Strengthening Primary Care: A Pilot with Four Large Purchasers
June 10th, 2022
Extensive research and pilot programs have shown that easily accessible, person-centered and team-based primary care that integrates behavioral health and other supports can significantly improve patient outcomes and experience. It can also increase population health, reduce overall costs and serve to improve equity in our health care system.
It is for these reasons that PBGH’s California Quality Collaborative (CQC) has been working for over a decade to improve primary care. That work has culminated in the development of shared attributes and measures that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the kind of care research tells us will bring about the best results for patients.
Together with the Integrated Healthcare Association (IHA), PBGH brought together four large health care purchasers in California to pilot this set of performance measures that emphasize patient experience and outcomes. The PBGH/IHA partnership, known as the Advanced Primary Care Measurement Pilot, began in January 2022, and participating purchasers include Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System.
Partnering to Better Primary Care in California
Our already weak primary care system has been further hampered by the pandemic, and these purchasers recognize that the time to strengthen it is now. The four participating purchasers have aligned by incorporating the same Advanced Primary Care attributes and measures into their health plan contracts. The goal is to identify the primary care practices throughout the state performing at the highest levels and delivering high-quality patient care.
The set of performance measures being tested through the pilot reflect the shared standard of Advanced Primary Care as defined through a multi-stakeholder process led by PBGH’s California Quality Collaborative that included input from purchasers, health plans, providers and patients.
The outcome will be an increase in understanding of where patients are getting the highest quality primary care. The pilot will give purchasers and health plans information to help them make decisions about their provider networks, resource distribution and consumer incentives. This information can be used to better connect patients to practices delivering Advanced Primary Care and incentivize improvement for other providers, increasing the availability of Advanced Primary Care.
How the Pilot Works: Existing Data for a New Purpose
Data already available through IHA is being used, so health plans and providers do not have to report anything new. The existing data will be used for a new purpose – to assess individual practices.
Performance information can be diluted when data from multiple practices is combined. By looking at each individual practice separately, we can gain the best understanding of which practices are delivering the best primary care and which ones need improvement.
The data will also be aggregated across purchasers and health plans for the first time to provide a more complete view of each individual practice’s performance, rather than looking at small segments of patients in a vacuum. This will allow for a better assessment of whether a practice has the systems in place to consistently provide high-quality care for everyone
Currently, ways to account for socio-economic and demographic differences in the performance analysis is being explored. This lens is crucial to ensure decisions made around the pilot promote equity and do not inadvertently increase the challenges vulnerable communities already experience in accessing high-quality care.
The analysis will include data from January through December 2022, and results and findings are expected mid-2023.
Supporting Non-Hospital Birthing Options: Employer Strategies to Improve Quality
May 23rd, 2022
Maternal infant health outcomes in the U.S. remain the worst among high-income countries, and Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women are. Additionally, U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.
To underscore the high costs disproportionate to the poor maternal health outcomes, the cost of maternity care represents American employers’ second-highest annual health care expenditure – $1 in every $5. Faced with unacceptable results, employers are looking for pathways to improve maternal health care quality, affordability and the overall patient experience.
Improving Quality and Lowering Costs
Consumer surveys have shown that more patients are seeking non-hospital, community-based childbirth options, such as midwives, doulas and birth centers. This is particularly true for birth participants of color who are looking for alternatives to the hospital-physician childbirth experience.
Recent CDC 2020 vital statistics data mirror what we have seen from consumer surveys. Although overall births declined, in 2020 the number of births in birth centers nearly doubled. This is a significant indication that more women want choice in their maternity care team and care location and that more families, when given a choice, are seeking a non-hospital childbirth option.
Non-hospital maternity care options can help to address the problem of high-cost, low-quality care. Evidence shows the use of midwives improves overall maternal and infant health and decreases the cost of maternity care. In fact, research shows that collaborative care led by certified nurse midwives can result in 22% fewer primary C-sections. It also helps address a growing shortage of perinatal health providers. Despite these benefits, however, certified nurse-midwives are vastly underutilized, delivering only 9% of babies nationally.
