Value-based primary care providers are testing new strategies to improve population health

The dilemma of Alzheimer’s disease in primary care, as well as other health challenges in an aging population, were the focus of a recent Institute for Value-Based Medicine® event in Portland, Oregon.

Am J Accountable Care. 2022; 10 (4): 47-49. https://doi.org/10.37765/ajac.2022.89289

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Cognitive problems often present in primary care with age, although not all memory loss will progress to dementia dysfunction. However, the number of Americans diagnosed with Alzheimer’s disease (AD) could rise to nearly 14 million by 2060, up from 6.5 million currently.1

To buck this trend, much of the recent focus has been on the success or failure of drugs to slow the progression of this devastating neurological disease, most notably the controversial 2021 FDA approval of aducanumab, a monoclonal antibody, or the results of lecanemab , another biologic that slows cognitive decline in patients with early-stage disease, but, like aducanumab, is associated with brain swelling and bleeding.2

Unless viable disease-modifying treatment options emerge, the out-of-time primary care provider (PCP) will continue to see these patients and families first as the incidence of AD increases over the coming decades.

This predicament, and one organization’s efforts to alleviate the challenges of AD for both PCPs and their patients and caregivers, was the topic of a session at the Value-Based Medicine Institute® (IVBM) population health event in Portland, Oregon. This IVBM session, hosted The American Journal of Managed Care®, was held on November 16, 2022. Other value-based population health initiatives presented tonight included a multispecialty quality improvement effort to control blood pressure and a transitional care model that aims to reduce overuse. A panel discussion at the end of the evening featuring several of the presenters weaved the sessions together.

One of the co-chairs of the event, which was held in partnership with Optum and the Vancouver Clinic, said he hopes attendees take home 1 key takeaway: “that there really is no relationship between the cost of care and the quality of care.”

“If anything, there’s a feedback loop,” said Ken Cohen, MD. “At some point, the more care that’s given to the patient, the worse the outcomes.”

Implementing evidence-based medicine, data and technology to optimize care

To illustrate his points, Cohen, executive director of translational research for Optum Care, provided numerous examples of low-value, high-cost care that doesn’t lead to better patient outcomes. At the top of the list is lumbar spine surgery, which accounts for $6 billion of the roughly $10 billion Medicare spends on health care services that provide little or no benefit each year, he said.

Optum manages cases of chronic low back pain — which accounts for $90 billion in U.S. healthcare costs each year — through its Optimal Care model, which combines evidence-based medicine with data and technology. Rather than turning first to prescription drugs and surgery, low back pain is coordinated through a PCP, physical therapist, or chiropractor. If the back pain does not subside, it escalates to 2 drug therapies of proven benefit, meaning non-steroidal anti-inflammatory drugs and the antidepressant duloxetine; rehabilitation services; and cognitive behavioral therapy for pain management.

Referral for surgery is a final step, Cohen said, and occurs only after engaging in shared decision-making based on the results of a lumbar fusion calculator that takes into account various patient characteristics to predict the chance of a successful outcome, as well as discussions for lumbar fusion or spinal decompression without fusion, choice of surgeon and where to perform the surgery.

However, Cohen stressed, most patients do not need surgery. “If they really need surgery, the physiatrist is the one who chooses the spine surgeon based on their expertise,” he said.

Reducing the toll of dementia and AD in primary care

Unlike many chronic conditions seen in primary care and treated with low-value services, most cases of dementia go undiagnosed, noted Martin Levin, MD, MBA, chief medical officer at The Polyclinic, a group of primary care providers. support and specialists, which is part of Optum in Seattle, Washington.

The prevalence of dementia ranges from 10 percent of adults 65 or older to 50 percent in those 95 or older, but families and doctors dance around the topic at office visits, trying to explain symptoms by citing the aging process.

“Alzheimer’s is not a word that means burden,” he noted; the disease is named after the doctor who published an article about it in 1910. “It is a very common part of the day in primary care.”

“We have pills, but I’m not going to talk about pills tonight,” said Levine, an internist and geriatrics specialist
through training.

The biggest impact on AD care stems from something else, he said.

“The interventions that really make the biggest difference are working with families so they understand what’s going on and take advantage of services in the community, gain greater self-understanding, self-efficacy so you can plan and actually we can change people’s lives if we provide them with these services.”

