The idea is to help doctors move from "volume to value, from what is now a cottage industry to a modernized, organized system," says one observer.
Most doctors don't know it yet, but the federal government thinks far too many of them don't have what it takes to provide the kind of care needed in the new value-over-volume world. So it's dropping $840 million for projects that remodel the physician's office practices.
Behind the move are the government's expectations that clinicians should:
- Be able to share critical information with other doctors in new "medical neighborhoods," and expect to get feedback fast.
- Be able to sort their patients by diagnosis to see on a real-time dashboard which patients need follow-up care.
- Broaden their office schedules for patients who need a short-notice visit, to avoid trips to the emergency room.
- Stop ordering unnecessary tests and performing unneeded procedures by observing the Choosing Wisely campaign's recommendations.
The idea is to help doctors move from "volume to value, from what is now a cottage industry to a modernized, organized system," says Donald Crane, President and CEO of the California Association of Physician Groups (CAPG), which represents 80,000 doctors in 200 medical groups in several states.
"It's all about moving away from the inefficient—one doctor in one office seeing 28 patients—to clinically integrated teams where you have a captain of the ship, the primary care provider, supervising physician extenders," from nurse practitioners to pharmacists, he says.
Authorized by provisions in the Patient Protection and Affordable Care Act, the Transforming Clinical Practice Initiative (TCPI) hopes to do all that and more when it rolls out next May. Even with its four-year timeline, it's among the largest chunks of federal money granted for healthcare initiatives since 2010.
The goal, according to the Centers for Medicare & Medicaid Services, is to "improve health outcomes" and "reduce unnecessary hospitalization and other overutilization of services" for five million Medicare, Medicaid and Children's Health Insurance Program beneficiaries. The practices of 150,000 clinicians will be transformed.
'All of a Sudden There Will be Money'
Crane says the average doctor is unaware of this program, or the huge amount of money allocated to it. But it's starting to get attention. "Big organizations are looking into this now," CAPG included, he says.
"Everyone is coming out of the woodwork thinking maybe they can play a role…All of a sudden there will be money for education, to pay for trainers. It's a big boost," Crane adds.
The money will flow from four buckets:
- $670 million for Practice Transformation Networks or PTNs
- $30 million for Support and Alignment Networks or SANs
- $100 million for agency implementation
- $40 million to quality improvement organizations (QIOs) for recruitment and assessment.
Harold Miller, President and CEO of the consulting group Center for Healthcare Quality and Payment Reform, says the programs "parallel what CMS did to launch the Hospital Engagement Networks (HENs). The money didn't go to hospitals, but to hospital associations. You can think of it as passive and active technical assistance."
One piece will create webinars and learning modules that physicians might access, while the other will launch programs that send experts into physician practices to work through specific issues, he says.
"I think everybody who can apply for it will apply, if they can write a proposal" by the Jan. 6 deadline, says Shawn Martin, a vice president with the American Academy of Family Physicians.
"There's a lot of creative ideas out there…You'll have everything from the medical home concept in primary care practices to horizontally integrated cancer ACOs that incorporate nutrition, caregiver, and at home services," Martin says.
Organizations already participating in federal payment reform demonstrations such as ACOs, or the Comprehensive Primary Care Initiative, will be excluded "to avoid confounding effects of possible overlap," CMS says.
Shari Erickson, a vice president with the American College of Physicians, says CMS appears to want programs that create written rules by which primary care and specialist physicians exchange relevant information about the patients they refer and treat. They will promise to share certain kinds of information quickly to help with follow up.
"Such documents might say 'this is the information you're going to get from me with any of my referrals, and this is the information you will give back, within this time frame [of the patient's visit],' to set up accountability with each other," Erickson says.
Today throughout the country, "there are inconsistencies, and sometimes information is not shared with the primary care practice. They may not know where their patient went or what happened and that makes it difficult to be a medical home," she says.
What will be accomplished for each grantee depends on what the applicants propose, and how they choose to be measured. But it could range from helping physicians restructure their schedules to provide weekend and night office hours, to telephone or telemedicine response to patient calls.
Creativity is the key, according to CMS medical director Patrick Conway, MD, who said in a teleconference that the agency hopes applicants will borrow techniques used by some accountable care organizations and bundled payment models.
A Few Concerns About TCPI
Miller says the program's goals are worthy, but implementation may be problematic because there are no tie-ins to payment.
For example, it's nice to reorganize a physician's schedule to allow for short-notice appointments, "But doctors now keep their schedules full because that's how they get paid. How many slots should they leave open when it may cost them money, he asks.
Erickson says the ACP wants to see some meshing with specialty society maintenance of certification (MoC) requirements, and indeed the FOA indicates that is a possibility. "We'd like to see some projects funded that align practice transformation and the physician's ability to achieve MOC credits…and ideally capture data on measures that would be relevant, and could be submitted to the physician quality reporting system," in essence killing three birds with one stone, she says.
But Erickson also hopes the programs approved will help doctors improve their EHR interoperability competencies, which is a big complaint among doctors who can't afford technical support or the time to learn how to use their systems most effectively.
That's what's missing, says Ted Mazer, MD, an otolaryngologist and former San Diego County Medical Society president.
"Whether you're talking about ACOs or any of what this $840 million is supposed to buy—[what's missing] is interconnectivity between providers and facilities," he says.
TCPI, he says, is "just more ideas that keep silo-ing and segregating care, and just the opposite of what we should be spending money on." Doctors need to see what's happening to their patients regardless of what system they're in, but they often can't, especially if the patient is being seen in a network outside that of the primary care or specialty doctor who is part of the care team.
Doctors who purchase EHRs for their practices get an initial training session, but after that, "you have to hire an information technology person, and pay to maintain the system, and continually help you and your staff use it. Doctors, now matter how well they're using their systems, can barely meet meaningful use criteria." Federal incentive payments of about $44,000 don't come close to paying for that, Mazer says.
More pilots are not what is needed now, he says. "It's time to stop piloting esoteric things, while other important things are floundering, you're not really moving the ball forward."
Crane says most groups he's talked to are still trying to comprehend what's at stake. "All of us still find it a little confusing." The new program, he says, came out of the blue."