Dr Melissa Levine on Implementing Value-Based Care in the Primary Care Setting

Value-based care initiatives have gained traction in the oncology space, and an American Journal of Managed Care^® (AJMC^®) Institute for Value-Based Medicine^® event hosted in tandem with Arizona Oncology saw a panel of oncologists and primary care providers provide insight into opportunities for care improvement, cost savings, and collaboration between clinicians.

Melissa Levine, MD, Arizona Community Physicians, Abacus Health

In an interview with AJMC, Melissa Levine, MD, a family medicine specialist at Arizona Community Physicians and medical director for the Abacus Health accountable care organization (ACO), discussed strategies for success in an ACO and how primary care can complement oncology care for patients diagnosed with cancer.

This interview has been edited for length and clarity.

AJMC: In your experience with Abacus Health, what population health strategies do you think have been most impactful in improving quality measures and mitigating health care costs?

Levine: One of the things that Abacus introduced was a goal that is bonused for Medicare annual wellness visits. This was really the first requirement we had. Arizona Community Physicians is a physician-owned, physician-run group—that's a lot of different individual physician practices that came together for the scale, so when the ACO was formed, a lot of what we did was trying to herd the cats. The first value-based measure we did was requiring 70% of our Medicare-aged patients to have an annual wellness visit. And quite honestly, I think that has been the biggest difference in terms of quality scores and cost savings.

It wasn’t payer-driven—we try to be payer-agnostic—but if you have your annual wellness visit, you're more likely to have your mammogram, you're more likely to have your colon cancer screening, you're more likely to have your pneumonia shot and your flu shot—and now your [respiratory syncytial virus] shot. So, that was the first thing we did, and some of our doctors were unhappy about it, but our rate of annual wellness visits went from, if I recall, around 48% to maybe 72% in the first year.

If you didn't have a 70% or greater annual wellness visit rate, you lost a significant chunk of money. Now, some doctors considered that a stick and thought we should be providing carrots, not sticks. But the answer is if you do that, it's a carrot. It wasn't your money. It was value-based money that came into the group, and if you help elevate the group on the value-based contracts, you get that carrot. And now we have multiple other models. We have controlling high blood pressure, we have controlling diabetes, we have transitional care visits. We have those various things, but the first—and I think the greatest—was annual wellness visits.

AJMC: What tools or resources are most important for fulfilling the goals of an ACO or for pursuing value-based care initiatives in general?

Value-based payments are probably the biggest tool. It's a lot of clicks, right? There's [electronic health record] fatigue. And if I'm asking myself—or the 120 doctors in our organization—to click a bunch of boxes, to find these things, to order these things, to do these things, money is a big motivator for that.

In terms of other tools, we have internal analytics. I get a list of my highest cost patients every month. And—this was originally sent in a list, and now it's a report that's run in EPIC—I have my diabetic patients that aren't controlled or haven't had a [hemoglobin] A_1c, or my patients whose last blood pressure was not controlled, so that I can get those patients in. I can run the report of my patients who haven't had their annual wellness visit and are due.

So, our internal analytics [system] is a huge tool that we use. But I do think the resource of bonusing doctors who do well on their quality measures helps. Primary care doctors want to do the right thing by their patients, but the money is a nice reward for doing the right thing.

AJMC: How can primary care providers help facilitate value-based care for patients diagnosed with cancer?

I think primary care doctors can promote palliative care, which I think is huge for oncology patients. Most oncology patients should be in a palliative program while they are undergoing treatment where side effects can be aggressively managed. Quite honestly, I think that program should be coordinated by the primary care.

My goal for a palliative program would be that a patient who has a serious illness gets a consult with a palliative care doctor, who then basically writes out a plan saying, “This is what you do for pain control, this is what you do for nausea and vomiting, this is what you do for diarrhea. These are the steps you can go through to try and take care of those things at home,” and sends that plan to the primary care doctor. And then the primary care doctor, who knows the patient best, sees the patient depending on where they are on the spectrum of low risk, moderate risk, high risk, or should be in hospice, and implements that plan with the patient. That would be the ideal goal.

That would lower costs and improve quality of life for those patients, so if I had my magic wand, that is what would happen. I would have a palliative care consultant, and they would then give me the plan, and I could follow it. And if things escalated and I needed another consultation, OK. But for the most part, if they gave me a comprehensive plan, I could manage it. And then I can say to the patient—who I've known for the past 25 years—that this is what we're going to do now. And as part of that, the primary care doctor is discussing goals of care repeatedly, because goals of care change, right?

When a patient of mine is diagnosed with a serious cancer, the first thing I tell them is, “You are the captain of the ship, it's not your oncologist. You get to decide if you want to do a treatment or not.” So many times—and it happens with other specialties, as well—it’s, “We did this and it didn't work. Okay, now we're going to do this, and now we're going to do this.” And the patient's wishes get steamrolled, and they don't get to decide. So, that's the first thing I say: “You get to decide—you get to decide how aggressive you want to be, what you want to tolerate, and what you don't want to tolerate.”

I think the primary care doctor should be the primary point. I should know everything that's going on and I should be able to pull that up, have the consultation notes, and have the latest labs. I should have all of that, because honestly, it's usually me that gets the questions. And I think the biggest cost savings would be if we could get patients into palliative care.

So many palliative care groups are really hospice groups that use their palliative care program to feed into their hospice, and that's not what palliative care should be, or is. Palliative care is controlling symptoms in patients that have a serious illness. Some of them may go on to hospice, and we do know that patients who are in a palliative care program get into hospice much sooner, but some of them will graduate from palliative care. Their cancer is cured, they're no longer having issues with pain or nausea or vomiting or neuropathy, and they graduate from palliative care. But we need to make sure that palliative care option is available for all patients who are experiencing a serious illness.