The Accountable Primary Care Model, from Maryland Heights, Mo.-based Lumeris, incorporates a series of concepts and steps called the Nine C's to help physicians achieve what Lumeris calls the "Triple Aim Plus One."
The Triple Aim, developed by Dr. Donald M. Berwick at the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI) before he ran the U.S. Centers for Medicare and Medicaid Services (CMS) in 2010-11, calls for care that produces better patient outcomes and improved population health at a lower cost. Triple Aim Plus One adds physician satisfaction, a concept Dr. Tom Doerr, director of innovation research at Lumeris, added in 2010 based on the work of the IHI and others in healthcare quality improvement.
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Doerr told InformationWeek Healthcare that he based the model on proven workflow strategies and accepted best practices, as well as research he conducted on accountable care. Lumeris is leveraging its own patient-clinician portal and online communications hub to assist in adoption of the Accountable Primary Care Model, which includes the following:
C1: First contact for each patient's health needs;
C2: Comprehensive care, spending more time with patients for most of their health needs and referring to specialists only when absolutely necessary;
C3: Continuous, longitudinal, person-centered care, including the development of personalized care plans;
C4: Coordinated care across the entire spectrum of providers;
C5: Credibility and trust through engaging communication that respects each patient's wishes;
C6: Collaborative learning, which means a dedication to IT-enabled continuous education about specific patients and medicine in general, collaboration with colleagues, communication across departments and organizations, and monitoring for safety, cost and outcomes;
C7: Cost-effectiveness by providing appropriate, efficient care to the right patient at the right place and the right time;
C8: Capacity expansion through new models of care that allow physicians, nurse practitioners, care managers, social workers and others to practice to the fullest extent of their professional licenses, as well as through electronic communications;
C9: Career satisfaction for physicians.
The first four items come from the patient-centered medical home concept. "The medical home is not enough but it's a good start," Doerr said. "There are important pieces in the medical home that are missing."
That is where the idea of the accountable care organization (ACOs) comes in. According to Doerr, ACOs are "blending the role of payers and physicians," Doerr said, echoing the sentiments of some entities that include both payer and provider elements.
Lumeris is a spinoff of such an organization, Esse Health, a group of about 70 primary care physicians in the St. Louis area. In 2004, Esse Health doctors started Essence Health Care, an insurer that offers coverage under the Medicare Advantage program, privately administered managed care for Medicare beneficiaries. Lumeris provides operational support to Essence Healthcare and Esse Health, as well as others, Doerr said.
One Esse-affiliated physician, Dr. Thomas Hastings, a solo practitioner in Chesterfield, Mo., has been sold on the idea of accountable care for a long time. "I like to think I've been doing this for 20 years," Hastings said.
"It's not rocket science. It's just taking a lot of common sense and bringing it together," he added.
Hastings said he receives 60% of his insurance reimbursements in the form of bundled payments or other risk-sharing formulas, and he has been participating in Medicare Advantage and its precursor, Medicare+Choice, since its inception in 1997.
Hastings said he goes to the Lumeris portal daily. "It allows us transparency to cost," listing the out-of-pocket patient responsibility for various services and prescription drugs, based on each person's particular insurance coverage and deductible.
Based on claims data collected by Essence, users can see if individuals have filled their prescriptions or have received recommended care, including preventive screenings. "I can look up to see if they've had a mammogram or a colonoscopy," Hastings explained.
He also can make sure he gets a clinical report if he sees a billing claim or, if there is a report but no claim, Hastings can know if a patient has gotten a health service or test elsewhere. "It's a way of closing the loop," he said.
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