The reasons dementia goes undiagnosed are complex, he said, and can include PCPs who don’t feel confident they know how to diagnose it, or feel they don’t have the time to do so — or as Levin put it, they don’t want to open a “can of worms” when their office staff does not have a team to address and direct all subsequent psychosocial needs of the patient and family members.

However, there are also problems with not dealing with dementia, Levine stressed. “These are missed opportunities to improve people’s quality of life. That’s what it’s all about. That’s the problem we saw in our team.”

This year, to meet that need, The Polyclinic and another Optum clinic, Evergreen, created a program called Memory Loss and Caregiver Support for Medicare Advantage (MA) patients. This is enabled by a change CMS made in 2020 to add dementia to the Medicare Part C risk adjuster; each diagnosis amounts to about $2,900 in revenue, and those funds are funneled back into paying for the clinic’s social work services.

However, the program does more than add social workers to the mix. Levin said doctors are required to do 3 things to make a social work referral:

  • Receive training to assess patients for dementia using standardized cognitive and functional instruments
  • Make the diagnosis
  • Inform the patient and family about the diagnosis

The PCP can then refer the patient to social work services. Social workers, who began working on the program in late June 2022, free PCPs from the non-medical aspects of caring for a dementia patient, some of which can be fraught with tension between provider, patient and family – e.g. , long, emotional discussions about giving up driving.

“So the doctor shouldn’t tell the person, ‘You’re not going to drive a car anymore.’ Doctors, we’re going to get it off your back,” Levin said.

Other aspects of care that social workers manage include patient and family education, dementia staging, providing referrals to community resources, screening for safety and behavioral problems, assessing interest in drug therapy, and more.

Best practices, including improving the cognitive screening tool used at the annual wellness visit, are being implemented in the electronic medical record workflow – the Polyclinic uses Epic – which will enable the creation of population-based metrics.

So far, almost all of the Polyclinic’s 270 doctors have been trained and participate in the program and are supported by a 7-part video series on dementia. In just a few months, the program increased dementia diagnoses while generating revenue.

In December 2021, The Polyclinic and another Optum clinic (The Everett Clinic) had 1,658 patients diagnosed with dementia, a prevalence rate of 6.3%, out of an MA population of 26,436.

At the end of October 2022, there were 408 new cases of dementia out of an MA population of 32,284, with a prevalence rate of 6.4%. With CMS risk adjustment, 408 cases translate into $1.18 million in revenue.

What also stands out, Levine said, is the increase in the risk adjustment factor (RAF) score; for all hierarchical chronic conditions the RAF rose by 11% this year, while for dementia it rose by 25%.

“So the lesson from this is that when we combine a clinical service that is meaningful with coding … we do much better. And that really drives our business case and our ability to continue to fund and develop new services,” Levine said.

Downstream risk-driven innovation, data – can it scale?

Fee-for-service models only allow payment for an immediate health or medical service, with no room or budget for anything else, Cohen said as he began the panel discussion that ended the evening. He was joined by Levin; event co-chair Craig Riley, MD, medical director of population health and medical education at the Vancouver Clinic; Kyle Lamb, MD, associate medical director of the Vancouver Clinic for Population Health; Stan Bauer, director of clinical operations at the Vancouver clinic; and Michael Paul, MD, Vancouver Clinic Medical Director of Primary/Urgent Care and Continuous Improvement.

One audience member asked if the panelists thought the concept behind MA could be extended to other populations if it worked so well.

“I think we really, as a society, need to figure out how to provide value-based care for all ages,” Levine said.

Riley, who previously cited findings from a landmark study on healthcare hotspots that focused on patients with high utilization of care3 when discussing the experience of

Vancouver Clinic’s model of transitional care for complex, high-needs patients agrees.

“I think we’re taking the same approach — generally, can we prove this as a proof of concept in this population so that ultimately we can convince our payers that it makes sense to invest in it across the board,” he said.

REFERENCES

1. Alzheimer’s Disease Facts and Figures in 2022 Alzheimer’s dementia. 2022; 18 (4): 700-789. doi:10.1002/alz.12638

2. Van Dyck CH, Swanson CJ, Aisen P, et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. Published online November 29, 2022 doi:10.1056/NEJMoa2212948

3. Finkelstein A, Zhou A, Taubman S, Doyle J. Healthcare hotspotting—a randomized, controlled trial. N Engl J Med. 2020; 382 (2): 152-162. doi:10.1056/NEJMsa1906848

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