How COVID-19 May Drive Changes in Health Care Delivery, Investment in Value-Based Care

As coronavirus disease 2019 (COVID-19) continues to drive significant change in health care delivery, physician leaders affiliated with the Council for Accountable Physician Practices (CAPP) have worked to increase investment in strategies to address disparities in care exacerbated by the pandemic, such as value-based care and telemedicine, said Norman Chenven, MD, vice chairman of CAPP.

Transcript

AJMC^®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care^® is pleased to welcome back Dr Norman Chenven, vice chairman of the Council of Accountable Physician Practices, or CAPP. Norman, great to have you back, can you just introduce yourself and tell us a little bit about your work?

Chenven: Sure. I'm Norman Chenven, a family practitioner by training. I'm the founding chief executive officer of Austin Regional Clinic—we’re a large medical group of 340 physicians with about, I'm going to say about because I'm not sure if we've opened our most recent clinic, but about 29 locations in 4 counties surrounding Austin, Texas. Our group has been involved in managed care, capitated care, and so on for many years, that's really been our focus, as we've grown.

AJMC^®: To start us off, can you speak on the opportunities presented by the COVID-19 pandemic in regards to how health care is delivered and perceived?

Chenven: Well, I know that COVID-19 was a surprise for everyone. Certainly, in my career, I've never seen anything quite like it. It's a tricky disease. It's been very poorly understood, and we're just now getting our arms around it. The most fascinating part of this is that it has forced the health care industry to respond to “it.” We've been chasing after “it” for quite a while.

So, our group started this year as a very active, growing practice, a lot of excitement, things were going very well, and then in mid-March COVID-19 hit and it was like going off a ledge. Visits dropped by, I would say 30% to 40% overnight, literally overnight. By the third week of March, we were standing around wondering what hit us. And then there was time to react and start designing what we were going to do with telemedicine.

We have spent many years trying to evolve and develop telemedicine with very little success. We had, I would say maybe 2% to 5% of our visits being on telemedicine until COVID-19 hit and then within a matter of 7 to 10 days, 70% of our visits were on telemedicine. It was a challenge, but it was also a credit to our staff and the way we're organized to be able to respond that way.

It still remains a difficult disease to manage. It has changed the way we bring people into the office. It's changed the way the rhythms of the office go and so on, but it's been a great success to be able to respond to it, and it's really empowered our organization as an organization.

AJMC^®: Aligned with these challenges, recently, the CAPP conducted interviews with participating physician leaders of multispecialty medical groups and health systems on their current strategies of health care delivery, as well as future plans. Based on findings of the interviews, physician leaders cited 6 major initiatives that they think should be encouraged to shape the health care system post-COVID-19. Can you speak further on each of these initiatives?

Chenven: Yes, so these initiatives are really the result of many, many years of CAPP work, meetings, studies, and so on. What has happened though, they've all come to support the way we responded to COVID-19. So again, it is a situation where all this planning is rewarded. All of this thinking about how health care should be delivered is rewarded–in a challenge, in an emergency like that of COVID-19.

So, the first and really basic principle is a business model of medicine that we all would prefer. We all have mixed business models at this point, but paying for value, being paid for taking care of patients, for the outcomes, for keeping people healthy, and out of the hospital—we all have contracts like that. Not all of our contracts, there's still a lot of fee-for-service, which pays for unit services—very transactional. It's not a relationship thing, but paying for value is something that helped us, because in the COVID-19 situation where the visits fell off abruptly, because we had pay-for-value contracts, we weren't affected as badly as other groups that do not emphasize that kind of contracting.

The second thing is investing in remote care—that's been part of our ethos for a long time, every one of the CAPP groups have very, very strong electronic medical record systems. Everyone has the patient portal so that we can do telemedicine visits. All those patient portals are linked to the record, so we have a record of all the conversations and what has been given. And multispecialties can look into and see what other specialties are doing. So, we've invested in that and this was the payoff, we were able to take really good care of our patients.

Another piece that we do as part of value-based medicine is try to deliver care at home. There's so many patients that struggle with mobility, patients with chronic problems. They don't want to be back and forth to the clinic to get their services and treatments. So, there's a lot of technology available today and for the sickest of our patients, bringing the technology into the home and monitoring from home, telemedicine visits, that is a boon to the patients, it's actually considerably less expensive to the system, and you get much better outcomes. Families are better served, as well as the patients.

Primary care, if you are trying to deliver care in an organized way in a coordinated way, you want to facilitate that by having every patient have an access point into the system as opposed to making it up as they go along. Oh, my ear hurts, should I call an ENT [ear, nose, and throat] doctor? No, if you have a primary care doctor and that doctor’s staff, you can get advice without having to come in for a visit. You don't have to guess where you're going, it can be directed, and there's a coordination and a connection between primary care and the delivery system. So, that's another major principle that we've always believed in, and it is shown to be very, very valuable in a setting like this.

Social determinants of health (SDOH) has recently become a major discussion and COVID-19 really pulled back the curtain to show just how how much differential there was in access to care, the quality of care, and ability to do well when COVID-19 hit, because communities of color or communities that are underserved and don't have the resources really suffered tremendously.

All of our organizations work through not only commercial insurance, but Medicare and Medicaid, and we've always been working on solutions to these things. Now, I think none of us understood quite the impact that something like COVID-19 can have; hopefully that will enable and energize us, as well as the political system, to start responding and figure this thing out better.

It has cost the United States dearly to not have invested in dealing with SDOH and not doing a good job in dealing with disparities, because in the end, we're going to end up taking care of very sick people where we could have intervened much earlier and in a much more organized way.

Lastly, as I mentioned earlier, our organization CAPP was founded by leading physicians and leading medical groups, feeling that physician voice and physician leadership needed to be heard more. The health care system is huge, it's complicated, it's a beast, and there was a sense years ago and really still that physicians are not heard enough. The insurance industry, pharmaceutical industry, and frankly, the hospital systems often have a louder voice and more influence.

Physicians should be really consulted much more and put in positions of leadership, all of the CAPP groups have extremely strong, coordinated, organized groups of physician leaders who work for the values of those groups, in terms of delivering care, as best as we can in the most creative and practical ways that we can.