- Kenny Lin, MD, MPH
Much has changed in the past six years since our last Health Policy Journal Club at Georgetown. Our residency, formerly a collaboration with Providence Hospital, is now known as the Medstar Health/Georgetown-Washington Hospital Center Family Medicine Residency Program. I stepped down as director of the Robert L. Phillips, Jr. Health Policy Fellowship three years ago, though I still enjoy working alongside these talented family physicians in clinic, such as Dr. Brian Antono, who recently blogged about his fellowship experiences for Harvard Medical School's Center for Primary Care. And this academic year I am not only working remotely due to COVID-19, I am more than 2,000 miles off campus as a visiting professor at the University of Utah in Salt Lake City.
What hasn't changed is that our family medicine residents remain excited about health policy and advocacy. Since their continuity clinic continues to be located in Maryland, we decided that a great topic to revive this series of seminars was the Maryland Primary Care Program (MDPCP), which was recently featured in a Milbank Memorial Fund Issue Brief.
MDPCP is a multi-payer "advanced primary care" program modeled after previous patient-centered medical home projects such as the Center for Medicare and Medicaid Innovation's (CMMI) Comprehensive Primary Care initiative. CMMI partnered with Maryland's Department of Health to launch MDPCP last year with Medicare as the first participating payer. (CareFirst Blue Cross Blue Shield joined the program in 2020.) With 476 participating primary care practices, MDPCP provides prospective, non-visit based payments known as "care management fees" and operational support from a program management office and Care Transformation Organizations (CTO). According to MedChi, the average practice received $176,000 in care management fees in 2019.
Interestingly, Medstar not only participates through its network of Medstar Medical Group practices, but is also a CTO serving Medstar and non-Medstar practices throughout the state. MDPCP practices must implement "data-driven, risk-stratified care management," integrate behavioral health services, screen patients for social needs, convene a patient advisory council, and use health information technology for continuous quality improvement.
We spent some time discussing one unique aspect of MDPCP, a tool to reduce avoidable health services developed by the University of Maryland's Hilltop Institute. This electronic tool uses artificial intelligence to sift through patients' demographics, claims, and other data to produce a list of those with the greatest likelihood of an emergency department visit or hospitalization, theoretically allowing primary care physicians to intervene to prevent the event and its associated medical expenses. However, it wasn't clear to us how easy it would be to apply this information, given that we usually need to prioritize patients on the schedule for that day.
Another feature of the program allows MDPCP practices to identify "high-volume, high-cost specialists" in order to "focus attention on the relative costs between specialists and to have providers engage specialists in conversations and cooperative agreements about creating value." First, though it may be helpful to know which subspecialists are more likely to prescribe (possibly inappropriate) expensive tests or procedures, the tool does not measure excellence in other areas, such as patient satisfaction and quality of communication with primary care physicians. Also, patients may not have a choice of specialists, depending on the insurer's network. Finally, it seems awkward and unrealistic for a family doctor to tell a specialist that his or her practice style is too aggressive, even if there's good data to back it up.
MDPCP promises to narrow the primary care-subspecialist reimbursement gap and provide opportunities to improve patient care in the short term. However, expecting primary care practices to bend the health care cost curve on their own, even with additional funding and support, may backfire in the long run. Whether MDPCP represents incremental progress in primary care, or a genuine breakthrough, remains to be seen.
