“Targeted Gatekeeper Model” Needed for Successful CPC+ Payment Reform and Delivery Transformation

11:00 EDT 8 Aug 2017 | Businesswire
Cave Consulting Group, Inc.

Comprehensive Primary Care Plus (CPC+) is designed by the federal government to strengthen primary care through payment reform and care delivery transformation. The CPC+ payment design gives primary care physician (PCP) practices additional financial resources to improve quality of care and reduce the number of unnecessary services their patients receive.

“The CPC+ performance-based payment component is paid prospectively to practice sites. However, practice sites need to retrospectively pay back potentially large amounts, if utilization measures that drive total cost of care are not achieved,” stated Dr. Douglas G. Cave, President of Cave Consulting Group (“CCGroup”).

Dr. Cave continued, “Therefore, participating PCP practices need to stay focused on their approach to reduce unnecessary services. For this reason, PCPs want to know the services to focus on first to reduce unwarranted practice variations. Medical condition-specific MedMarkers™ answer this question.”

MedMarkers™ are process of care quality measures and are key services associated with cost-of-care in treating a medical condition. For instance, the key MedMarker™ in more routine gastroesophageal reflux disease (GERD) is upper GI endoscopy.

“Clinicians also want to know the appropriate level of utilization that does not represent potential under- or over-utilization of MedMarker™ services. CCGroup’s Clinical MedMarker Protocol Ranges™ address this latter question,” defined Dr. Cave.

He stated, “For a covered CPC+ patient population, the identified top 10 medical conditions and associated MedMarker™ services (with the most practice pattern variability) drive over 50% of all patient cost and quality improvements.” This is where the Targeted Gatekeeper Model, developed by CCGroup, comes into play.

Under the Targeted Gatekeeper Model, PCPs become more active participants in patient care for the identified top 10 medical conditions and MedMarkers™. This is because, presently, PCPs are involved in treating only 40% of these episodes of care. And of the 40% of episodes that PCPs are involved with, PCPs refer about 35% of these episodes to specialists. “In effect, PCPs are solely involved in about one-quarter of these top 10 medical conditions,” detailed Dr. Cave. Care delivery transformation requires significantly more PCP involvement in these top 10 medical conditions.

One reason PCPs may not be involved, or refer more often than necessary, is that they are not empowered to understand what to do next for the patient. This is why the Targeted Gatekeeper Model implores the need for quantitative clinical pathway development. The process for building quantitative clinical pathways involves a retrospective view of claims data to determine what services are currently delivered to patients with the top 10 medical conditions. Then, clinical leaders decide those services that are, and are not, appropriate to perform. This information is presented to PCPs to enable better shared decision-making with their patients.

“A key objective of the Targeted Gatekeeper Model is to increase PCP involvement from the existing 40% of episodes of care to at least 50% (in the top 10 medical conditions). We also want to reduce the current specialist referral rate from 35% of episodes of care to 20%. And when a referral is necessary, only refer to those specialists that efficiently and effectively treat the patient’s specific medical condition. Often today, PCPs refer to specialists based on factors other than efficiency and quality of care,” outlined Dr. Cave.

The Targeted Gatekeeper Model offers PCP practices the opportunity to be successful under CPC+. Each PCP practice site needs to initially identify those medical conditions with the most practice patterns variability. Then, PCPs need empowerment to lead the delivery of patient care through developed quantitative clinical pathways.

About Cave Consulting Group, Inc. (CCGroup)

Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 27 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.

Mr. Yuri Alexandrian, 650-286-4100


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