CASE STUDY PRIMARY CARE FOR LOW-INCOME POPULATIONS SEPTEMBER 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations What strategies do independent primary care clinicians use to help low-income and otherwise vulnerable patients who are at risk of developing health problems? Martha Hostetter Sarah Klein Consulting Writer and Editor Consulting Writer and Editor The Commonwealth Fund The Commonwealth Fund PROGRAM AT A GLANCE TOPLINES KEY FEATURE: Two independent primary care clinics, one in Vermont and I ndependent primary care one in New Hampshire, have leveraged their independence to tailor services to clinicians often fill gaps in care patients who struggle to afford care, have chronic physical or behavioral health in low-income, rural, and other conditions, and/or need help finding social supports. underserved communities. TARGET POPULATION: The practices serve a wide swath of patients, e look at how two primary W including many people covered by Medicaid and others with bare-bones care practices tailor services to private plans. patients who struggle to afford care, have chronic physical or WHY IT’S IMPORTANT: Independent primary care clinicians are often absent behavioral health conditions, from debates about how to reform U.S. health care. Independent primary care and/or need help finding social clinicians, particularly nurse practitioners, often fill care gaps in underserved supports. communities, which have been hard hit by the coronavirus. BENEFITS: Both clinics have achieved high levels of performance on measures of preventive services and chronic disease management. They have earned some additional revenue through value-based or capitated contracts. CHALLENGES: The practices struggle to sustain their small businesses while dealing with disparate and evolving payment arrangements. They’ve also had difficulty finding psychiatrists for their patients. To cope, the Vermont clinic hired a part-time psychiatric nurse practitioner. How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 2 INTRODUCTION This case study is the fourth in a series profiling In 1927, the Harvard Medical School professor Francis how primary care clinics — federally qualified Peabody, M.D., reminded the graduating class to make health centers, independent clinics, and clinics time to listen to patients’ stories and offer the bedridden sips of water or adjust their sheets. These small gestures, that are part of large health systems — are he explained, help earn patients’ trust, and trusting meeting the needs of low-income patients who relationships are key to healing. His advice — “the secret of often lack the resources to stay healthy. The the care of the patient is in caring for the patient” — is part series profiles clinics that exhibit some or all of of the medical school’s curricula today.1 the following attributes: Many of the medical students who choose to go into • Medical home capabilities as a foundation primary care today do so because they want to develop these sorts of personal relationships with patients. But • Multidisciplinary teams with community pressure to meet productivity targets and administrative health workers burdens often prevent them from doing so. Half of primary care clinicians say they are burned out, compared • Integration of primary health care with a third of physicians in fields such as orthopedics, with public health, social services, and psychiatry, or general surgery, and fewer medical students behavioral health choose to go into the field each year.2 • Using data to manage and improve This case study offers examples of primary care clinicians patient care and clinic performance who have remained independent out of a desire to deliver care the way they want to, including spending ample • Geographic empanelment, looking at time with their patients. The practices are not owned or health needs across a region and using managed by health systems, nor are they part of safety-net risk stratification to target interventions clinics. Many independent primary care clinicians opt to • Proactive patient and family engagement open practices in poor communities, where they find gaps in the market and feel a sense of mission to serve. to address physical, social, and cultural barriers to care We’re focusing on independent primary care clinicians, including physicians, nurse practitioners, and their care • Leveraging of digital tools to improve teams, because they are often absent from debates about health. how to reform U.S. health care. We’re also focusing on primary care because there is widespread agreement This case study profiles two clinics: Thomas that improving population health and reducing health Chittenden Health Center in Vermont has a care spending requires that we get much better at helping multidisciplinary care team that works to people stay well and identifying and treating problems as address patients’ physical health, behavioral early as possible. health, and social needs. Nurse practitioners at Wright & Associates Family Healthcare This case study explores how two independent primary care practices, one in New Hampshire and one in in New Hampshire seek to develop trusting Vermont, are leveraging their independence to tailor relationships with patients while providing services to patients who struggle to afford care, have low-cost, comprehensive primary care. chronic physical or behavioral health conditions, and/ or need help finding social supports. We also explore commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 3 the struggles these practices face in sustaining their small businesses while attempting to benefit from new value-based payment models. NEW HAMPSHIRE The