Use of Telehealth Early and Late in the COVID-19 Public Health Emergency: Policy Implications for Improving Health Equity.

INTRODUCTION: Early in the COVID-19 pandemic, primary care adopted telehealth rapidly to preserve access. Although policy flexibilities persist, but with in-person access restored, insight regarding long-term policy reform is needed for equitable access, especially for underserved, low income, and rural populations. METHODS: We used electronic health record data to compare primary care telehealth use in practices serving primarily commercially insured patients versus clinics serving low-income uninsured patients, in March-June 2020 ("early COVID") and March-June 2022 ("late COVID"). RESULTS: Primary care visit mode differed significantly (P < .0001) between settings in both periods. In early COVID, video visits were most used in the commercially insured practices (54.50%), followed by office visits (32.76%); in the low-income, uninsured clinics, phone visits were most used (56.67%), followed by office visits (23.55%). In late COVID, 81.05% of visits to commercially insured practices and 92.04% to uninsured clinics were in-office; continuing telehealth use was primarily video. Smaller but significant (P ≤ .0001) differences in telehealth use by race/ethnicity were also observed, with Black and/or Hispanic patients less likely than White patients to use telehealth during both periods, after adjustment for other characteristics. CONCLUSIONS: Findings demonstrate the importance of both phone and video visits in preserving primary care access early in the pandemic. Telehealth use declined in late COVID, but still accounted for ∼20% of primary care visits in the commercially insured setting and less than 10% of visits in the community care clinics. Differences in telehealth use were largely by setting, reflecting income/insurance status, indicating disparities needing to be addressed.

Assessing adherence and cost-benefit of colorectal cancer screening for accountable providers.

The objective of this study was to assess adherence and costs-benefits of colorectal cancer (CRC) screenings from an accountable care organization/population health perspective. We performed a retrospective review of 94 patients (50-75 years of age) in an integrated safety net system for whom fecal CRC screening was abnormal for the period of June 1, 2014, to June 1, 2016. A cost-benefit model was constructed using Medicare payment rates and a sensitivity analysis. Most patients included in the study (64/94, 68%) received or were offered a colonoscopy. Of those receiving a colonoscopy, 24 of 45 (53%) had an abnormal finding. Total direct medical costs avoided by screening the patient panel was $32,926 but could have exceeded $63,237 had more patients received follow-up colonoscopies. A sensitivity analysis with 1000 patients demonstrated total monetary benefits between $2.2 million and $8.16 million when follow-up and colonoscopy rates were allowed to vary. Although the resulting rates of follow-up were within the range reported in the literature, there is room for improvement, especially considering the monetary benefit that could be used on other diseases. Health systems and payers should work cooperatively to structure payment models to better incentivize CRC screenings.

Diagnostic Accuracy in Primary Care E-Visits: Evaluation of a Large Integrated Health Care Delivery System's Experience.

OBJECTIVE: To compare diagnostic accuracy between primary care E-Visit and face-to-face (F2F) encounters for low-acuity illnesses. PATIENTS AND METHODS: This cross-sectional retrospective analysis of electronic health records in a large not-for-profit integrated delivery system included patients covered by the health care system's employee health plan with an established affiliated physician-patient relationship and an F2F encounter in the past 12 months who had an E-Visit (n=490) or an F2F (n=2201) primary care encounter for a low-acuity illness from July 1, 2015, through December 22, 2016. Patients with a related follow-up visit within 10 days resulting in a revised diagnosis, as determined by 2 physician reviewers, were compared (1) including only the first encounter for each patient and (2) including all encounters more than 10 days apart for included patients. RESULTS: In both analyses, a follow-up visit occurred within 10 days more than 40% of the time in both groups. However, follow-up visits related to the initial diagnosis occurred only 9% to 12% of the time. Only 2.1% to 2.4% of initial diagnoses were identified by both physician reviewers as revised, whereas 3.8% to 5.5% were so identified by at least 1 reviewer. The only significant difference observed between the E-Visit and F2F groups was in the rate of related follow-up visits when only each patient's first encounter was considered, which was higher for E-Visits (12% vs 9%; P=.04). CONCLUSION: Diagnostic accuracy for low-acuity illnesses in this population was equivalent between E-Visit and F2F encounters.

Aligning payment reform and delivery innovation in emergency care.

Current alternative payment models (APMs) that move away from traditional fee-for-service payment often have explicit goals to reduce utilization in episodic settings, such as emergency departments (ED). We apply the new HHS payment reform taxonomy to illustrate a pathway to success for EDs in APMs. Despite the unique challenges faced by EDs, a variety of category 2 and 3 APMs may be applicable to EDs in the short- and long term to improve efficiency and value. Full and partially capitated models create incentives for longitudinal and episodic ED providers and payers to unite to create interventions to reduce costs. However, prospective attribution remains a challenge for EDs because of exogenous demand, which makes it important for EDs to be one of the components of capitated payment along with longitudinal providers who can exert greater control on overall care demands. The goal of payment and delivery reforms in ED care is to improve population health across the continuum of acute and longitudinal care. In order to deliver cost-conscious care, ED providers will need additional resources, expanded information, and new processes and metrics to facilitate cost-conscious decisions. Improved availability of electronic information across settings, evidence generated from developing and testing acute care-specific payment models, and engaging acute care providers directly in reform efforts will help meet these goals.

Fully Capitated Payment Breakeven Rate for a Mid-Size Pediatric Practice.

BACKGROUND AND OBJECTIVES: Payers are implementing alternative payment models that attempt to align payment with high-value care. This study calculates the breakeven capitated payment rate for a midsize pediatric practice and explores how several different staffing scenarios affect the rate. METHODS: We supplemented a literature review and data from >200 practices with interviews of practice administrators, physicians, and payers to construct an income statement for a hypothetical, independent, midsize pediatric practice in fee-for-service. The practice was transitioned to full capitation to calculate the breakeven capitated rate, holding all practice parameters constant. Panel size, overhead, physician salary, and staffing ratios were varied to assess their impact on the breakeven per-member per-month (PMPM) rate. Finally, payment rates from an existing health plan were applied to the practice. RESULTS: The calculated breakeven PMPM was $24.10. When an economic simulation allowed core practice parameters to vary across a broad range, 80% of practices broke even with a PMPM of $35.00. The breakeven PMPM increased by 12% ($3.00) when the staffing ratio increased by 25% and increased by 23% ($5.50) when the staffing ratio increased by 38%. The practice was viable, even with primary care medical home staffing ratios, when rates from a real-world payer were applied. CONCLUSIONS: Practices are more likely to succeed in capitated models if pediatricians understand how these models alter practice finances. Staffing changes that are common in patient-centered medical home models increased the breakeven capitated rate. The degree to which team-based care will increase panel size and offset increased cost is unknown.

Case study: Transforming cancer care at a community oncology practice.

To assist practices and institutions throughout the country in implementing clinical redesign supported by - and aligned with - payment reform, we present a case study of the New Mexico Cancer Center (NMCC) based on numerous stakeholder interviews, literature reviews, and a comprehensive site visit. This study explores the complex barriers oncologists face in improving the quality and outcomes of cancer care and reducing overall costs in a sustainable way. This case will explore the following questions: How did the NMCC redesign care to improve quality, enhance patient experience and results, and reduce costs? How can an organization demonstrate they are improving quality to enable new payment contracts that enable sustainability? Are alternative payment models sustainable for an independent, community oncology practice?