Care Redesign

Transforming Specialty Practice in Pursuit of Value-Based Care: Results from an Integrated Cardiology Practice

Article · March 21, 2019

Despite the rapid growth of vertical integration of both primary care and specialty care practices with health care delivery systems over the past decade, physicians and executives alike are recognizing the limitations of such models.1 Increasingly we are discovering that the infrastructure of brick-and-mortar hospitals, employed physicians, and electronic health record (EHR) systems alone do not guarantee success.2 Without a robust effort to address care fragmentation, the quality, cost, and patient experience of care may be suboptimal.3,4 Organizational strategy, culture, and processes need to be aligned to ensure the functionality of system-based practice where primary care and specialists work together within the context of vertical integration.

Within primary care, the patient-centered medical home (PCMH) has risen as a blueprint to guide team-based, whole-person-oriented care. However, implementation of a PCMH without symmetric work on specialty practices cannot fully meet patient needs across the continuum of care. Initial analyses of PCMH initiatives have shown mixed results, without consistent improvement in utilization, cost, and quality.5,6 The ability to safely and efficiently comanage shared populations in patient-centered medical neighborhoods is increasingly necessary for both primary care and specialty groups.7

The standards and incentives for specialty practice reform are in place. In March 2013, the National Committee for Quality Assurance (NCQA) defined the patient-centered specialty practice (PCSP), expanding upon the PCMH model for primary care.8 Updated in 2016, the patient-centered specialty practice includes six standards and 26 elements (Table 1). These standards serve as a blueprint for all specialty clinics to reinforce care coordination, improve access to specialty care, reduce use of unnecessary and duplicative tests, and enhance communication, while also helping to measure and improve performance. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule indicates that “participants in certified patient-centered medical homes, comparable specialty practices, or an alternative payment model designated as a Medical Home Model” will automatically earn full credit for the improvement activity domain of the Merit-Based Incentive Payment System (MIPS).9

Providence Heart Clinic Operational Interventions and Timeline for Patient-Centered Specialty Practice PCSP

Table 1. Click To Enlarge.

In 2014, Providence Heart Clinic (PHC) East became one of the first cardiology clinics in the United States to be patient-centered specialty practice recognized. In 2017, all 15 eligible PHC sites received NCQA recognition. Here we describe our PCSP-guided practice improvement project for a multisite cardiology practice in a large, integrated delivery system and report the impact on access, care coordination, patient experience, growth, and operational efficiency.

Methods

PHC is a multisite integrated medical group that provides cardiovascular care within Oregon and southwest Washington. It currently employs 61 cardiovascular specialty physicians, including general cardiologists, interventional cardiologists, heart failure cardiologists, electrophysiologists, cardiovascular and vascular surgeons, as well as 32 advanced practice providers (APPs). Providers deliver cardiovascular care at eight acute care hospitals in Oregon and 21 outpatient clinic sites. There are an estimated 64,000 total outpatient visits annually, with $50 million in outpatient clinic variable and staffing cost.

In 2013, PHC became one of 64 early adopters for the NCQA patient-centered specialty practice pilot.10 The PCSP project team consisted of the Providence Heart Institute executive sponsor and clinical and operational dyads who led the project team and oversaw the operational improvement, workflow implementation, impact assessment, and data analysis. Workflow design and optimization were led by clinical and operational leaders in each department at each PHC site. Part-time project manager and administrative duties were shared with existing PHC staff at each site for project rollout. Over the project years, 24 clinic support staff full-time equivalent (FTE) were added to achieve implementation at all 15 clinics. We collaborated with and learned from other specialty practices, Providence Medical Group primary care, and external primary care colleagues in the community during this project. The impact evaluation, data collection, and analyses were performed by a biostatistician and a research scientist, with academic input.