two practices offer different illustrations of independent primary care. The AND VERMONT: one in Vermont is quite large and has benefitted from state policies supporting A LOOK AT multidisciplinary team care. By contrast, the practice in New Hampshire has NEIGHBORING less state support; it has kept costs low by fielding teams of nurse practitioners and medical assistants, who work together to meet patients’ needs. STATES Nearly all adult residents have Research comparing individual states and the United States as a whole to other countries has linked stronger primary care to better health insurance (92% in New health outcomes, fewer health disparities by income or race, and Hampshire, 94% in Vermont) lower costs. For example: and a usual source of care A 2019 study found that having 10 additional (87% in both states). primary care physicians in an area was associated with a 51.5-day increase in life expectancy. Residents in both states face high costs of living, Poor people are more likely to live in particularly related to housing. rural and urban communities with shortages of primary care clinicians. In 2017, New Hampshire was among a handful of states with the nation’s highest death With fewer physicians going into primary care, nurse rates from drug overdoses. practitioners and physician assistants have filled some of the gaps. Suicide deaths also have Primary care nurse practitioners are significantly more likely increased in recent years. than primary care physicians to serve a high proportion of uninsured patients and other vulnerable populations. They’re In both New Hampshire and also more likely to practice in rural communities. Vermont, the proportion of Physician assistants are also more likely to practice in rural areas low-income residents who say and serve uninsured patients. they are in fair or poor health has increased in recent years. In many communities, independent primary care So has the number of low- clinicians help ensure access to care. Yet the number income people who are obese of independent practices has declined in recent years. or have lost six or more teeth. For the first time in the U.S., the percentage of physicians employed by a health system or other entity has grown Sources: Commonwealth Fund larger than the percentage working for themselves: In 2018, Health System Data Center; Missouri 47.4% of practicing physicians were employed, compared Economic Research and Information with 45.9% who own their own practice. Center, Cost of Living Data Series. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 4 THOMAS CHITTENDEN HEALTH CENTER Progressive State Policies and Capitation Thomas Chittenden Health Center — the largest, single- Payments Support Extra Services site independent primary care practice in Vermont — In recent years, supportive state health reforms and recently celebrated its 50th anniversary. With five capitated contracts have enabled Chittenden to expand its physicians, three nurse practitioners, and four physician care team and services. assistants, it provides 35,000 visits a year to some 18,000 Since 2018, the clinic has received capitated payments to people. About half are covered by Medicare, Medicaid, or provide care for about 30 percent of patients (including both and most of the rest are covered by private insurance. those covered by Medicare, Medicaid, and private The clinic offers visits seven days a week and clinicians marketplace coverage) through an all-payer pilot led by take calls to answer questions after hours. During the OneCare Vermont, an accountable care organization first few months of the coronavirus pandemic, two of the (ACO) involving nearly all the state’s hospitals and most of practice’s clinicians offered in-person visits and the rest its medical practices. In 2019, the rate was set at $33.50 per offered virtual visits. member per month, plus a $3.25 per member per month care management fee. The additional funds from capitated Located in the small town of Williston, a short drive from payments — representing a 10 percent increase in Vermont’s largest city of Burlington, the practice serves revenue — as well as the more predictable revenue stream multiple generations of families that include University of have enabled Chittenden to give primary care clinicians Vermont professors, farmers, artists, and people struggling their first raise in a decade. Enhanced, stable funding to get by. “We have a fair number of patients who have also has allowed the practice to hire more staff and offer three generations in one home, who live paycheck to additional services, including nutritional counseling and paycheck if they have a paycheck,” says Joe Haddock, M.D., psychiatry to all patients, regardless of whether their medical director. insurance covers those services. Williston, Vermont — a short drive from Burlington — was the home of Thomas Chittenden, the state’s first governor. