The Spotlight on Improvement series highlights real stories of health care quality improvement.
January 26, 2021
Sue Birch, Director
Judy Zerzan-Thul, MD, Chief Medical Officer
Washington State Health Care Authority
626 8th Avenue SE
Olympia, WA 98501
Sent Via Electronic Mail
Dear Director Birch and Dr. Zerzan-Thul,
We write this letter, in partnership with the Purchaser Business Group on Health (formerly the Pacific Business Group on Health) and the undersigned organizations to express our support for efforts you are taking to transform the delivery of primary care in Washington state by engaging health plans, as well as health care providers in the development of a multi-payer model.[i] As business and union trust leaders that support the health and well-being of their workforces of approximately 350,000 in Washington state, the important role of primary care in a high-quality, efficiently delivered health care ecosystem is affirmed.
We understand that primary care has been historically under-resourced and that the fee-for-service payment mechanism does not provide reimbursement for many of the primary care services described below. We recognize that new financial incentives are required to change the current model to realize the aspirations we hold for primary care. We ask providers and health plans in Washington state to work together with those of us paying for healthcare services to generate new payment models that increase the proportion of health care spending on primary care, and to do so in a way that is aligned and reduces unnecessary administrative complexity on patients, purchasers, and providers.
Population-level payments in the form of per member per month amounts (care management fees in addition to fee-for-service or primary care capitation in lieu of fee-for-service) have demonstrated a return-on-investment in other settings.
The kind of primary care purchasers want from their investment in the healthcare system includes:
- Convenient and flexible care options that allow individuals to easily access the right care in the right setting when it is needed. This requires primary care providers to offer multiple modes of care (telephonic, video, as well as asynchronous modes including email, electronic messaging, etc.) and extended hours of availability. After-hours access is essential to avoiding the unnecessary use of costlier points of access, such as the emergency room.
- Team-based care that holistically support the needs of individuals. This requires a recognition that behavioral and social needs greatly influence health status, and primary care plays a central role in assessing and connecting individuals to the services required to address these needs. We do not believe it is necessary that all resources be physically present at each practice location for primary care to play an important assessment and coordination function.
- Care is continuous over time to support individuals with ongoing healthcare conditions, and coordinated across multiple settings as needed to support individuals with complex conditions requiring care outside of the primary care setting. This requires providers to invest in systems that support optimal patient support at the point of care while also providing population level insights that allow providers to proactively identify patients with gaps in their care plan. This also requires that primary care be connected outside of its own care setting to other providers (regardless of organizational affiliation) that also provide services to their patients.
- Care is culturally sensitive and is organized to address the needs of individuals, as well as populations. This requires improved competencies around language access and cultural humility, and infrastructure that supports equitable primary care access, communication and delivery.
We further request that any new prospective payment models be implemented by health plans and providers with the following considerations in mind.
- Payment approach and amount should be fully transparent to employers and union trusts that fund health care services on behalf of our plan participants.
- Payment models should be consistent across all payers/payer types in both the method of payment and performance measurement approach, such that it minimizes the administrative burden on providers, and supports a seamless experience for purchasers and their employees.
- Primary care providers eligible to receive new prospective payments must be carefully vetted to ensure they are willing to make the changes necessary to provide more coordinated, continuous, and comprehensive care. The level of prospective payment should be commensurate with their ability to deliver care that is truly differentiated through demonstrated differences in health care outcomes, as well as the experience of the patient.
- Primary care providers that receive prospective payments through new models must be held accountable for outcomes and measures of quality that are important to us as purchasers and to our plan participants as patients.
- Health plans and other key stakeholders that hold more complete information about the patients for whom primary care providers are held accountable must commit to providing a way for information to be shared in a real time, secure fashion to ensure optimal care at the individual patient and population levels.
- New prospective payment models will require that a members’ primary care provider be determined before payments can be made. The majority of the plans in Washington state are PPOs that allow plan participants open access to a broad network of providers. We ask that new mechanisms used to identify an individual’s primary care provider for prospective payment purposes be open and transparent such that we, as primary funders of health care services, can understand how our payments are applied, and individuals can understand which providers are accountable for their care.
- Understanding the health status and needs of individuals and populations is essential to building a primary care payment model that scales to the needs of the patient, just as patient care models must scale from keeping the healthy well to improving the health of those with complex chronic conditions.