In 2013, the patient-centered specialty practice was implemented at four PHC practice sites covering the east side of the greater Portland area (PHC East). PHC East is served by 10 general cardiologists, four interventional cardiologists, one heart failure cardiologist, two electrophysiologists, seven APPs, and approximately 58 staff FTE. In 2014 and 2015, the process was refined and improved, with a gradual rollout to all PHC clinics in 2015 and 2016. These clinics included 11 Oregon and southwest Washington practice sites served by 16 general cardiologists, eight interventional cardiologists, three heart failure cardiologists, five electrophysiologists, six cardiovascular surgeons, three vascular surgeons, 23 APPs, and approximately 102 staff FTE. Six PHC sites were not included in the PCSP process nor in this study, five of which were critical access facilities or qualified rural health clinics, and one was a contracted site with a private facility, of which direct oversight was outside our purview.

Key Interventions

The patient-centered specialty practice project focused on three key areas of work directly related to the PCSP-defined standards: access, care coordination, and patient satisfaction. Details of the operational interventions and time line are provided in Table 1.

Provide better patient access and team-based care.

At baseline, there was no standard reporting or distinction of scheduling blocks for routine and urgent appointments. During project rollout, PHC adjusted the provider scheduling template according to referral needs with new and same-day patient blocks, extended office hours, and standardized scheduled time for each patient visit. Electronic non-visit consultations (e-consult) and a nursing advice triage line were implemented. Together, these operational changes improved patient access. Furthermore, PHC East formed care teams typically made up of two to three cardiologists, one to two APPs, a nurse, a scheduler, and other clinic support staff to share a panel of patients. Stable and routine follow-up patients were shifted to APPs, allowing physicians to see new and urgent referrals as well as complex or unstable patients. Team members had defined roles and responsibilities and communicated in the form of a daily or weekly huddle.

2. Improve referral tracking, communication, and care coordination with primary care and other referring clinicians.

Prior to the patient-centered specialty practice, providers had individualized note formats for consultation, follow-up, and test results. Incorporating feedback from primary care and other referring clinicians, providers from PHC practice sites established and adopted a standard format and elements for encounter and procedure notes. For referral tracking and care coordination, PHC East refined and standardized the existing workflow around referral receipt, patient contact, appointment scheduling, consultation, and closing of the referral loop by implementing a standard process and time line to complete and send consultation notes back to the referring provider. A step-by-step result reporting workflow was established to follow up test results with patients and referring providers.

Using PCSP standards as the blueprint for optimal operational processes, the project team worked with leaders from each department and clinic site to brainstorm and redesign clinic workflow as necessary. If PHC clinics were performing to NCQA standards, existing workflow was kept in place. In preparation for the NCQA survey, more than 60 workflow process documents were prepared. These were then implemented by each affected department, such as scheduling, medical records, phone nurses, device clinic, etc. The workflow documents were kept in binders and electronically on the clinics’ intranet and were used to train and on-board new employees. With each new workflow, documents were updated and a go-live date was set. Clinical leaders and site managers ensured the implementation of each iteration of a new standard workflow. Face-to-face or online group meetings were used to share best practices and new workflows across different clinic sites.

3. Improve measurement and performance for patient access and patient satisfaction.

At baseline, PHC did not intentionally measure patient access. Providers were scheduled in outpatient clinic after all inpatient and call schedules were filled. By creating a monthly “supply/demand” report to assess new patient referral needs and scheduling blocks available for new patients, we were able to adjust physician scheduling templates according to patient access needs. At baseline, patient satisfaction surveys had been conducted, but the data were not analyzed and workflow had not been tailored according to patient feedback. During the PCSP transformation project, PHC held training sessions for staff around patient greeting, interaction, telephone etiquette, etc. Standard workflows were implemented for patient check-in, rooming, medication reconciliation, patient education, and review of the written after-visit summary.

Patient satisfaction was measured using the Press Ganey Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey.11 Real-time assessment and incorporation of patient feedback was achieved through suggestion boxes available to patients and families at each of the practice sites. Survey results and feedback were shared with staff, and process improvement was implemented.

Data Collection and Analysis

To examine the impact of the patient-centered specialty practice on clinical, operational, and quality end points, three types of data were gathered: clinic operational and financial reports, chart review, and patient satisfaction survey data. Data were collected retrospectively from 2013 as baseline and prospectively from 2014, 2015, and 2016 for comparison; each year was defined as January 1 through December 31.

