Report From the FMAHealth Practice Core Team: Achieving the Quadruple Aim Through Practice Transformation

Family Medicine for America's Health (FMAHealth) is a strategic planning organization effort that was created out of the reevaluation of the first Future of Family Medicine project from 2004. This article is a summary of the key findings of the FMAHealth Practice Core Team. At the highest level, we find that family medicine practices have compelling intrinsic and extrinsic reasons to evolve to new models of care delivery. We have demonstrated that payment transformation is imperative to successful practice transformation and that comprehensive payment models that include attention to physician work within the social determinants of health and require fewer administrative burdens will be key to achieving the quadruple aim. To bridge payment reform and practice transformation will require better and fewer measures of physician effectiveness in order to allow the physician-patient dyad to thrive in these new models. Achieving these goals will require a sustained national effort involving not only the many family medicine membership organizations, but their collaborative work with others in the health care transformation industry who may not have been our traditional partners. Educational initiatives must be robust, available to all family physicians regardless of professional organization membership, and focused on meeting physicians and physician practice managers where they are with the goal of moving them toward a state of more advanced care delivery. This article outlines the work done by the FMAHealth Practice Team that supports the above assertions.

Development, Value, and Implications of a Comprehensive Primary Care Payment Calculator for Family Medicine

Background and Objectives: Fee for service (FFS), the dominant payment model for primary care in the United States, compensates physicians based on volume. There are many initiatives exploring alternative payment models that prioritize value over volume. The Family Medicine for America’s Health (FMAHealth) Payment Team has developed a comprehensive primary care payment (CPCP) model to support the move from activity- and volume-based payment to performance-based payment for value. Methods: In 2016-2017, the FMAHealth Payment Team performed a comprehensive study of the current state of primary care payment models in the United States. This study explored the features, motivations, successes, and failures of a wide variety of payment arrangements. Results: The results of this work have informed a definition of comprehensive primary care payment (CPCP) as well as a CPCP calculator. This quantitative methodology calculates a base rate and includes modifiers that recognize the importance of infrastructure and resources that have been found to be successful in innovative models. The modifiers also incorporate adjustments for chronic disease burden, social determinants of health, quality, and utilization. Conclusions: The calculator and CPCP methodology offer a potential roadmap for transitioning from volume to value and details how to calculate such an adjustable comprehensive payment. This has impact and interest for all levels of the health care system and is intended for use by practices of all types as well as health systems, employers, and payers.

Findings From FMAHealth’s Bright Spots in Practice Transformation Project

Background and Objectives: Family physicians are increasingly making or contemplating various methods of practice transformation, but most report significant barriers to making that transition. Given strong interest in practice transformation, and perceived barriers to doing so, it is important to examine how some practices are implementing changes and overcoming barriers. In this project, Family Medicine for America’s Health Practice Team learned from practices across the United States that are transforming and experiencing the benefits of working in a comprehensive, value-based practice. The objectives of the project were to identify drivers of transformation to value-based care and ways of working with drivers to mitigate potential barriers, and to determine relationships between practice transformation and joy of practice. Methods: Fifteen practices of varying size and type from 11 states participated in this project. Practices were sent a short-answer survey about their practice, transformation, and payment structure. Next, practices participated in a 45-60-minute deep-dive interview. All surveys and interviews were iteratively coded to identify themes using Thomas Bodenheimer, MD, et al’s building blocks of high performing primary care framework. Results: Engaged leadership, data-driven improvement, team-based care, and comprehensiveness and care coordination were primary drivers of transformation, with payment as a needed foundation. Practice transformation helped meet the triple aim and was correlated to joy of practice. Conclusions: Practices are transforming to comprehensive value-based care delivery and experiencing greater joy in practice; but payment reform is required to spread and sustain practice transformation.

The development of a new service for older adults

In July, 1986, Wesley Long Community Hospital, Greensboro, North Carolina, opened its Older Adult Unit. Staffed to accommodate twelve patients, the unit is often operating at capacity. Key to the success of the unit is the process the hospital followed in its development. The hospital tested its preliminary concept for the unit with its consumer populations and tailored the concept to address the needs specifically identified by the populations. In addition, the hospital recognized the importance of an educational role in the promotion of a new service and incorporated this in its marketing strategy. This article outlines the steps followed in the development and successful introduction of the unit.

Role of calcium as an inhibitor of rat liver carbamylphosphate synthetase I

The mechanism of Ca2+ inhibition of carbamylphosphate synthetase I has been investigated using purified enzyme obtained from livers of rats fed a high protein diet. Binding of Mn2+ to the enzyme was measured by EPR techniques at pH 7.8, and Scatchard plots of the data indicated one Mn2+-binding site with a K'd of 13 microM. From competition studies between Mn2+ and Ca2+ or Mg2+ binding, values of 180 microM were obtained for K'd (Mg) and 193 microM for K'd (Ca). A nonlinear least squares curve fitting program was used to calculate the K'm for MgATP2- at the metal-nucleotide binding sites using a simplified rate equation of the enzyme reaction mechanism. Values of 140 and 2420 microM were obtained for K'm (MgATP) at the first and second sites, respectively, at pH 7.8, with a free Mg2+ of 1 mM and other substrates and activators present at saturating concentrations. Variations of the bicarbonate, N-acetylglutamate, and ammonia concentrations in the absence and presence of different amounts of total calcium, from which free Ca2+, free Mg2+, MgATP2-, and CaATP2- concentrations were calculated, permitted values for K'i (CaATP) to be obtained by graphic procedures. Mean values of 375 and 120 microM were obtained for K'i (CaATP) at the first and second sites, respectively. Using the above kinetic constants, a computer model of the enzyme reaction was constructed and tested using two further sets of kinetic data obtained by varying the concentrations of Mg2+, Ca2+, MgATP2-, and CaATP2-. Poor fits were obtained unless the formation of a mixed complex involving CaATP2- competition with MgATP2- at the second metal-nucleotide-binding site was incorporated into the rate equation. Nonlinear least squares curve fitting of both sets of experimental data gave a well determined value of 124 microM for this final CaATP2- inhibitory constant. Sensitivity tests for variation of the primary kinetic constants with the computer model showed that the inhibitory effect of free Ca2+ was weak and that the observed calcium inhibition of carbamylphosphate synthetase can be accounted for primarily by competitive interaction of CaATP2- at the second MgATP2- binding site. With 1 mM free Mg2+ and 5 mM MgATP2-, half-maximal inhibition of enzyme activity was obtained with 0.2 mM CaATP2-.