We understand that purchasers have the ability to support the transformational efforts of providers and health plans, and agree to consider doing so in the following ways:
- Emphasize the importance of having a primary care provider and using that provider as the first point of contact for all new health care events and as a continuous source of coordination across the health care ecosystem.
- Support and/or advocate for mechanisms that provide our plan participants with a clear understanding of both provider quality and capabilities.
- Ask plan participants to identify their primary care provider of choice, voluntarily, with added incentives, or as a condition of coverage.
- Ensure there are no unnecessary financial obstacles that preclude the use of primary care as described above.
- Support differentiated copays (lower primary care vs. specialty care).
- Support implementation of the expanded definition of preventive services that allow specific services to be accessed before the deductible limit has been met in qualified high deductible
- Support differentials in primary care benefit designs that steer plan participants to high performing providers in instances when there is evidence of a clear difference in the outcomes of care for specific primary care
- Support and advocate for new payment models that meet the parameters described in this letter.
The kind of transformational primary care we describe and support in this letter is fundamental to the success of broader accountable care models that require all providers and health plans to work collectively to achieve the triple aim aspirations for health care – a better experience of care, healthier individuals and populations, and a lower per capita cost of care. We collectively support the efforts to transform primary care with the understanding that it is the foundation upon which future success is built.
Community Health Plan of Washington
First Choice Health
Kaiser Permanente Washington
Kaiser Permanente NW
Molina Healthcare of Washington, Inc.
Premera Blue Cross
Providence Health Plan
Washington Academy of Family Physicians
Washington Association of Community Health
Washington Chapter of American Academy of Pediatrics
Washington Chapter of American College of Physicians
Washington State Hospital Association
Washington State Medical Association
[i] Multi-Payer Transformational Model (https://hca.wa.gov/about-hca/multi-payer-primary-care-transformation-model).
Recent data estimates 22% of the state population or 1,269,000 Washingtonians have a diagnosable mental, behavioral, or emotional disorder. The problem is that for far too many, access to behavioral health care is not just limited, it is nonexistent. Some Washington counties have no practicing psychiatrists and for those that do, wait times for appointments are not measured in days or weeks, but months. Couple that with an increase in the number of people who have seriously considered suicide and that the highest risk of suicide due to the pandemic is expected to occur between October and December 2020 and put simply, we are facing a mental health crisis. Some mental health experts call it a perfect storm.
But this isn’t news. Limited mental health resources and the mental health workforce shortage is well-documented. Between 2017 and 2030, the expected number of new entrants into the field of psychiatry is woefully short of the number retiring. In ten years, the supply of psychiatrists, nurse practitioners and psychiatric physician assistants may help blunt the shortfall, but it will not offset it. In Washington state, there are several efforts to help improve available mental health resources.
To increase our infrastructure, there are new facilities in the works. In November, King County voters approved a $1.74 billion bond to support improvements over the next 20 years at Harborview Medical Center. Of that funding, $79 million is designated to expand capacity for Harborview’s behavioral health services and programs. In 2023, UW Medicine will open a new behavioral health facility to offer more treatment beds. For those interested in the field, there is an effort to create a Behavioral Health Support Specialist bachelor-level credential, and additional psychiatry residency and fellowship positions have been added to the UW School of Medicine. But these are long-term solutions. Given the importance of mental health access and its effect on better treatment adherence and patient outcomes, what we really need is to help health care providers who are de facto mental health practitioners now.
- The Psychiatry Consultation Line (PCL) is available seven days a week, 24 hours a day and helps prescribing providers with patients who are 18 and older. Started in July 2019, callers from primary care clinics, community hospitals and emergency departments, substance use treatment programs, county and municipal correctional facilities, and other settings, can get help with their patients’ assessment, diagnosis, and treatment planning, including medication management, from faculty of the UW Medicine Department of Psychiatry and Behavioral Sciences. Within 24 hours of the consultation, the provider requesting assistance receives a written summary of the recommendations. There are no restrictions on the number of times a provider may call the PCL at 877-WA-PSYCH (877-927-7924) and follow-up calls regarding a particular patient’s progress or changing needs are welcome.
- The Perinatal Mental Health Consultation Line for Providers (PAL for Moms) provides support for any provider caring for pregnant or postpartum patients (that includes midwives and doulas). By improving mental health for this population, experts believe more serious mental illness can be avoided. Started in January 2019, the consultation line is available weekdays from 9 am to 5 pm. Common topics of consultation include anxiety, depression, substance use disorders, or other psychiatric disorders, such as bipolar disorder or post-traumatic stress disorder. Callers to PAL for Moms at 877-725-4666 (877-PAL4MOM) will consult with faculty members with perinatal mental health expertise at the UW Medicine Department of Psychiatry and Behavioral Sciences and will receive written recommendations following the consultation.