Clinic accessibility was measured as the number of new and follow-up patients seen, normalized by physician-available clinic hours. To evaluate the impact of the patient-centered specialty practice on this annual metric, we performed simple linear regression analysis with year as a factor and 2013 as the referencing category.

To measure the impact of the patient-centered specialty practice on care coordination, we used PCSP Standard metrics and performed chart review to capture the time interval between the scheduled consultation appointment and when the consultation note was sent back to the referring provider. Patient charts from each of the four PHC East sites were reviewed for 30 consecutive cases or all the cases in 3 consecutive months, whichever was reached first, according to requirements for PCSP recognition. Comparisons between baseline 2013 and 2016 data were performed using chi-square or Fisher’s exact test, as appropriate.

Patient experience was measured using Press Ganey CG-CAHPS surveys. We reported the PHC East Top Box scores for all Specialty Comparison domains, grouped by Press Ganey methodology: “access to care,” “see provider within 15 minutes of appointment,” “test result reporting,” “physician communication quality,” “recommend this provider or office,” and “overall doctor rating.” Results at baseline year 2013 and each post-PCSP intervention year were presented.

Although not a specific intention of the PCSP project, financial impact on practice growth was measured using percent change in gross outpatient revenue per physician FTE, encounters per physician FTE, and work relative value unit (wRVU) per patient encounter. Encounters were defined by any evaluation and management visit or procedures such as electrocardiogram, echocardiography, nuclear stress testing, vascular testing, cardiac surgery, electrophysiology, and percutaneous procedures. In addition, variable and staffing cost per wRVU produced was used to measure operational efficiency. Variable and staffing cost was defined as salaries, benefits, depreciations, taxes/licenses, professional fees, clinic supplies, and purchased services, as well as costs such as rent and utilities. For these four measures, 2014, 2015, and 2016 data were compared with that from baseline year 2013, and percent change was presented.

Results

The first key intervention for the patient-centered specialty practice was to improve clinic access for referrals, in particular new patient and urgent or same-day referrals. Following implementation of the patient-centered specialty practice in PHC East clinic in 2013, new patient access incrementally improved in 2014 and 2015, and then levelled off in 2016 (Figure 1). Compared with 2013 (mean ­± standard error [SE] = 0.44±0.015), the average number of new patient visits per physician available clinic hour increased significantly in 2014 (mean ± SE = 0.49±0.015, 10.7% increase, p=0.03), 2015 (mean ± SE = 0.58­±0.015, 31.8% increase, p<0.001), and 2016 (mean ± SE = 0.55±0.015; 24.9% increase, p<0.001). Follow-up patients seen per physician available clinic hour was stable or slightly increased throughout the study time period, with a non-significant trend toward an increase in 2016 (mean ± SE = 2.00±0.069) compared to 2013 (mean ± SE = 1.81±0.069; 10.8% increase, p=0.052).

Providence Heart Clinic Imporved Access for New and Follow-up Patients in Patient-Centered Specialty Practice PCSP

Figure 1. Click To Enlarge.

Care coordination was the second major focus of the project. To evaluate how interventions around referral tracking and response impacted referral loop closure, we performed chart review according to the NCQA requirement (Table 2). Compared with 92.6% at baseline in 2013, 100% of charts were closed in 2016 (p=0.005). PHC East set a target of 2 workdays for referral loop closure, which was met 79% of time in 2013 and 2016. In 2013, four physicians did not achieve the target for timely referral loop closure, while in 2016 only one physician did not.

Providence Heart Clinic Improved Referral Loop Closure After PSCP Implementation

Table 2. Click To Enlarge.

Patient experience was the third key element of PCSP intervention. Over the 4 years of this study, there was an improvement in Press Ganey CG-CAHPS Specialty Comparison scores for test result reporting for PHC East, from 80.4% to 92.3% of Top Box results, i.e., survey respondents selecting the highest response possible (Figure 2C). Seeing the provider within 15 minutes of the appointment measure improved from 88.8% to 93.8% (Figure 2B). Overall doctor rating increased from 83% to 85.6% (Figure 2F). Patient satisfaction around access to care, physician communication quality, and recommend provider/office did not substantially change as a result of PCSP implementation (Figures 2A, 2D, 2E).

