Dr Carol Regueiro: Integrating Team-Based Care, Shadow Bundling for Improved Patient Outcomes

In this interview with The American Journal of Managed Care^® (AJMC^®), Carol R. Regueiro MD, MSc, director of complex care transformation at Allegheny Health Network (AHN), discussed the Physician Partners of Western PA (PPWPA) practice support model, a clinically integrated network designed to enhance care quality and efficiency through team-based support in primary and specialty care.

She also highlighted the shadow bundle distribution model, a non-contractual, year-long cost-management approach within the network. Unlike traditional, time-limited CMS bundles, it holds physicians accountable for total patient care costs.

Additionally, this approach fosters collaboration between primary and specialty care teams, as seen with the role of PPWPA's congestive heart failure (CHF) group in managing emergency department (ED) utilization, enhancing patient education, and improving care integration.

This transcript has been lightly edited for clarity.

Transcript

Could you begin by discussing the Physician Partners of Western PA (PPWPA) practice support model and its key components?

PPWPA is our clinically integrated network (CIN), and it's a regional collaboration of physicians who are committed to doing efficiency and quality work together.

Our support model really evolved with primary care physicians, initially, with an effort to build in team-based care that they could access for their patients, including dieticians, behavioral health, social workers, etc. That model, we found, has been very helpful, and that's been a key to our thinking about leveraging support for patients in these specialty bundles.

What is the shadow bundle distribution model? How does it function in practice?

The shadow bundle has really grown out of our Medicare Shared Savings Program (MSSP). The shadow bundles, we call them shadows because they're not contractual with CMS, they're within our own CIN. How we've structured them is, at the beginning of the program, we identify which physicians are part of the group that's in the bundle.

For our cardiology group, we identified those practices and the associated patients at the beginning of the year. Then, we can accrue patients if we get patients who see those physicians up to June 30, so halfway through the calendar year.

Those physicians are responsible for the total cost of care of those patients. I think it's notable that in contrast to CMS's other types of bundles, like BPCI [Bundled Payments for Care Improvement], etc, it's not a 90-day thing. It's a whole year, and it's not disease-specific. It really entails everything, which is a big shift in how specialists think about that.

If we succeed in MSSP generally and have gained shares in MSSP, then we look at the money we've earned. There's a 20% holdback for the organization for infrastructure, etc, and then that money gets allocated back to cardiology, the remainder, based on the proportion of patients they're seeing, so the number of attributed members.

How does the shadow bundle distribution model align with the PPWPA practice support model?

I think the distribution model aligns in a lot of ways because it helps reinforce and support some of our team-based care work. I also think that because it has both primary and specialty care physicians involved, it has really leveraged interaction between the 2 groups, probably more than the traditional referral letter.

I think, first of all, we were lucky to have a very proactive and collaborative CHF physician group that had a really robust pathway, but they were willing, as we moved along, to consider how the pathway could integrate more with our primary care practices. Examples would be when we've asked them to be responsible for ED use, even if it's not CHF.

Initially, the specialists were like, "What are we supposed to do about that?" We said, "Well, the biggest thing is to educate your patients about primary care and how to access appropriate sites for nonurgent types of things." That's been a pretty successful work stream and also has helped us really change the culture in specialty care.