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 5 Joe Haddock, M.D., medical director of Thomas Chittenden Health Center, has deep roots in the Williston community. In addition to his medical practice, he runs a sheep farm and plays guitar at his patients’ and neighbors’ funerals. Capitated payments have helped sustain the practice during the pandemic, according to Haddock. “This program may be seen in a more favorable FUNDING SOURCES FOR light by other practices after all this,” he says. Still, with 70 percent of the THOMAS CHITTENDEN practice’s revenue tied to fee-for-service reimbursement, the practice is HEALTH CENTER’S CARE facing shortfalls as patient volume fell by about 9 percent during the first TEAM MEMBERS five months of 2020 and has not fully recovered. Chittenden has received federal support from the Paycheck Protection Program (PPP), as well as Salary subsidized with funds CARES Act funding, to purchase protective equipment and pay for new earned through capitation pilot: cleaning and screening procedures. “So far, we have had no layoffs or • Social worker and care significant reduction in hours,” Haddock says. “But the upcoming months coordinator may be more difficult, after using all the PPP funds.” • Nutritionist/diabetes educator The practice also has benefitted since 2013 from Vermont’s Blueprint for (part time) Health, a statewide effort to improve health and reduce costs by fielding • Psychiatric nurse practitioner nurses, counselors, social workers, community health workers, and others to complement the work of primary care clinicians. At Chittenden, Salary paid through Blueprint these staff members help patients manage their chronic conditions, find for Health: treatment for addiction and other behavioral health conditions, and connect with social supports. Their salaries are partially or fully paid for • Medical social worker through the Blueprint, which is funded through contributions from public • Nurse care coordinator and private payers. Salary paid through capitation For example, Lisa Anderson, a social worker and care coordinator, pilot and Blueprint for Health: offers services to patients who are identified as high risk based on their past hospitalizations and emergency department (ED) visits as well as • Patient panel and referral clinicians’ knowledge of their medical and social circumstances. “Our managers care coordinator helps people stay out of the hospital by doing things like commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 6 Thomas Chittenden Health Center has a cozy, welcoming atmosphere, with hardwood furnishings, rocking chairs, and photos of children adorning the walls. “A lot of patients see it as a cocoon,” says Haddock. finding their medicine or helping them find a place to stay supplemental nutritional benefits and called to check on so they don’t have to sleep in a car,” says Haddock. her every week; Liz Moss, a medical social worker, offered counseling and, eventually, referred her to Gaby, who In 2018, the clinic hired Nina Gaby, a psychiatric diagnosed and began treating her for depression. nurse practitioner, to meet demand for behavioral health services; previously, clinicians struggled to find By the time Haddock and Gaby met the baby — who psychiatrists for patients. Having someone in house weighed less than five pounds at birth — the new mother also helps convince those who may be reluctant to had gained a sense of confidence in her role. “She’s looking pursue psychiatric care. “They feel like they already at the baby, this little tiny thing, and she said, ‘I never know me because Joe Haddock has walked them over thought I would ever be able to produce something so and introduced me,” Gaby says. “That really improves beautiful,’” Gaby says. “So the bonding has happened. I compliance.” She has been surprised by the acuity and think in order to bond, people need to feel they are safe.” range of patients’ behavioral health needs. Gaby also has worked with several “independent Vermont men who have never ever talked about any of the things that have Panel Management and Performance gone on in their lives.” Improvement Thomas Chittenden Health Center has leveraged its Having Anderson, Gaby, and other team members electronic health record (EHR) system to flag patients enables Chittenden to surround vulnerable patients with supportive services. When an 18-year-old patient became with chronic conditions whose disease is out of control, pregnant, Haddock knew she and her baby were at risk. identify those who need preventive care, and generate She was overweight and had had a troubled childhood. automated calls or messages to patients. From 2016 to Haddock tapped several colleagues: Mary Anne Kyburz- 2019, the number of hypertensive patients with their Ladue, the nutritionist and diabetes educator, offered blood pressure under control rose from 54 percent to 59 advice to the young woman when she developed percent and the number of patients with diabetes under gestational diabetes; Anderson helped her apply for control went from 85 percent to 89 percent. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 7 Rick Dooley, a physician assistant, used the system to WRIGHT & ASSOCIATES FAMILY HEALTHCARE increase the number of adolescent patients who receive In neighboring New Hampshire, Wright & Associates the human papillomavirus (HPV) vaccine. Notices are Family Healthcare was founded by two sisters: Wendy automatically sent to families with teen children who Wright, a nurse practitioner, and Becky Manter, the were overdue for annual wellness visits and nurses receive practice manager. The sisters opened their first clinic in electronic reminders to ask about HPV vaccination status Amherst, N.H., in 2007 and the second in 2011 in Concord, at each adolescent well visit. Dooley also published the state capital, where they recognized a need in the monthly reports on each prescriber’s HPV vaccination market. “There was just one primary care provider in rates and quarterly reports comparing the clinic’s HPV Concord taking new patients,” says Wright. “You would rate to the state average. put your name on a list and, as patients left, they would enroll a new patient.” Improvement in HPV Vaccination Rates by Age 18, Wright & Associates’ Concord practice is part of an 2015–2019 increasing number of nurse practitioner–led clinics that are filling gaps in access to primary care. Twenty- two states and the District