- The Partnership Access Line (PAL) was the first psychiatric consultation line established in Washington state, started back in 2008. Now it provides mental health support for primary care providers caring for pediatric and adolescent patients regardless of insurance type in Alaska, Washington, and Wyoming. In Washington, in addition to providing psychiatric consultation, a master’s level social worker is available to assist doctors, nurse practitioners, and physician assistants with finding mental health resources to help patients under 18 years old, weekdays from 8 am to 5 pm at 866-599-7257. Based out of Seattle Children’s and staffed by psychiatrists with expertise in child and adolescent psychiatry at Seattle Children’s and the UW Medicine Department of Psychiatry and Behavioral Sciences, assistance was provided to 3,218 calls to PAL in the 2019 to 2020 fiscal year.
While these consultation lines cannot address our state’s mental health crisis in totality, they are critical to helping caregivers provide patients with important mental health treatment support now. “These psychiatric services help ensure children and adults with behavioral health needs receive high-quality services at the right time and in the right setting,” said MaryAnne Lindeblad, State Medicaid Director at the Health Care Authority. “We hear regularly from providers how important these services are to helping them with complex medication, diagnosis and treatment situations. These services also help to keep the care with local community providers, which is good for the patient, their families and the system.”
Feedback to the program has been overwhelmingly positive, with comments from providers such as “amazing,” “fantastic,” and “wonderful.” One captured the downstream effects perfectly, “It makes me feel so much more confident to know that I have an expert available for tricky questions, and then I can apply that knowledge to my next patient in a similar circumstance.”
You can help spread the word about these valuable resources, by passing them along to an individual or organization that can help get the word out to providers.
The Washington Health Alliance (Alliance) and Bree Collaborative (Bree) at the Foundation for Health Care Quality are teaming up to encourage everyone involved in the Washington state health care system to act to improve health and health care for all Washingtonians. Bree Chair Dr. Hugh Straley and I asked participants at the close of our recent Value-Based Care Summit (recording available here) to join this effort and make it a priority.
At the Summit, we heard Washington State Health Care Authority (HCA) Director Sue Birch and Chief Medical Officer, Dr. Judy Zerzan-Thul discuss the ways in which HCA is advancing the adoption of value-based payments on behalf of the Washingtonians it represents, which includes all public, and many school district employees, along with those who access care through the state’s Medicaid plan, Apple Health. The HCA has made steady progress towards the goal of driving 90% of state-financed health care to value-based payment by 2021, but to help realize the changes required to fundamentally shift the way care is delivered in the state, all stakeholders need to act.
We are delighted to be partnering with the Bree on this important initiative. Watch your inbox for a special joint communication that will give you the opportunity to make public your commitment to change as we prepare the ways we will support your efforts. In the meantime, I hope you will consider some of the Alliance’s many resources that can help you achieve your organizational goals to increase value-based care.
If you are a purchaser:
- Make the commitment to purchase for value and educate employees why this is important to their health and well-being. Compare how medical groups and clinics rank across the state with the Quality Composite Score and see the 10 services that accounted for 94% of the low-value care analyzed over four years in the latest First, Do No Harm report, and incorporate these findings into benefit plan design.
- Ask health plan partners, brokers and consultants about the contracts health plans have in place with providers to reward high value performance and how that high value care is best accessed by your employees.
If you are a provider:
- Review the Alliance’s Quality Composite Score to see where you are doing well and which areas could use some attention across 29 measures considered strong indicators of primary care quality. Have you incorporated these findings into your quality improvement priorities for 2021?
- Evaluate how much low value, non-evidenced based care you are providing. The Alliance’s First, Do No Harm report identifies 47 measures of common treatments, test, and procedures identified by Choosing Wisely® and the medical community to be overused. Compare these results to your internal data and identify opportunities for improvement.
- Recognize that there is tremendous variation in practice patterns in our state. What operational steps are you taking to raise the practice level of all practitioners within your group to as close to the 90th percentile of national performance metrics as possible?
If you are a plan:
- Consider whether your value-based plan offerings balance quality and cost performance of providers, or are they more heavily weighted toward cost savings? Increasing high value cost-effective preventive care, particularly for people with chronic diseases, for example, can result in better outcomes, and significant long-term cost savings.
