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    MGMA senior editor Daniel Williams, MBA, MSEM, sat down with Dr. David Hatfield, president and CEO, Hatfield Medical Group, and Jim Schafer, administrator, Hatfield Medical Group, to discuss how to successfully implement a value-based care model at a medical practice and what best practices they would suggest to others interested in pursuing value-based care initiatives.

    Q. Can you tell us about the history of the Hatfield Medical Group, including its history?

    Hatfield: My dad started it all as a solo family practitioner, and he was one of those country doctors who did a little bit of everything – he would deliver babies, perform minor surgeries, admit patients to the hospital. He started the Hatfield Medical Group in the late 1960s and when he convinced his three sons to go into medicine, we all gained a love for primary care. Back in those days, he was on call all the time and we saw that our father had a great relationship with his patients and would deliver quality care to those patients.

    When we joined, it was an eat-what-you-kill, fee-for-service model … the goal of high-quality care initiatives was to see how many patients you could see in a day, and we viewed that as part of serving the community and creating access to care. Little did we know that by seeing that much volume, ultimately you sacrifice some of the quality piece. When my father retired and the sons took over, we survived in a fee-for-service model but we started to see reimbursements drop and value-based discussions started to happen ... As physician burnout increased and retention decreased with the high volume of patients we were serving, we quickly decided our current model was unsustainable. We started to discuss how to align our practice in a value-based model and which quality metrics we would have to measure.

    Q. What were some of the biggest challenges in making that shift?

    Hatfield: Meeting with payers who didn’t understand what we knew about the value-based payment model. We had to help teach them and explain how we needed to be graded and paid based on value and what those value metrics look like.

    One other critical component was changing the overall culture of the practice, of our providers and of our support team and then taking that culture to the payers. Without payer support, without them reimbursing us this way, it doesn’t work. Another of the key moments during this transition that helped propel us forward was meeting Jim Schafer. … [He] recognized we would have to make some tough financial decisions and implement cultural change.

    Schafer: Additionally, one of the toughest challenges we faced was improving access to care. We had to make sure a system was in place to ensure patients could get in to see their physician same day or next day depending on their issue. ... We also wanted to make sure that the whole patient experience was improved, which may not be the first thing you do in a fee-for-service model. Changes were made to streamline the check-in and checkout process; the lobby area was made more enjoyable, as well as the check-in area; and we also changed how we structured our hiring process.

    Hatfield: Once again, one of our biggest challenges was also working with the payers so that they understood why we were moving to a value-based payment model. In the past, the payer-provider relationship was very adversarial. Jim and I started to have discussions with them around total medical expense, where we were leaking and where we needed to rein it in. As a provider, this was a new experience for me, but we had to build relationships with payers and helped them understand what we’re doing.

    Q. What about the day-to-day for you and your staff and how that compares to before?

    Hatfield: We really started to live our mission. Value-based or population health care is simply this: quality, compassionate care to every patient every day. … We live it and breath it in every one of our clinics. I can train anybody to take a medical note or navigate the EHR, and Jim can work with any front office person to help them understand our workflows, but we make sure to hire and interview kind people. We believe in a strong culture of being kind and treating every person like you would treat your mother.

    Moreover, if you expect it, you better have a way to measure it. We measure our patient experience and our quality outcomes. [Our practices] have dashboards that we put up to tell us how we’re doing and where we need to improve. You have to be able to produce data if you want to produce change.

    Schafer: One of the big changes was that we became a more data-driven organization and we wanted to be able to aggregate this data and make it actionable. We took a more proactive approach, which included outreach to patients – calling them for annual wellness visits and getting them into more of a preventative pattern. When patients are healthy, when they can ask questions and you can get to know them and make sure their medications are reconciled appropriately, you can better handle and manage care. We also became much more interoperable with other organizations and gathered data from outside sources to make sure that we could provide actionable, quality, evidence-based outcomes.  

    Q. In hindsight, what are some of the things you might have changed early on?

    Hatfield: Get out in front of more payers. ... Today, I believe we should be more aggressive in our approach. We want to be held accountable, so we’re alright if payers hold us accountable. Being held accountable means managing the cost to care for the patient.

    As an example, Jim came to me and said that we needed to implement diabetic retinal eye exam screenings in our clinics. … [We] bought cameras, trained our medical assistants to take pictures, trained our doctors how to make sure it was being ordered and created flags in our EHR that were soft reminders of who’s diabetic and hadn’t had their diabetic retinal exam screening done. … Payers started to ask how we were going from a two-star ranking to a five-star. We explained what we were doing, and ultimately they wanted to pay for that service. That’s not where the benefit comes from. The benefit comes from the cost savings from screening and finding diabetic retinal eye disease early.

    Q. Have you seen results on how your patients are responding to value-based care?

    Hatfield: We view ourselves as a medical team, not just the physicians, and value-based payment is a heavy lift — it takes a team. Other than feedback from patients and the time that providers spend in the room reviewing actual medical problems and helping them navigate their social determinants of health, we have our chronic care managers who are trained specifically to outreach to patients who have multiple chronic disease conditions. There’s a protocol for following up with patients. We also don’t put a time limit on them and we address all their concerns. On a high level, we’re helping them navigate a lot of different areas of their life, and the only way you can do that is to create time. Going from fee-for-service to value-based means that my average daily patient intake went from 45 to 50 patients a day to 20 to 21 patients a day. You don’t need data to tell you that patients are going to be happier if you spend more time with them.

    Schafer: We have to start thinking about the patient differently. The word “noncompliant” is restricted from the vocabulary at our clinics. We want to identify and overcome barriers to patient care, specifically; we found some didn’t have a ride to their appointment. If we can get them a ride to the office, we can get them access to care and don’t have to wait until something goes wrong. We have seen a lot of success with that and in the understanding of barriers and social determinants of health.

    Q. Have your value-based contracts through payers made a positive impact to the overall practice revenue or created value by reducing cost?

    Hatfield: It has to be both. We started to improve the types of visits we would do and we started to charge for things we didn’t know we could, such as having discussions around tobacco cessation, which improves a patient’s health, and having discussions around advanced directives and living wills. These conversations improve population health and … lower total medical expense on the plan side. When you start to have those shared savings contracts in place, the payers are more willing to give you part of it. They know that the real expense happens when a patient doesn’t get the right care at the right time in the right place. It’s not rocket science when you can avoid unnecessary hospitalizations.

    Q. What are your key takeaways for those who would want to invest in value-based care initiatives?

    Schafer: Align quickly, move down that path and don’t hesitate. When you’re doing the right thing, it feels great and the patients have a great experience. If you make a couple mistakes, redirect and learn what you can from it. Any process you’re implementing – whether it be chronic care management, transitional care management or discussions around advanced directives with patients – start the process and fine tune it as you go.

    Hatfield: Don’t be afraid to start. Go sit with payers and whoever is leading your [accountable care organization]. We weren’t great at any of it initially and we wanted to find out the baseline. Start somewhere, set goals and you’re going to move a lever and then another and you’re going to see success. As Jim likes to say, “We are continually beating the drum of value-based medicine.” All you have to do is create the “why” in your medical group. Ours is to deliver quality, compassionate care to every patient every day, and we want them to have an experience in our clinics with our providers and medical care teams that are second to none.

    – Edited by Kelsey Brading, MGMA content production coordinator

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