A birth center is a midwife-led childbirth facility that offers individuals and families a more natural, lower intervention and less medicalized childbirth experience. Birth centers are freestanding facilities and separate from acute obstetric or newborn care where care is provided in the midwifery and wellness model of care. Birth centers typically have relationships with other community health providers and arrangements with other facilities, such as hospitals, for transfers to other levels of care when needed.
The CMS Strong Start program demonstrated that women who received prenatal care in birth centers had better outcomes and lower costs. This included lower rates of:
- Preterm births
- Low birth weight
Additionally, costs were more than $2,000 lower per mother-infant pair during birth and the following year for women who received prenatal care in birth centers.
How Purchasers Can Support Non-Hospital Options
Employers know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient centered. Here are three ways employers can influence the health system and health plan leaders’ perspectives to address the barriers preventing birth center expansion, collaboration between hospitals and birth centers and access to midwives:
- Benefit design: Benefits programs can be designed to expand access to midwives and birth centers. For example, eBay has started covering out-of-network midwives at in-network rates to improve access to community providers.
- Payment and contracting: By paying for care differently and moving towards value-based payment rather than fee-for-service models, employers can greatly improve access to high-value facilities such as birth centers. A simple birth center bundled payment model would allow all prenatal, labor and delivery and postpartum care provided by the birth center to be captured under one claim/invoice. A bundled payment project with Qualcomm produced valuable lessons learned that could benefit other employers pursuing a bundled payment option.
- Quality improvement: In the event of a transfer from a birth center to a hospital, the transfer process is smooth and respectful for the patient and their family. PBGH is leading a project in California to establish a model to inform procedures regarding transfers.
In response to the lack of comprehensive, coordinated care and the overmedicalization of childbirth PBGH has developed several strategies to help employers impact their maternity marketplace.
How Primary Care Providers Can Improve Depression Screening
May 4th, 2021
Depression screening is an essential tool for primary care providers to better understand and meet their patients’ needs, especially as behavioral health conditions have dramatically increased in the past year. Patient-centric approaches and thoughtful implementation of depression screening can lead to earlier intervention, improved overall health outcomes and reduced utilization of health care services.
In March 2021, PBGH’s California Quality Collaborative (CQC) hosted a webinar on the importance of depression screening for patients, providers and payers and shared practical advice for patient-centered depression screening. Experts from PBGH, Montefiore Medical Center and UCLA identified four key takeaways during the discussion:
1. Primary care providers should start screening patients for depression now. There is increasing demand being placed on primary care clinicians to screen patients for depression. Health plans, employers and other purchasers of health care recognize that depression affects millions of patients, and they are investing in behavioral health as a strategy to improve health outcomes. In California, there is momentum from organizations like the Integrated Healthcare Association, which runs statewide performance improvement programs, and Covered California, to include depression screening as a required health care quality measure. Providers will be financially accountable for completing depression screening in the next several years as part of existing pay-for-performance programs.
2. Care teams need training to be comfortable screening patients for depression. Care teams require resources and information about depression screening and how to follow up appropriately with patients in need of behavioral health services. Specialized trainings with role-playing opportunities are effective, as are resources, such as a list of frequently asked questions developed by the Advancing Integrated Mental Health Solution (AIMS) Center from University of Washington.
3. Screening workflows can be integrated into virtual visits, with intentional planning. During the public health emergency, UCLA Health increased the use of virtual primary care visits. The system’s clinical and operations teams created a depression screening workflow that leveraged “virtual rooming” steps, during which clinical support staff register and prepare patients for telehealth visits just as they would for in-person clinical appointments. To address safety concerns associated with suicidal ideation documented in patient depression questionnaires, they tested and implemented several solutions by which the provider would monitor a patient’s response, or the electronic health record would issue an automatic alert.