Impact of PCSP on Patient Satisfaction at Providence Heart Clinic

Figure 3. Click To Enlarge.

In an ongoing effort to improve the quality of cardiovascular care, PHC measures and reports internally, publicly, and to professional organizations multiple clinical outcome metrics, with continual process improvement efforts targeted at each metric. The following list of quality metrics and reports were submitted to NCQA: American Heart Association’s Mission Lifeline® ST-Elevation Myocardial Infarction Get With the Guidelines® Database, National Cardiovascular Data Registry (NCDR®) Get With The Guidelines (GWTG™) Acute Myocardial Infarction Database, NCDR CathPCI Registry® (Catheterization and Percutaneous Coronary Intervention Registry), PCI Care Package Bundle Score Card, CG-CAHPS Patient Satisfaction Survey, Patient Rating and Comments, Providence Myocardial Infarction Dashboard, Echo Lab Quality Reports, Stress Echo Appropriate Use Report, and Transthoracic Echo Appropriate Use Report. Detailed clinical outcome data from each of these quality reports is beyond the scope of this paper.

While not required by NCQA standards for the patient-centered specialty practice and not a prospective intent of this project, we examined financial growth and operational efficiency for PHC East during the study period. We observed incremental increases in the number of encounters per physician FTE (compared to baseline 2013, 2014 = 15.38% increase, 2015 = 31.49% increase, 2016 = 25.33% increase) and gross revenue per physician FTE (compared to baseline 2013, 2014 = 9.06% increase, 2015 = 34.62% increase, 2016 = 37.76% increase) (Figures 3A, 3B). wRVU per encounter increased each post-implementation year, from 2.92 in 2013 to 3.03, 3.13, and 3.38 in 2014, 2015, and 2016, respectively (15.7% increase from 2013 to 2016; Figure 3C). Variable and staffing cost for clinical operations per wRVU decreased incrementally in PHC East from 152.28 in 2013 to 129.9, 118.66, and 114.01 in 2014, 2015, and 2016, respectively (25.1% decrease from 2013 to 2016; Figure 3D).

Improvements in Productivity and Efficiency After PCSP Implementation at Providence Heart Clinic

Figure 3. Click To Enlarge.

Discussion

To our knowledge, this is the first published report detailing the implementation and operational, patient experience, and financial impact of PCSP transformation in a cardiology practice. With strategic oversight from Providence Heart Institute, clinical and operational leadership from PHC undertook this project to guide continuous practice improvement efforts and prepare for new value-based payment models. Importantly, the overarching goal was to redesign the outpatient clinic workflow from the eyes of patients navigating the journey of specialty care. In contrast to the rapid and broad uptake of PCMH nationally where, to date, 13,454 primary care practices are NCQA recognized nationwide, only 457 specialty practices are NCQA recognized as patient-centered specialty practices.12 This may in part be due to specialists’ lack of understanding of the importance of specialty care reform, outpatient care coordination, and specialty clinic operational improvement to help build and refine the medical neighborhood.

In addition, unlike PCMH models, which are linked with payer incentives, PCSP recognition has not been associated with direct financial incentive from payers. PHC absorbed the cost of NCQA multisite group survey fees of $3,300 and $27.50 for each additional clinician, cost of project management and support staff, cost of staff time to design and implement new workflows, and unknown cost of dissemination of standard practice of patient-centered specialty practices into existing staffing and workflow. Our results indicate that PSCP transformation can bring direct benefit to patients and care coordination (Figure 2 and Table 2), as well as indirect, remarkable financial benefit for specialty practices in terms of growth and operational efficiency (Figure 3).