of Columbia allow nurse Percentage of females practitioners to care for their own patient panels and work completing series independently of physicians. While the supply of primary 67.5% care physicians increased only nominally from 2010 to 2016, the number of primary care nurse practitioners doubled. Compared with physicians, nurse practitioners are more likely to practice in rural and low-income areas and to serve Medicaid beneficiaries.3 A recent study found 43.9% that, compared with patients treated by physicians, 38.9% Percentage of males patients treated by nurse practitioners incurred fewer completing series hospitalizations, including for conditions that may be treatable in ambulatory care settings.4 Word of the Concord clinic spread, attracting patients from up to an hour away. Today three nurse practitioners 13.2% serve about 2,500 patients; the small panel size enables nurse practitioners to hold much longer appointments than are typical in primary care. Some patients are homeless or struggle with substance abuse. (The clinic 2015 2019 is located next to a soup kitchen and homeless shelter.) Data: Thomas Chittenden Health Center. Others are recent immigrants who work in the region’s manufacturing plants or young people drawn to the area’s Dooley also has leveraged the EHR system to track and relatively low cost of living. About a third of patients are reduce potentially unnecessary opioid prescribing. He’s covered by Medicare, Medicaid, or Tricare (for active convened clinicians each month to review their prescribing and retired members of the military), and most of the Source: patterns and invited University of Vermont pain remainder by private insurance. Wright and Manter management specialists to offer advice on best practices. consider many of their privately covered patients to be From 2018 to 2019, this resulted in a 22 percent reduction in underinsured because they face very high copayments opiate morphine milligram equivalent prescribing. and deductibles. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 8 Wright & Associates Family Healthcare’s Concord office is sandwiched between a soup kitchen, homeless shelter, and the public defenders’ office. It’s down the street from the state capitol building. During the pandemic, the Concord practice has remained visits enable nurse practitioners to offer comprehensive a lifeline to residents as other local primary care practices preventive and problem-based treatment; this approach closed their doors. It has remained open for in-person visits, is not only consistent with nurse practitioners’ training including curbside COVID-19 testing, as well as virtual visits in holistic health but also serves patients’ interests, since seven days a week. With patient volumes plummeting 60 most have more than one condition or concern. The percent in the spring, leaders had to furlough three nurse additional time also enables clinicians to build rapport practitioners and four medical assistants across the two with patients. “We hear from patients, ‘I’ve never spent so sites. By summer, they were able to rehire all but one staff much time with a clinician before. You actually listen to member as volumes rebounded. The practice has been me,’” says Manter. “And that’s the biggest thing.” sustained by a $300,000 forgivable loan from the Paycheck Protection Program as well as $7,000 from the CARES Act to Integrating Behavioral Health Services After purchase protective equipment. Struggling to Find Psychiatrists In 2017, Concord began screening all patients for Lean Staffing, Long Visits depression and substance abuse and uncovered a To limit operating costs, the Concord clinic is minimally startlingly high degree of need. About 40 percent of staffed and shares office space with unaffiliated providers, patients are diagnosed with some type of behavioral including a lab testing service. Each of the three nurse health problem, mostly commonly depression, anxiety, practitioners partners with a medical assistant, who and/or substance use disorder, often related to past queues up tasks before office visits, follows up on tests instances of sexual abuse or other trauma. Nurse and referrals, and works with other medical assistants to practitioners are typically able to refer patients to handle billing and scheduling and field patients’ calls. counselors, but they struggle to find psychiatric providers Only 10 to 12 appointments are scheduled for each nurse for patients requiring medication management. In recent practitioner a day, giving them a full hour to devote to months, staff have seen even more patients struggling new patients, 45 minutes for well-child visits or visits with anxiety and depression. “Visits were long and hard following surgeries or hospitalizations, and 30 minutes for before the pandemic; they’re longer and harder now,” says other follow-up appointments. By contrast, the average Wright, noting that patients have been returning to the primary care visit lasts 20 minutes. Wright says the longer 5 office “mentally and physically exhausted.” commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 9 Thanks to a statewide settlement agreement, the clinic now has access to emergency psychiatric services for patients who appear to be suicidal, delusional, or otherwise in crisis. Over the past year, the mobile crisis team came to the clinic five times to perform an immediate evaluation and transfer. Concord clinicians also have helped people coping with addiction, mainly opioid use disorder, treating some 360 patients since 2011 with antagonist medications that block the effects of opioids. Nurse practitioners do not offer treatment with buprenorphine, an