negotiations. Independent practices "fee schedule" fell father and farther behind larger systems which then gobbled up more independent practices

5/ Well-intentioned payment reforms like "pay for performance" that gave small "tips" on top of FFS, added a whole lot of paperwork and fed a "check the box" mentality without fundamentally changing practice economics

Medicare's "MIPS" program MAXIMUM bonus was 1.68%

How-to:

6/ COVID19 crashed into this jury-rigged payment and delivery system, and busted it wide open

Primary care practices told patients to stay safe @ home and-paid only for patient visits-saw revenue fall by 20-40%.

$100Bs of bailouts went mostly to... yep, large health systems

7/ But here's where some rays of hope begin to poke out.

Some payers have been moving ahead with a different model of compensating primary care, but in 2019 @BlueCrossNC decided to make a true commitment to get to 100% value-based primary care

They didn't have to

8/ There was no "burning platform" forcing change.

They were a well-functioning, well-respected tax-paying non-profit that has a strong market position.

They chose to be proactive about value-based care & addressing consolidation from a position of strength.

Take pain now

9/ In 2019 @BlueCrossNC chose @AledadeACO as their partner to help independent practices move to value across all product lines

They offered the practices a good contract, we worked together to identify the first set of target practices- within 6 weeks 80% of them signed up!

10/ The health plan gave us full claims data, but they did not have to pay for any of the work we did with the practices over the next year- practice coaches, data feeds from hospitals and practice EHRs, our tech platform

We go at risk-we get paid if our docs earn shared savings

11/ We are able to have such confidence because physician-led accountable care works.

It's works in Medicare. Physician-led, not hospital ACOs account for nearly all the Billion + in savings recorded for the Medicare Shared Savings Program

and it works with commercial patients

12/ In our first year, these practices reduced costs by 5% for commercial patients and 6% for MA

So while COVID is decimating FFS revenues, these 47 independent primary care practices earned a payout of more than $10,000,000- for keeping patients healthy and out of the hospital

13/ “Finally we are getting the credit we deserve"

That was the reaction from Vivian Leftwich, practice manager in the office of Dr. Challie Minton, a family physician and U.S. military veteran who has been serving the rural county of Surry, NC since 2009
https://www.aledade.com/north-carolina-practices-are-getting-credit-they-deserve

14/ Read this whole blog piece by @AnnetteDuBard about how the practices, Aledade, and the Blue worked together https://www.aledade.com/north-carolina-practices-are-getting-credit-they-deserve

Dr John Scheitler summed it up perfectly: “This is the first time in all my years of practice that I have ever thought of a payer as a partner”

15/ During COVID, @BlueCrossNC continued to show that the existence of independent practices matter to them

Alone among all health plans AFAIK, they committed to making practices whole to what they paid them in 2019
No reporting requirements, no clawbacks https://www.aledade.com/accelerate-value-bold-smart-and-it-should-inspire-other-payers

16/ They are not a bunch of soft-headed idealists. (well, certainly not soft-headed)

As @azaleakim @RahulRajkumar11 @scottheiser + coauthors detail, health plans that care about cost, quality, access should focus on independent PCPs

why don't they??

https://www.healthaffairs.org/do/10.1377/hblog20200721.6981/full/

17/ We are expanding the partnership in North Carolina as more practices sign up every day.

This map is already woefully out of date

We can't wait to add Medicaid lives in value contracts as soon as we can (and hope @SecMandyCohen is successful at Medicaid expansion )

18/ If you're with a health plan- why not run the @BlueCrossNC playbook?
*keep independent primary care practices from going out of business (or bought out)
*Simplify and deepen how you engage w practices
*Move away from FFS to shared risk
*Only pay when quality cost