- Can we work collaboratively to develop a common set of quality performance measures to really move the needle on improving the quality of care in Washington, while minimizing administrative burdens for providers that have a different set of measures for each health plan they work with?
It’s true that no one stakeholder group can move the market to value alone. By working collectively, I know we can make this happen.
All the best,
You often hear me talk about driving our work to action and I’m delighted to share some exciting news on a project that will do just that. The Alliance has been awarded a $350,000 grant by Arnold Ventures to work with self-funded purchasers to improve the value of care delivered across Washington state. Arnold Ventures, a philanthropy dedicated to improving lives by investing in evidence-based solutions is focused on four areas, criminal justice, education, finance, and health. It has funded more than a thousand projects since 2010, supporting “efforts to understand problems and identify policy solutions.”
This grant will enable the Alliance to assess the value of the care received by enrollees of up to eight employers and provide targeted technical assistance to help each employer implement effective strategies to reduce low-value care and increase high-value care. The work will occur in two phases. First, we will use the Milliman MedInsight™ Health Waste Calculator to analyze claims data for each purchaser to get results that are specific to its covered population. Then, we will bring together purchasers, commercial payers, and clinical leaders to develop strategies and provide technical assistance necessary to help ensure patient and clinician incentives are aligned to support the delivery of high-value care. Interventions will be designed with the specific purchaser’s needs in mind, but we expect it will be a combination of benefit coverage and design, shared decision-making, and consumer education. The results of the case study will be published in a white paper summarizing key findings which can potentially be used by policy practitioners and healthcare experts to improve the value of care delivered and increase the efficiency of healthcare delivery across the country.
Our Director of Performance Improvement and Innovation, Karen Johnson, will be leading the effort and we are fortunate to have expert advice from Dr. A. Mark Fendrick, who conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan. Most recently, Fendrick built on the decades long work in VBID and introduced VBID-X, a cost-neutral approach that encourages the reallocation of savings derived from reductions in low-value care to support an increase in the use of high-value services. In “V-BID X: Creating A Value-Based Insurance Design Plan for The Exchange Market”, Fendrick and his colleagues described this concept stating that “By abandoning blunt cost-sharing strategies and using a more clinically nuanced approach, V-BID X plans incentivize consumers to use more of the services that improve their health and less of those that don’t.”
In our latest First, Do No Harm Report, we said that “transparency is foundational for taking action – shining a light on low-value care, unwarranted variation, and the opportunities it presents. But taking action is paramount.” I’m proud that we will have the opportunity to take action with purchaser members who are dedicated to reducing low-value care and to strategize with provider and health plan members on ways we make these changes happen together.
I look forward to reporting on our progress at driving greater health care value.
All the best,
Pregnancy causes changes that cascade through a woman’s life and that of her family, and can have large health impacts—especially for those already struggling with chronic disease, poor mental health, or stressful circumstances. We now know that pregnancy timing and circumstances affect not only a prospective mother’s health but also the wellbeing of her children. A woman’s pre-pregnancy status can shape her child’s developmental trajectory and risk of chronic conditions decades later. But in Washington State, 37 percent of pregnancies are unintended, a measure that is included in the Washington State Common Measure Set for Health Care Quality and Cost. Such a rate does not allow many women and doctors to build preconception resources that support healthy pregnancy, healthy babies, and healthy parenthood.
State-of-the-art contraceptive technologies—long acting “get-it-and-forget-it” IUDs and progestin implants—are 20 times as effective as the Pill. They dramatically reduce mistimed or unwanted pregnancy, as shown by the Colorado Family Planning Initiative, which cut teen births and abortions nearly in half and reduced preterm births. Professional bodies now recommend implants and IUDs as top-tier protection for most women, including teens and those who are HIV-positive. But busy primary care providers often don’t know whether a patient wants to get pregnant or avoid pregnancy, and so may miss opportunities to help patients.
With unintended pregnancy so common and the consequences so significant, the American College of Obstetricians and Gynecologists now recommends that health care providers touch on reproductive life planning at every visit with reproductive-age women. Clinicians want to help their patients manage health conditions and stack the odds in favor of flourishing children, but are swamped with ever more tasks and topics to cover and ever smaller chunks of time in which to address them all.
