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Katherine Capps

By Katherine H. Capps, Co-Founder and Executive Director, GTMRx Institute; President, Health2 Resources

October 16, 2020

Changing how we pay changes what we do: Recap of Patrick Conway on team-based care

Our Oct. 9 GTMRx Executive Roundtable yielded a wealth of insights, and in the coming weeks, I’ll share with you more of what we discussed. Suffice to say we’ve reached a critical juncture in our work to advance a more personalized, team-based, comprehensive primary care model—that includes value-driving elements we found when we optimize medication use through a coordinated, systematic approach to medication use we call comprehensive medication management.

Today, however, I want to relate some of what we learned from our keynote speaker, Patrick Conway, MD, CEO of Care Solutions at Optum.

He’s a terrific storyteller who brings multiple perspectives—physician, payor (public and private) and policymaker—to any discussion.

He began by laying out the problem: Care quality is uneven, the cost trajectory is unsustainable and the experience is often not as good as we would want for ourselves, for our loved ones or, frankly, for anyone. “The core issue is what actions can be taken now to change that paradigm?”

It starts with changing how we pay for health care.

Incentives transform behavior

He shared how, during the nearly five years he led the CMS Innovation Center, CMS went from no alternative payment models to over 30% of payments. That represents more than $200 billion and over 200,000 signed provider agreements across the country. “When you aligned those incentives, you saw people drive change, whether it was medication management or engaging with patients or delivering care in different ways.”

Blue Cross North Carolina also shifted payments under his watch as CEO. The goal: Have more than half of payments in advanced alternative payment models—and do it within two years. They finished ahead of schedule.

The first year, it saved over $150 million. Medicare Advantage premiums went from about $140 a month to $0 across the state. In the individual market, premium dropped by more than 10%, through value-based incentives, quality, total cost of care and experience.

He shared all this not to boast but to demonstrate change is possible.

But for change to happen, all actors need to be involved and on the same page. At the system level, that includes providers, employers, policymakers, public payors and consumers.

Similarly, at the practice level, the entire team must be engaged. This leads to a topic close to my heart: team-based care.

All about the interprofessional team

Many doctors today—including Conway—were not trained to think of care delivery as a team activity. It was mostly after his formal training that Conway learned about the importance of the entire clinical team: the clinical pharmacist, the nurse, the social worker, the psychologist–and the patient and the family.

During his time at the CMS Innovation Center, payments in primary care moved to per-member per-month and practices built out their teams with clinical pharmacists, social workers, behavioral health specialists and others.

Moving primary care to a population-based payment model allows that team to be built out, he explains. “I think this is critical for long-term transformation. It actually doesn’t make sense—and I can say this as a physician—for physicians to do all the work. We have to figure out what’s the team and the clinical care delivery model that utilizes all people on the team.”

He shared an anecdote illustrating the value of each team member working at the top of their license.

“True story: I watched a dietician tell my intern about how to do the TPN (total parental nutrition) orders in the hospital one day. And I went to our expert, and I said, ‘Do we have a rule about who can write diet orders?’ It turned out we did.”

Medicare required physicians to write TPN orders. Not anymore. “We got rid of that rule.”

The change allowed nutritionists—the experts in writing nutrition orders—to directly write the orders, rather than adding it to the physician’s already heavy burden. And it resulted in over a billion dollars of savings across the entire system.

Team-based medication management efforts

He was speaking to GTMRx leaders and supporters, so, of course, he made special mention of medication. Integrating a clinical pharmacist—the medication expert—into the team has the potential to add tremendous value. He’s seen this in action at CMS—especially in the Medicare Advantage space, as well as at BCBSNC and Optum. Medication management drives cost and quality outcomes.

Subsequently, delivering the right medication at the right time to the right patient requires a fully engaged patient.

The patient as full team member

GTMRx believes patients should be recognized as members of the integrated team—not adjuncts, but full contributing members. Patrick provided us with several concrete examples of what happens when we listen to their voices; I only wish we had room to include them all.

As our second belief statement frames it, “We must align systems of care to integrate comprehensive medication management, engaging patients to ensure that they are willing and able to take those medications that are indicated, effective and safe to optimize their outcomes.”

At Optum, he’s working to create opportunities for individuals and families to co-design interventions. We know that leads to improvement, but practices and systems don’t do it—at least not reliably. “The norm seems to be that a clinical team says, ‘I think this is right. I’ll deploy it,’ without actually doing the work to engage patients and families.”

It requires a change in the way we’ve always done it. And it requires a change in how we pay for it. New models are necessary but far from sufficient.

The future

We all expect a continued drive for value from both private and public payors. It is a rare area of bipartisan agreement.

It can’t happen fast enough for him, though: “So at the end of the day, it’s going to take all of us driving for that change. I think I get less and less patient as I get older,” Conway told us. “But it is personal for me. It’s individuals and families that need change now in our system, and they’re telling us that. So how do we deliver that care better, faster, each and every day?”

Based on what I learned from the roundtable last week, we’re well on our way to figuring it out. Stay tuned.

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