Using the NCQA PCSP standards as a blueprint, PHC formed care teams, refined appointment templates, improved staffing, standardized EHR note templates, and streamlined workflow around test result reporting and communication with patients and referring providers. PCSP transformation was focused on how specialty care was delivered, not what specific clinical intervention was delivered. The research method and data reported here were prospectively designed to evaluate the impact of our PCSP project, focusing around the specific interventions done. The metrics collected were aligned with what was reported to NCQA and where possible, in accordance to NCQA definitions. PCSP transformation does not fundamentally change what care is delivered, which is driven by evidence-based medicine and clinical guidelines, but how care is delivered. Therefore, clinical outcomes were tracked using multiple quality metrics but intentionally not included as an end point in this study.

With the formation of care teams and adjustment of the scheduling template according to referral needs, PHC was able to improve new patient access while maintaining full support of inpatient service needs and follow-up patient appointments (Figure 1). The choice to use new patient seen per physician clinic hour as the measure of new patient access instead of the industry standard of third available appointment was driven by the unique and often urgent nature of cardiology referrals and the need for individual cardiology providers to cover both inpatient service and outpatient clinic. In order to accommodate urgent referral and patient needs, PHC builds same-day urgent patient slots into physician scheduling templates. In this context, third available appointment is irrelevant to the true availability of the practice as a whole, whereas new patient seen reflects overall clinic access to referral needs. The ability to accommodate new patient referrals is an important measure to specialty practice given its linkage to downstream revenue and representation of market share, although the approach to improving patient access needs to be holistic.13 The result of increased new patient seen per physician clinic hour reflects a growing market as well as the ability of PHC to meet such referral demand. Operationally, the supply/demand report for new referrals is tracked on a monthly basis to inform staffing needs, decision to hire, and adjustment of scheduling templates.

As a result of PCSP implementation, PHC developed closer relationships with referring provider groups, enhanced by improvements in closing the referral loop (Table 2). Through the establishment of care agreements, PHC is able to transfer the care of stable patients back to referring practices in a more timely manner in order to better comanage patients and reduce unnecessary or duplicative care. Other examples of improved patient co-management include designating routine medication refills back to primary care to avoid unnecessary routine cardiology clinic visits. Test result reporting is shared with patients via patient portal and back to primary care, so that providers caring for the same patient are informed of the same patient-provider communication. Prompt test result communication with the patient is both a patient satisfier (Figure 2) and also reduces unnecessary follow-up patient appointments. We anticipate that better co-management of patients and avoidance of unnecessary, duplicative care may reduce overall health care cost. Future work should examine this more closely.

Despite objective evidence of increased new patient access, patients’ perception of access remained suboptimal (Figure 2A), likely because of additional unmet market need, as well as the lack of sufficient availability to meet the needs of long-term, albeit stable, follow-up patients. Further, this finding highlights the complexity of patient satisfaction surveys as a surrogate for operational or clinical outcome measures, due to various intrinsic biases.14,15 PHC is in the process of hiring APPs to improve follow-up patient access. Because of the implementation of standard clinic workflow around patient check-in and rooming processes, we observed a slight improvement in patients’ perceptions of the timeliness of the appointment (Figure 2B).

The most striking improvement in patient satisfaction was seen for test result reporting (Figure 2C). This likely reflects the implementation of a standard, improved workflow in test result communication and documentation. All test results were annotated by ordering physicians and APPs and routed to nursing staff, who then called the patient and documented the conversation. For patients who had signed up for direct messaging through the EHR portal, providers routed the comments and explanations, along with the test result, to both the patient and their primary care provider (PCP) directly, thereby reducing clinic nursing staff time for phone calls. Patients’ overall doctor rating improved slightly over the study time period (Figure 2F). There was no change in patient satisfaction around physician communication or recommend physician/practice; however, these measures had high baseline scores and the PCSP intervention did not specifically target these components of care (Figures 2D and 2E). Real-time patient feedback was collected in suggestion boxes at each clinic site. Patient compliments were shared with staff individually and in all clinic staff meetings. Patient complaints were directed to clinic site managers to address and improve upon.

