How one primary care practice innovated to improve outcomes for high-risk Medicare patients

To improve the U.S. healthcare system, it might help to start by optimizing care to the patients who use the lion's share of its resources: seniors with multiple chronic conditions.

One innovative Florida primary care practice has done just that - increasing patient satisfaction, boosting the amount of time doctors and patients spend together, improving patients' medication adherence, and achieving lower rates of hospital use than its peers, according to an report in the June issue of leading health policy journal Health Affairs.

ChenMed is a primary care-led group practice that serves low-to-moderate-income elderly patients with an average age of 72 through the Medicare Advantage program. In 2011, 73% of the practice's patients had five or more chronic conditions. That's significant, because patients with five or more chronic conditions are responsible for more than 79% of Medicare spending, up from 50% about 25 years ago, according to Health Affairs.

The practice has won some notable fans. Bob Kocher, a venture capitalist and former health policy official in the Obama administration, says ChenMed "may be the best primary care system in the U.S."

A little more background on the practice: Nearly all of its patients are enrolled in Medicare Advantage, which is advantageous for the practice because the program uses a risk-adjusted reimbursement model that offers higher reimbursement - and therefore reduced risk - in caring for patients with multiple chronic conditions. Additionally, Medicare Advantage's capitation model has proven more favorable to the practice than traditional fee-for-service.

"Because providers are paid according to the size of their patient panel in a capitated system, they have an incentive to develop and test innovations to determine which ones lower the cost of care without compromising quality—and, ideally, increase it," the report states.

Ultimately, one of the biggest reasons for ChenMed's success is that it has optimized its delivery system for risk- and value-based payments, as opposed to fee-for-service. "Some systems may try to have it both ways, but this can be exceedingly difficult," the report states.

Here are five key elements of ChenMed's model:

Convenience and access: The practice offer a broad set of additional services on site, including dental care, digital x-ray, ultrasound, and acupuncture, as well as five to 15 high-volume specialists. Because access to care is a major issue with seniors, the practice provides door-to-door van transportation at no charge.

Patient and physician time: The practice's primary care physicians, all internists, have a panel of 350 to 450 patients, and those small panel sizes allow physicians to spend more time with their patients. With lowered barriers to access, patients visit the practice more frequently for care; an average of 13 times per year in 2011. This enables physicians to better educate and coach patients on behavior change and enhances doctors' ability to provide "the kind of compassionate, personalized care" that requires time and familiarity, according to the report.

Dispensing of prescription medications: To boost medication adherence, physicians dispense presealed medications at the time of the patient visit. As a result, patients are then more willing to discuss side effects and other issues that interfere with medication adherence, the practice's physicians report.

Physician culture: ChenMed seeks to promote a physician culture of collaboration, transparency, and accountability for high-quality care. The practice's primary care physicians meet three times a week to review hospitalized patients and discuss complex cases and practice approaches, and are sometimes joined by specialists and hospitalists. The practice has also designed its office space in a way that promotes physician collaboration and communication, the report says.

Customized electronic health records (EHR) and decision support: The practice developed its own in-house EHR system and has customized it for use with chronically ill patients. The system requires much less documentation than most off-the-shelf EHRs, allowing physicians to make concise notes, which enhances their productivity.

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