agonist medication commonly used in treating opioid use disorder, because prescribing it requires a waiver process that is too time- consuming and expensive, says Manter. Many patients with opioid use disorder find their way to Concord because the clinic partners with residential drug treatment facilities. Before discharging patients, staff from the facilities bring patients to the clinic for a “warm handoff” to a nurse practitioner. The clinic guarantees they’ll see these patients within seven days of their discharge. About a third of clinic patients with opioid use disorder recover, but many others end up in prison or stop turning up for treatment for other reasons. “It’s heartbreaking,” Wright says. “In the short time we have them, we try to address Wright & Associates Family Healthcare was founded by two sisters, Wendy some of their primary care needs. Because, unfortunately, when we get them, Wright, N.P. (above), and Becky Manter, 50 percent are hepatitis C positive and about 10 percent are HIV positive. So practice manager (below). that is the alarming part.” Leveraging Value-Based Payments to Enhance Care In 2012, Wright & Associates’ Amherst and Concord practices joined with New Hampshire’s 10 other nurse practitioner–led practices to form the nation’s first nurse practitioner ACO under a contract with Anthem Blue Cross Blue Shield.6 (At the time, Medicare only accepted practices led by physicians into its Shared Savings Program for ACOs.) The 11 practices pooled their patients into one risk pool to test whether they could succeed under value-based payment. Under the contract, each of the practices received per member per month fees — from $3 to $7, depending on patients’ acuity, in addition to fee-for-service payments — to coordinate and oversee care for Anthem patients, including those with marketplace coverage and Medicaid managed care beneficiaries. The practices were eligible to share in any savings from better coordinating patients’ care if they met benchmark performance levels on measures of preventive care, chronic care management, and cost control. Overall, the nurse practitioner practices met quality thresholds over three years of the program and their patients cost $66.85 less per member per month than did physician-managed patients in another Anthem risk pool, mainly because of lower hospitalization rates. Unlike most other private insurers, Anthem pays nurse practitioners on par with physicians, so the lower reimbursements did not account for the nurse practitioner practices’ lower costs. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 10 The data also showed that New Hampshire’s nurse practitioners were caring for very sick patients, including Wright & Associates Family Healthcare, Concord: those with multiple chronic conditions (such as cancer, Quality Performance Compared with State coronary artery disease, diabetes, and kidney disease). Averages, 2019 “There’s a misperception that nurse practitioners are Statewide mostly taking care of younger, healthier patients and average handling straightforward things,” says Wright. “This Concord among clinic primary care work showed that’s just not true.” Measure rate practices For the past two years, the Concord clinic has had a Cervical cancer screening 87% 66% separate ACO contract with Anthem (rather than pooling Breast cancer screening 89% 63% patients with other nurse practitioners-led clinics). In Chlamydia screening 79% 52% 2019, the clinic exceeded the average performance rate among primary care practices statewide on several Percentage of days covered by 88% 81% measures of appropriate preventive care and chronic hypertension medication disease management. Clinic patients also had fewer Percentage of hospitalizations than the statewide average, though they days covered by 68% 78% had higher-than-average rates of avoidable ED visits, cholesterol medication which leaders attribute to ingrained behaviors related to Diabetes hemoglobin 100% 86% the region’s primary care shortages. “Going to the ED is A1c testing all the patients have known,” says Manter. Data: Anthem BlueCross BlueShield Scorecard, as provided by Wright & Associates Family Healthcare. To help change behavior, the clinic launched a campaign to educate patients about the circumstances under which they should seek emergency, urgent, or primary care — emphasizing the concept of a primary care medical home that can address most health concerns. Along with posting educational signs in the office and holding regular conversations with patients, the clinic sends letters to patients who’ve visited the ED for a condition that could have been managed in primary care. The letters note that ED visits could wind up costing patients more out of pocket than office visits. Concord has earned modest shared savings from its participation in ACO contracts — about $35,000 in the first year, $20,000 in the second, and $6,000 in the Concord clinicians partnered with a Doctor of Nursing Practice third — which has enabled leaders to hire another student to develop a campaign to educate patients about when to seek primary, urgent, or emergency care. medical assistant. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 11 SHARED APPROACHES has begun to reduce that number. Staff at Chittenden say Vermont’s Thomas Chittenden Health Center is much it can be hard to convince stoic Vermonters to accept help, larger than Wright & Associates’ Concord clinic and has particularly for social services like Meals on Wheels when more supportive state policies to lean on. Still, leaders at they can no longer cook for themselves. “I play guitar at both practices face similar challenges, including engaging funerals, and I always play the song ‘Amazing Grace,’” Haddock says. “I tell patients it takes amazing grace to patients in care, recruiting clinicians, and financially accept help. Most of them, they’ll buy that.” sustaining their practices. Below, we outline some of the strategies they’ve developed to address these challenges and develop care models that benefit the low-income Attending to affordability concerns patients they serve. Acknowledging patients’ concerns about the affordability of care and taking steps to minimize their out-of-pocket Building trusting, long-term relationships costs are other engagement strategies. At a time when patients are shouldering more of the costs of care, only a People have many reasons for not seeking primary care. minority of physicians say they’ve broached the subject of Some are practical: They can’t miss work or find childcare, treatment affordability with patients.7 or they’re worried about costs. Others have personal reasons: They don’t trust the health care system, they had a Wright & Associates’ Concord practice follows a “no bad experience with a doctor, or they don’t want to be told surprises” policy: Staff check people’s insurance before they should stop smoking or lose weight. Fears surrounding visits and let patients know precisely what services will the coronavirus also have hindered many from seeking cost them. The clinic also has secured agreements with a routine services, such as vaccinations or cancer screenings, local hospital and lab so their patients can get discounted or from reaching out when they feel unwell. tests or imaging services. Concord’s leaders say their treatment approach — doing as much as possible in one One way the independent primary care clinicians profiled visit — respects patients’ time and means they don’t here encourage people to pursue care is by forging have to pay additional copayments for follow-up visits. personal connections, which they say are key to earning a The clinic also offers patients the option to pay off their patient’s trust and promoting healing. For instance, when services via installment plans. a Wright & Associates’ patient repeatedly turned up at the ED after her husband died — apparently looking for Both organizations profiled in this case study say that company — a medical assistant helped her get a service patients requiring medications, lab tests, and other dog and scheduled an office visit for her every month until services to manage chronic conditions often face cost she felt less lonely. At Chittenden, both clinicians and care barriers because their plans require high deductibles coordinators visit patients in their homes, particularly and copayments. Clinicians report that many patients when they haven’t turned up for appointments, and seek can’t afford prescription drugs, particularly medications to build trust in the practice — something Haddock refers needed to manage chronic conditions. Kyburz-Ladue, to as “institutional bonding.” Chittenden’s nutritionist and diabetes educator, says it’s not unusual for a patient with diabetes to stop taking Still, it is often hard for these clinicians to engage patients. insulin because of costs. Staff at both clinics help enroll The Wright & Associates’ Concord practice is open from eligible patients in pharmacy assistance programs and 7:00 a.m. until 5:30 p.m. on weekdays and Saturdays. look for alternatives to expensive drugs, but costs remain But every day, a handful of patients fails to turn up for a major barrier. Nationally, one of five adults under age 65 scheduled appointments, although a new texting system hasn’t filled a prescription because they can’t afford it.8 commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 12 Helping patients find social supports Clinicians at Wright & Associates’ Concord practice also New England poverty can be obscured by its charming point to a lack of affordable housing, along with a lack towns and mountainous landscapes, but clinicians in both of public transportation and services in rural areas. Vermont and New Hampshire report that some of their Medical assistants help patients sign up for Medicaid, patients are living hand to mouth. “Nurse practitioners discounted utility programs, or other benefits. But with who make home visits say the house is in squalor, that it fewer supportive programs in New Hampshire than in is freezing, that they are living on minimal amounts of neighboring states, there are limits to what they can do. food,” Wright says. Thomas Chittenden Health Center has a full-time social worker to connect patients with social Growing a pipeline to cope with primary care supports, and the community is generous with resources workforce shortages like subsidies for fresh food and volunteers who visit older Both primary care practices struggle to recruit and adults. Still, there’s an acute lack of affordable housing. retain clinical staff. Unlike some competing academic “There are years-long waits for subsidized housing,” says medical centers, community health centers, or health Anderson, a social worker and care coordinator. “I go care organizations in health professional shortage areas, through Craigslist with people trying to find the cheapest the clinics can’t offer loan repayment or forgiveness apartments. In the summertime, people who are homeless programs as recruiting enticements. And leaders say many live in the woods.” clinicians aren’t comfortable working as autonomously as is required in independent practice, and they may be lured by higher pay offered elsewhere. Everything comes back to To cope, both practices have tried to build their own primary care. A patient who had pipelines. been started on opioids in the ED Leaders at Wright & Associates’ Concord practice invest was told, ‘Contact your primary significant time in developing staff members’ skills and helping them feel comfortable working independently. care provider to manage your For their first six months, newly hired nurse practitioners pain.’ We sent a patient to a work at a significantly reduced schedule and Wright reviews and offers feedback on their patients’ charts. behavioral specialist, a nurse In addition, one of the clinic’s medical assistants, who practitioner who can prescribe, recently earned a nursing degree, will help triage patient and she said, ‘I no longer calls and has begun offering diabetes management classes. Recently, the clinics received federal grants to support its prescribe any of those. Go back nurse practitioner mentorship and residency programs. to your PCP.’ It all comes back to Chittenden is paying for one of its nurse practitioners to us, and that’s so, so hard. receive a psychiatric certification to help meet demand. But Wright & Associates’ Concord practice has not been able to recruit a psychiatric provider and struggles Becky Manter, Practice Manager to find places to refer patients needing psychiatric Wright & Associates Family Healthcare care. Nationally, more than half of U.S. counties lack of Concord, N.H. a psychiatrist and fewer than half (43%) of practicing psychiatrists accept Medicaid.9 commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 13 Leveraging delivery and payment reforms fees, but one one estimate finds that this approach will Thomas Chittenden Health Center’s success to date under not represent an increase in revenue for most practices. a capitation pilot suggests it may be able to succeed were In addition, unlike the Comprehensive Primary Care such a payment approach extended for all its patients. But Plus multipayer initiative, which also seeks to strengthen capitation could prove harder for smaller independent primary care, Medicaid and private payers are encouraged practices or those that don’t have the external supports but not required to follow this approach. that Vermont’s primary care clinicians receive. During the pandemic, public and private payers began By joining with other independent practices, Wright & offering providers equivalent reimbursement for virtual Associates’ Concord practice has been able to participate and office visits. To ensure telehealth is a viable option in ACO contracts. While modest, the incentive payments for primary care practices longer term, these policies will have enabled leaders to hire an additional medical need to be continued, primary care leaders say. “Telehealth assistant to help close gaps in preventive care or chronic needs to remain an option,” says Wright. “Some people disease management. “It completely changed our work,” are still too scared and won’t come in.” In one recent case, says Manter. a Wright & Associates’ nurse practitioner used a virtual visit to help a husband perform an abdominal exam on his But Concord has struggled to develop other value-based wife to diagnose appendicitis. contracts with Medicare, Medicaid managed care plans, or private payers, which Wright attributes to the fact that LOOKING AHEAD the practice is too small to get much notice from payers. Even though nurse practitioners generally earn less than Advocates continue to argue that, to improve population primary care physicians, most payers have not recognized health and reduce overall health care spending, much their work or rewarded their cost effectiveness, Wright more money must flow into primary care. Some have says. “We’ve tried to negotiate as a group, but we just can’t argued for approaches that take into account and reward get a foot in the door.” the value of trusting relationships. States, including Rhode Island, are explicitly mandating higher spending While larger health care institutions can spread out their by Medicaid and private insurers on primary care, but financial risk by cross-subsidizing one service line with average spending on primary care in the United States another, independent primary care practices do not have is still well below other industrialized nations.10 Such that ability. Even though they operate as small businesses, investment also must take into account the social and they must juggle different types of payment from different behavioral health needs of vulnerable patients who, payers, and some payments arrive unpredictably and long as these profiles demonstrate, often require additional after a service is delivered. “We’re making it,” says Wright. supports that test the capacity of practices to sustain “My bills are paid, and I have no debt. But I take a paycheck themselves. only 50 percent of the time.” While committed to their patients and communities, Starting in 2021, smaller and independent primary clinicians at the Vermont and New Hampshire clinics care practices in some regions will have the option of agree that their work was hard to sustain, even before the joining the new federal Primary Care First program, pandemic: “The worst thing that could happen to primary under which they will receive capitated payments for care is if we didn’t change anything,” Haddock says. each patient covered by Medicare as well as $50 fees for office visits. Practices also can earn incentives for achieving performance targets tied initially to reduced hospitalizations. Some practices serving particularly complex patients may earn higher per member per month commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 14 NOTES 1. Francis W. Peabody, “The Care of the Patient,” JAMA 88, 8. Sara R. Collins, Herman K. Bhupal, and Michelle M. no. 12 (Mar. 1927): 877–82. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage 2. See, for example: Sara Berg, “Physician Burnout: Which Gaps, But More Underinsured (Commonwealth Fund, Medical Specialties Feel the Most Stress?,” Physician Feb. 2019). Health (blog), American Medical Association, Jan. 21, 2020; and Victoria Knight, “American Medical 9. New American Economy, “New Study Shows 60 Students Less Likely to Choose to Become Primary Care Percent of U.S. Communities Without a Single Doctors,” Kaiser Health News, July 3, 2019. Psychiatrist,” news release, Oct. 30, 2017; and Tara F. Bishop et al., “Acceptance of Insurance by Psychiatrists 3. From 2010 to 2016, the number of primary care nurse and the Implications for Access to Mental Health Care,” practitioners increased from 59,442 to 123,316 while JAMA Psychiatry 71, no. 2 (Feb. 2014): 176–81. the number of primary care physicians increased from 225,687 to 243,738. The number of nurse practitioners 10.A study by the Patient-Centered Primary Care per 100,000 population increased by a mean of 15.3 Collaborative found that public and private payers in the highest-income quartile to 21.4 in the lowest- in the United States spent just 5.6 percent of their income quartile. See Ying Xue, Joyce A. Smith, and annual medical spending on primary care between Joanne Spetz, “Primary Care Nurse Practitioners and 2011 and 2016, in contrast to an average of 14 percent Physicians in Low-Income and Rural Areas, 2010–16,” among Organisation for Economic Co-operation JAMA 32, no. 1 (Jan. 1/8, 2019): 102–5. A 2012 survey also and Development countries. The researchers used found that primary care nurse practitioners are more a conservative definition of primary care: services likely than primary care physicians to treat Medicaid provided by physicians in family practice, general recipients and other vulnerable populations. See Peter practice, geriatrics, general internal medicine, and I. Buerhaus et al., “Practice Characteristics of Primary general pediatrics. With a broader definition that Care Nurse Practitioners and Physicians,” Nursing included the services of nurse practitioners, physician Outlook 63, no. 2 (Mar./Apr. 2015): 144–53. assistants, obstetricians/gynecologists, general psychiatrists, psychologists, and social workers, 4. Chuan-Fen Liu et al., “Outcomes of Primary Care they found the average increased to 10.2 percent. See Delivery by Nurse Practitioners: Utilization, Cost, and Yalda Jabbarpour et al., Investing in Primary Care: A Quality of Care,” Health Services Research 55, no. 2 (Apr. State-Level Analysis (Patient-Centered Primary Care 2020): 178–89. Collaborative, July 2019). 5. Meredith K. Shaw et al., “The Duration of Office Visits in the United States, 1993 to 2010,” American Journal of Managed Care 20, no. 10 (Oct. 2014): 820–26. 6. Wendy L. Wright, “New Hampshire Nurse Practitioners Take the Lead in Forming an Accountable Care Organization,” Nursing Administration Quarterly 41, no. 1 (Jan./Mar. 2017): 39–47. 7. G. Caleb Alexander, Lawrence P. Casolino, and David O. Meltzer, “Patient–Physician Communication About Out-of-Pocket Costs,” JAMA 290, vol. 7 (Aug. 20, 2003): 953–58. commonwealthfund.org Case Study, September 2020 How Independent Primary Care Clinicians Leverage Trust to Help Vulnerable Populations 15 ABOUT THE AUTHORS ACKNOWLEDGMENTS Martha Hostetter, M.F.A., is a partner in Pear Tree The authors gratefully acknowledge the following Communications. As a consulting writer and editor for individuals who generously shared information and the Commonwealth Fund and a contributing editor to its insights. Thomas Chittenden Health Center: Lisa Anderson, quarterly publication, Transforming Care, she conducts Rick Dooley, Nina Gaby, Joe Haddock, Mary Anne Kyburz- qualitative research on health care delivery system reforms Ladue, Maggie Mangham, Cheryl McCaffrey, and Liz Moss. and innovations. Ms. Hostetter has an M.F.A. from Yale Wright and Associates Family Healthcare: Elizabeth Holt, University and a B.A. from the University of Pennsylvania. Becky Manter, and Wendy Wright. Sarah Klein is editor of Transforming Care, a quarterly publication of the Commonwealth Fund that focuses on innovative efforts to transform health care delivery. She has written about health care for more than 15 years as a reporter for publications including Crain’s Chicago Business and American Medical News. Ms. Klein received a B.A. from Washington University in St. Louis and attended the Graduate School of Journalism at the University of California at Berkeley. Editorial support was provided by Maggie Van Dyke. For more information about this case study, Commonwealth Fund case studies examine please contact: health care organizations that have achieved high Martha Hostetter performance in a particular area, have undertaken Consulting Writer and Editor promising innovations, or exemplify attributes The Commonwealth Fund that can foster high performance. It is hoped that mh@cmwf.org other institutions will be able to draw lessons from these cases to inform their own efforts to become high performers. Please note that descriptions of products and services are based on publicly available information or data provided by the featured case This case study is available on the Commonwealth Fund’s website at https://www.commonwealthfund.org/ study institution(s) and should not be construed as publications/case-study/2020/sep/how-independent- endorsement by the Commonwealth Fund. primary-care-clinicians-leverage-trust-help. commonwealthfund.org Case Study, September 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.