Although this project was not intended to improve throughput and clinic volume, we observed significantly increased productivity and growth. For PHC East, encounters increased by 25.3% and gross revenue increased by 37.8% in 2016 compared to 2013 (Figures 3A, 3B). Change in gross revenue may represent the cumulative effects of multiple contributing factors such as payer mix, conversion factor, price, and reimbursement rate, in addition to true productivity. Furthermore, encounters and gross revenue reported are not normalized to patients seen or lives covered; therefore, over-utilization cannot be ruled out, although clinical quality measures, such as appropriate use criteria for diagnostic catheterization, echo, stress echo, and nuclear stress tests, are tracked by the Providence Heart Institute. Vigorous prior authorization for cardiac procedures is also in place.

wRVU per encounter for PHC East increased 15.7% from 2013 to 2016 (Figure 3C), likely due to an increase in patient complexity and acuity, corresponding to the increase in new patient access. Operational efficiency also improved, as evidenced by a remarkable 25% decrease in variable and staffing cost per wRVU produced, despite the addition of 24 support staff FTE over the study period (Figure 3D). The significant decrease in variable and staffing cost per wRVU is predominantly due to the 15.7% increase in productivity, as well as increased new patient access, shifting the wRVU/encounter higher. Optimization of staffing and workflow also improved efficiency of staff support to productivity, further reducing cost/wRVU.

While we report the results of a cardiology patient-centered specialty practice project, PCSP standards are not specialty specific. Establishing the PCSP model in one specialty practice could catalyze adoption of this model in other specialties within the health system or medical neighborhood. For large integrated health systems, provider networks, or accountable care organizations, the use of a single set of specifications for all specialty practices may further improve patients’ comfort while navigating throughout primary care and specialty clinics.

As an extension of our PCSP project, we are now working to refine relationships with referral practices both internal and external to our health system to build a better medical neighborhood. Forty-six percent of the referring sites for PCH East and 55% for other PHCs are Comprehensive Primary Care Plus (CPC+) certified through the Centers for Medicare and Medicaid Services (CMS) and/or PCMH recognized through NCQA. The connectivity between PCMH and PCSP standards has built a solid foundation for our medical neighborhood. We have developed care agreements to define the roles and responsibilities for primary care and cardiology for each step of referral, access, consultation and communication, and patient co-management, as well as transition of care. In addition to care agreement relationships, PHC has ongoing work regarding referral process management, EHR and operational improvement, provider and staff engagement, population management, and patient activation. PCSP transformation is a continuous, iterative practice improvement process that offers tangible results to patients and providers.

Challenges in PCSP Implementation

The challenges we encountered in this project have included the initial resistance-to-change mindset, competing priorities and time commitment of project team members, and limited time and resources. The project time line also coincided with the early stages of merger of previously competing private practice groups as well as the implementation of a new EHR. Faced with such daunting systematic, personnel, and technologic changes, providers and staff were overwhelmed and often adopted a sense of learned helplessness. Applying design thinking to operational improvement and keeping the patient-centered mantra at the forefront of all interventions, PHC leadership enabled and empowered providers to have control over an employed practice model in an integrated health system and focus their attention on the core clinical and business functions of the specialty practice.16 Using PCSP standards as a blueprint, the operational interventions were carried out in an iterative process, with rapid cycles of prototyping, testing, implementation, redesign, and optimization. The organization slowly adopted a learning culture, incentivizing innovation, shared learning, communication, and dissemination.

PCSP Limitations

Limitations of this study include the observational design and the lack of vigorous controls. The iterative, stepwise implementation of operational interventions are unlike clinical trials where a single therapeutic intervention can be isolated and prospectively controlled for. PHC East and other PHC clinic sites had unique patient populations, referral sources, clinicians, staff, and management teams. We focused our report on the temporal trends in outcomes for PHC East, from pre- to post-implementation. Other PHC clinics trailing in PCSP transformation had directionally similar results (not reported). PCSP impact on clinical outcomes and financial cost-savings at the payer level were not reported. It is critical to recognize that this project was focused around process and workflow improvement and was not intended nor powered to result in changes in clinical outcomes.