The Oregon Foundation for Reproductive Health, a Portland-based nonprofit, has developed a simple, quick method called One Key Question® (OKQ) to screen routinely for pregnancy intentions in reproductive age patients. The one key question is this: “Would you like to become pregnant in the next year?” The clinician documents one of four patient responses: Yes, I’m OK either way, I’m not sure, or No, followed by evidenced-based care that supports their answer.
Patients who respond yes receive preconception counseling, which identifies health behaviors change or care that could support a healthy pregnancy. Patients who feel uncertain or ambivalent receive information about preconception care as well as contraception. A response of no leads to a conversation about family planning options, giving an opportunity to check in on current satisfaction and explore less familiar methods that might better fit. Inexpensive posters and tear sheets from the National Campaign to Prevent Teen and Unintended Pregnancy and a color coded medical eligibility chart from the CDC make it easy to step through family planning options
One Key Question is rapidly becoming a national model. One example is the state of Delaware, where Governor Jack Markell partnered with Upstream USA to retool contraceptive care statewide, so that women can receive the method of their choice same day, free of charge—including IUDs and implants. The upgrade, called Delaware CAN, included OKQ screening to identify the preventive reproductive health needs of patients.
In Oregon, OKQ is being deployed in a variety of settings, from home-visiting and WIC to primary care. A pilot project at One Community Health compared two major health centers, one in which OKQ was implemented and one without. At one month, 64% of electronic medical records for the intervention site documented appropriate screening for pregnancy desires, compared to 12% at the non-intervention site, suggesting that staff were able to incorporate the change into their normal workflow of patient care.
Even for clinicians who would like to improve reproductive outcomes for their patients, adopting a screening protocol such as One Key Question can be challenging.
- Sexuality and reproduction can be sensitive topics for providers as well as patients. In particular, those women who are young, poor, ethnic minorities, or in ill health can feel shamed or pressured unless conversations are carefully client-centered. That said, women say that they want their providers to ask.
- At a practical level, incorporating the OKQ algorithm into varying electronic health records continues to be a major barrier for health centers that want to use OKQ in a systematic and routine way.
- Asking about pregnancy intentions can uncover desire for better birth control or for preconception care, requiring staff training or other increases in capacity. (The “Beyond the Pill” program at UCSF offers onsite trainings to clinics wanting to upgrade contraceptive services, with grant funding for those that qualify.)
Keys to success
To ensure program excellence and compatibility of evaluation across settings, the non-profit Oregon Foundation for Reproductive Health trademarked One Key Question and asks for a signed memorandum of understanding prior to implementation. In settings that have adopted OKQ, the following components have been keys to success:
- Conduct comprehensive training with health center team before roll-out
- Integrate screening into current workflow practice
- Renew protocols or referrals for preconception and contraception care
- Develop a plan to evaluate impact of screening on other services provided
To learn more about One Key Question or to sign up for a monthly newsletter, please contact email@example.com.
CHI Franciscan is making great strides to reduce avoidable emergency room use. By focusing on providing their patients alternatives to more costly emergency room visits, they have become top performers in the region for their low rates of avoidable emergency room use.
Inappropriate use and overuse of antibiotics is a serious public health threat and is addressed by several specialty societies’ recommendations in the Choosing Wisely campaign. Learn how Virginia Mason reduced their inappropriate antibiotic use by over 50 percent in this month’s Spotlight on Improvement.
Swedish Medical Center: Rethinking the practice of ordering daily labs to reduce waste and improve careNovember 2014: Swedish Medical Center, Seattle, Wash.
Read how Swedish Medical Center is making a big impact through a simple, innovative solution—changing the practice of ordering “daily labs,” or a lab automatically ordered for every day a patient is in the hospital. Following Choosing Wisely recommendations, Swedish Medical Center encourages physicians to only order tests that are clinically relevant. The results? This simple process change is resulting in 14,000 fewer unnecessary lab tests annually.
Choosing Wisely® is a national initiative helping physicians and patients have conversations about the overuse of tests and procedures and supports physicians’ efforts to help patients make smart and effective care choices. Read how one health system has successfully embedded the recommendations into their existing quality improvement culture.
How do you successfully manage the health of a population? Pacific Medical Center did so by creating a strong patient and service-focused team environment. They built a robust quality infrastructure that uses patient registries and reporting to facilitate proactive care, developed improvement initiatives through patient care committees and focused on continuous improvement through internal and external benchmarking. Their hard work and focus on continuous quality improvement is clearly seen in their above average quality scores in the Community Checkup.