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Themes of Starfield Summit Participants' Discussion on Payment Representative Statements Reflecting Theme There is currently no streamlined, organized system of payment for healthcare. • Working with eighty different payers is difficult on a practice. • Different payment models serve to fragment our work by turning each aspect of healthcare into a separate transaction. Barriers and silos hamper innovative payment models. • The problem of a reductionist, disease-centered paradigm affects specialties as well as primary care. • We need to redefine the buckets of how we pay for social services and healthcare, with no walls between the issues that drive health, including upstream causes. • It is hard to innovate within regulatory environments that narrowly define healthcare. Payment models must support, and be supported by, appropriate data measurement, data collection, and delivery infrastructure. • How do we know when primary care is doing a good job? • We need good evidence on what makes a difference for the health of patients and populations. • We need payment models that support implementation of new effective services. Effective payment for primary care would pay for accessibility, comprehensiveness, continuity, and coordination. • Payment needs to honor the patient-provider relationship…and be structured around ways providers can be held accountable. • How we define primary care is currently the sum of our fee-for-service diagnosis codes. • Primary care needs to take accountability for population health and advocate for a payment system that reflects this. Payment needs to be flexible so that clinics, teams, and health systems can use global payments to meet patients in innovative ways and address population health. • The population health aspect of the triple aim lies almost entirely outside of the health system as it currently exists. • Mandated investments in primary care in Rhode Island shows you can bend the cost curve with a global per-member-per-month flexible payment on a large scale. An effective payment system needs to be risk-adjusted on the population level, rather than individual patients. • Risk adjustment is necessary to prevent further marginalization of vulnerable populations. Budgets for primary care need to include interventions that address the social determinants of health. • Social determinants of health are not just things that poor people face, they are a problem for everyone. • Why is there not time for pro-active case management by clinicians? • Need to address all the things that our patient's struggle with to create health. - Table 2.
Brainstorming Themes Regarding Measurement Discussed at the 2016 Starfield Summit
Themes of Starfield Summit Participants' Discussion on Measurement Representative Statements Reflecting Theme Measurement must reflect characteristics of health systems we know are related to improved population health, including accessibility, comprehensiveness, continuity, and coordination. • What really matters is the unmeasurable…We must measure trust, communication, relationships, openness … These are what correlates with outcomes. • Measures don't capture the range of what I do in my daily practice. Indicators of quality care must reflect various patient populations and individual patients' goals. • What are the priorities of my patients? • How can we bring in the patient's voice? • Patient preferences and quality of life change over time; how do we reflect that? Measurement leads to fatigue and burnout and thus, lack of innovation. • If our system was not so prescriptive, it would allow individuals and organizations to develop their own solutions. • We rely too much on clinician incentives and undervalue intrinsic motivation. Measurement needs to shift towards care coordination and team care, as one physician or one clinical practice is not responsible for health outcomes. • Break down the silos between primary care and specialties. • Measurements are disproportionately focused on certain providers–disease-specific measures do not capture primary care, but similarly, radiologists do not get measured on patient outcomes. Measurement needs to account for social determinants of health, as only 10% to 20% of individual health is related to clinical care. • Patient outcomes and patient panels are measuring the wrong issue because people with the worst problems don't come in for care–therefore, we need to have community-based measurement. • How do we create measures to account for community issues that neither patients nor providers can control–like transportation, access, employment? Measurement systems are too complicated. • Simplify the verbiage. • Too much reporting burden. • All payers should be using the same system. Measurement and payment need to be reformed together. • We can't really talk about population health outcomes without universal access. The current measurement system does not measure value. • Value is hard to define…and it is different for every provider and every patient. • Does measurement produce the product we want and need? Does it measure health or quality of life and care? • Do we really need to have incentives? The system is set up in the wrong way for us to deliver care we believe in. Measurement should focus on trends, not a point in time. • We need more long-term measures–not the first avoidable re-admission, but the number of re-admissions over a year or over five years. • There's so much devil in the details, no one gets it right the first time. - Table 3.
Brainstorming Themes Regarding Team-Based Care Discussed at the 2016 Starfield Summit
Themes of Starfield Summit Participants' Discussion on Team-Based Care Representative Statements Reflecting Themes Good teams require the integration of primary care with services outside the structure of the traditional primary care clinic. • We need Accountable Health Communities instead of Accountable Care Organizations. • We need to include community health workers and public health professionals to help address the social determinants of health. • We inadvertently stigmatize mental health issues every time we refer out of clinic. Team-based care can act as a catalyst to joyful practice, but will require upfront and continuous investment to function successfully. • We need to “Share the Care” with team members. • Teams can help prevent the death spiral of primary care via burnout • Team hygiene is critical: this requires coaching/leadership training. Team-based care can increase the comprehensiveness of services available and are more likely to meet patients' needs. • Teams are the antidote to the trend towards narrowing scope of practice within primary care. • Teams can facilitate communication with specialists and supportive services to improve comprehensive patient care. Specialists should be valued members of teams and our system should promote communication between specialties and primary care. • We ignore a large part of our health community when we don't partner with specialist colleagues. • Everything is about relationships and teams promote those stronger relationships. • We need to match the micro-culture of teams with the macro-culture of institutions. Creating excellent teams starts with having the right people in medical school–those who can be excellent team members–and how we train them to be those members. • We must stop training dehumanized cowboys. • We need to find and train individuals with substrate to be hybrids–the technologist and the humanist. Changing current practices to achieve team-based care will be difficult. • Where is the “UpToDate” for practice change? • Research is not enough to drive change. We need partnerships and alliances to fuel action. The patient needs to be a part of the team in team-based care. • Start each team meeting with a patient story. • We need to get out of the “safe” environment of our clinics and into the community to build partnerships with our patients. • We need to partner with patients for practice redesign–they have unprecedented power to advocate with us. • We need patient advocates with “lived experiences” to be on clinic boards and contribute to the betterment of the clinic and of the community.
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