During the 4 years of the study, there were significant secular changes in health policy, payment models, health systems, and technology, both nationally and locally in Oregon. The passing of the Affordable Care Act resulted in 18.5 million Americans gaining predominantly Medicaid insurance from 2013 to 2016.17 Payer mix gradually shifted from commercial to Medicare and Medicaid. Starting in 2009, CMS reduced reimbursement for cardiovascular imaging delivered in the office setting by 11%–26%.18 With subsequent passage of MACRA in 2015, delivery systems expect payment models to shift from fee-for-service to merit-based incentives and alternative payment models.19 Nationally, significant mergers and acquisitions between payers, hospital systems, provider groups, and retail pharmacies have occurred. These factors likely underlie much of the rapid vertical integration of cardiology practices with hospitals or health systems in the last decade, rising from 10% in 2008 to 44% in 2017.20,21 Nationally and locally, cardiologists remain at the leading edge of delivery reform, anticipating value-based payment models.22,23 For PHC, the study period coincided with the implementation and subsequent optimization of the EHR, necessitating significant workflow changes. Thus, it is difficult to conclude which of our results are specifically attributable to PCSP implementation alone.

Patient-Centered Specialty Practice Implications for Health Policy

With greater promotion of new payment models to incentivize population management and further integration of cardiovascular providers into health systems, specialty practice redesign will become increasingly important. The implications of PCSP transformation may be viewed from three different perspectives: patients, delivery systems, and payers. For patients, the patient-centered specialty practice allows tighter care coordination and communication between PCPs and specialists. For delivery systems, our study demonstrates that although PCSP transformation is not directly linked to higher reimbursement, improvement in productivity and efficiency is advantageous to health systems pursuing practice reform. Not reported here, and much more challenging to measure, is the impact of this type of operational improvement project on organizational culture, provider and staff engagement, and morale.

From a payer standpoint, our results of increased productivity may well reduce health care costs, through appropriate utilization of specialty care, better care coordination, and patient co-management. For example, the implementation of e-consult services to referring providers allows direct communication between PCPs and specialists to discuss testing and treatment plans via EHR chart review and direct messaging, which may obviate the need for a face-to-face encounter. Test result reporting workflow allows direct communication of test results to the patient, which may also limit the need for an additional in-person encounter, resulting in cost savings. Future research should examine the patient-centered specialty practice’s impact on payer-level cost data.

Using NCQA PCSP standards as a blueprint to transform an integrated cardiology practice is not only feasible, but it is also beneficial to both patients and clinical practice. While we report the benefit of PCSP transformation for a large, multisite cardiology practice in an integrated health system, PCSP standards also apply to independent practices and other specialties such as oncology, women and children, and orthopedics. Our results suggest a call to action in payment reform to reward more patient-centered, coordinated, and efficient specialty practice. Broader adoption of PCSP transformation for specialty practices would benefit from a national collaborative to share best practices for implementation and continuous quality improvement, as well as to define core measures to evaluate impact.


References

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A four-part framework developed by physicians at Partners HealthCare provides a stepwise process for assessing and integrating technologies to effectively use data through a continuous patient experience.

UCLA Health CKD Risk Stratification and Management

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Platforming Health Care Operations - Consumer-Driven Health Care - Business-Minded Optimizations

Platforming Health Care to Transform Care Delivery

Health care leaders need to focus less on ownership and control of the delivery process, and more on outcomes, cost efficiency, and customer experience.

Shah05_ integrated systems innovation pullquote

Build vs. Buy: What Should Health Systems Do?

The consolidation craze continues, but vertical integration has yet to demonstrate real progress toward the Triple Aim. Health care leaders would do well to consider innovative approaches that are working in other industries, including the tech-enabled full stack model.

Diagram Illustrating the COPD Care Pathway at Allegheny General Hospital

End-to-End Care for COPD Patients that Improves Outcomes and Lowers Costs

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.

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Topics

Coordinated Care

145 Articles

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease…

Care Integration

77 Articles

Platforming Health Care to Transform Care…

Health care leaders need to focus less on ownership and control of the delivery process,…

Assessing and Addressing Social Needs in…

Lincoln Community Health Center improved care quality by measuring and responding to upstream social and…

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