4. Technology can expand the reach of primary care to provide whole-person care. Montefiore Medical Center launched a smartphone app that includes screening, educational resources, appointment and medication reminders and near real-time chat, among other features. Providers using the Montefiore app with their patients found that it improved behavioral health care engagement with a diverse set of patient populations. In an analysis of the smartphone app pilot data, 72% of patients used it to access educational articles and videos, 69% used it to interact with their care teams via secure chat or text and 67% used the app to complete a depression or other behavioral screening scale.
For additional insights about how primary care providers can improve depression screening for their patients, watch the March 31 CQC webinar or access the presentation.
The Current State of Mental Health Screening and Access in California: Results from 35,000 Patients
October 26th, 2020
Mental health concerns are increasingly common, yet many patients in California are not screened for symptoms and are unable to access treatment. Understanding patients’ access to care is challenging; data are scarce and usually only available at a statewide level, even though there are likely wide regional differences due to workforce shortages.
In its Accelerating Integrated Care webinar series , the Pacific Business Group on Health’s (PBGH) California Quality Collaborative presented results from the most recent PBGH Patient Assessment Survey (PAS). The research measured the experience of 35,000 Californians regarding mental health screening and access to necessary treatment. Also measured was the degree to which patients were successful getting timely access to physical versus mental health care.
Screening Rates and Access to Mental Health Treatment are Low
Participants of the survey visited either a primary care or specialty medical provider between July and October of 2019 and were asked to rate their experiences with their medical care during the six months prior to receiving the survey. Survey participants were asked a series of questions, including:
- Were you asked about mental health symptoms during your medical visit during the past six months?
- Was treatment recommended?
- Did you need treatment?
- Were you able to get care?
- Were you able to get care when you needed it?
Many patients (67%) said that no one from their provider’s office – whether a primary care or specialist visit — had asked them about their mental health, despite 16% reporting feeling they needed care and 30% having accessed care on their own. One-third (33%) said a provider asked them about their mental health.
Half of all patients who were screened were recommended for mental health treatment. Two-thirds agreed they needed the care that was recommended.
Whether in need of mental or physical health care, 60% of those surveyed said they were always able to get access to needed services. Surprisingly, a higher percentage of survey participants in need of mental health services (57%) said they were able to get care when they needed it, compared to just 50% seeking physical health services.
Using Patient Reported Data to Improve Access to Mental Health Care
All provider organizations can utilize this data to improve upon the rate at which patients are screened for mental health symptoms and to ensure they gain access to needed care. Using either baseline data or the Patient Assessment Survey data presented here as a proxy, comparisons against state benchmarks to set goals for screening and access can be made. To begin improvement work, select evidence-based change tactics to create an action plan.
It is important to ask patients about their experiences accessing care at your organization. Encounter and claims data can be useful in instances when patients who have been seen for a medical appointment have also filled out a screening tool, though this data do not capture whether the patient was satisfied with their experience and felt they received care when they needed it. Follow the steps below to capture feedback from patients to identify populations that might need extra support.
If your organization does not already collect such data:
- Measure: Develop a survey to collect patient data.
- Interpret: Use the data presented in this article as a proxy benchmark until you collect your own data – assume your screening and access rates are similar (33% screened, 60% able to access care).
If your organization already collects patient experience data for mental health care:
- Measure: Identify a contact at your organization who can provide data on mental health screening and access.
- Interpret: Compare your internal data to the statewide data presented in this webinar (33% screened, 60% able to access care) – how does your organization compare? Which populations might need extra support?
For more details on upcoming CQC webinars focusing on how to improve mental health screenings and access to mental health treatment in primary care settings, sign up for the CQC Newsletter or visit the Webinars webpage . Later this year, PBGH will publish an Issue Brief with further results from this study. For more information, find the full recording of this webinar here and the slide deck here.