WASHINGTON, DC—If fledgling efforts to improve quality and lower costs by focusing extra primary care attention on patients with complex conditions are to succeed, ensuring physicians and patients are on board will be key, accordingto a new qualitative study by the Center for Studying Health System Change (HSC) for the nonpartisan, nonprofit National Institute for Health Care Reform (NIHCR).
So-called high-intensity primary care programs typically focus on a subset of patients with complex or multiple chronic conditions, such as diabetes, congestive heart failure, obesity and depression, providing them with additional care coordination, management and health education far beyond what is offered in traditional primary care practices. The high-intensity primary care model typically involves primary care physicians (PCPs) supported by care coordinators who help complex patients navigate the health system, adhere to treatment plans and improve self-care of their conditions.
A number of factors can foster physician and patient engagement in high-intensity primary care programs, the study found. For physicians, key factors include a say in which patients participate; financial commitment and administrative support from health plans; and well-designed financial incentives for quality and outcome improvements.
To encourage patient engagement, a personal invitation from physicians to join a high-intensity primary care program, as well as rapid access to physicians and care coordinators, appear to be highly successful approaches, according to the study.
“Early assessments of high-intensity primary care programs show promise, but engaging physicians and patients will be key to whether these programs succeed more broadly in improving quality and lowering costs,” said Tracy Yee, Ph.D., HSC researcher and coauthor of the study with Amanda Lechner, M.P.P., HSC health policy analyst; and HSC Senior Researcher Emily Carrier, M.D., M.S.C.I.
The study examined approaches to patient and physician engagement in six high-intensity primary care programs in New Jersey, New York, Washington, Oregon, northern California and multiple sites across the Southwest. There are three general approaches to high-intensity primary care: freestanding, practice-based and hybrid models. Regardless of approach, the goal is the same: Targeting high-intensity care to the right patients and motivating physicians to provide that care effectively by working with and supporting the efforts of care coordinators.
The study’s findings are detailed in a new NIHCR Research Brief—High-Intensity Primary Care: Lessons for Physician and Patient Engagement—available online at www.nihcr.org/publications/high-intensity-primary-care/. Other key findings include:
- Committed payers/purchasers are crucial to the development of high-intensity primary care programs. When a single payer—sometimes a self-insured employer—accounts for a significant proportion of a provider’s patient panel, that payer has both the leverage to negotiate successfully for changes in care delivery and the patient volume to enable providers to make changes more efficiently. If multiple payers are participating, standardizing elements of the program proved useful.
- Physician engagement requires significant time and resources. Programs relying on existing independent primary care physician practices invested heavily in recruiting PCPs to participate. Leaders of a high-intensity primary care program working with independent practices reported the physician recruitment process took three to six months and included cultivating relationships not only with physicians but also other clinical and front-office staff.
- Identifying the right patients can improve physician engagement. Primary care physicians reported frustration with high-intensity programs when health plan algorithms identified patients who the physicians themselves did not identify as high need. When algorithms were seen as error filled, physicians lost trust in the program.
- Overcoming physician reluctance to delegate tasks important to engagement. Primary care physicians in some sites initially were reluctant to delegate tasks to care coordinators. Over time, the presence of on-site care coordinators promoted PCP engagement, since care coordinators were able to develop rapport with patients and take over certain tasks, creating an immediate and concrete benefit to PCPs.
- Transfer of trust key to patient engagement. Because patients have little experience with high-intensity care, they may have difficulty appreciating the benefits, such as having a health coach or learning more about their chronic conditions, until they are in the program. Nearly all respondents reported that patients are much more likely to enroll if their own physicians invite them and explain the advantages of high-intensity primary care.
- Patients value rapid access to care providers. The strongest selling point for patients is the prospect of direct access to their care coordinator via phone or email, which allows them to schedule appointments, follow up on test results, and speak to their physicians in a timely manner.