Year 3. September 23. Value for Money.
As a leader within the health system, I think a lot about the complex business of health care. In the United States we exist in patchwork of systems that seek to reimburse us for the cost of care, but is imperfect particularly in terms of managing spiraling health care costs while ensuring the high-quality, coordinated and equitable care.
The healthcare industry continues to undergo rapid transformation. As the cost of care continues to rise, health care payors are embracing a business model that incentivizes keeping patients healthy rather than waiting until they are sick and requiring care that must be paid for. This move towards value-based payment and away from the classic fee-for-service model coincides with a seismic shift in demographics. The population is aging, with more chronic conditions that require long-term management. Moreover, social determinants of health – such as food and housing insecurity and systemic inequities – importantly contribute to health and to disease outcomes.
What might success for clinicians look like in this evolving world? It may be measured in terms of population and not at the individual level. And while this approach would reward specific metrics, such as a reduction in ER visits, they may further reward progress on efforts that keep people out of the hospital in the first place.
There are many members of the UCLA Department of Medicine (DoM) who are leaders in scholarship and analysis of many of these challenges. We are also leaders in implementation of the required changes that will put us on a trajectory to a more sustainable health care delivery model. DoM faculty are playing a leading role in implementing value-based care programs throughout the health system. Let me now share some perspectives based on conversations with Samuel A. Skootsky, MD, the Chief of Population Health for UCLA Health and an adjunct professor in the DoM.
Sam noted: “For decades, people wanted to work on things like reducing readmissions or keeping people out of the ER. There wasn’t much movement to improve those things because people were thinking about it too much at the level of the individual patient. What these new programs are doing is understanding the population, really getting at the root causes, and attacking them there.”
As payors shift their emphasis towards populations, prevention and coordinated care, the DoM is in many ways playing a leading role within our health system. Just a few weeks ago I shared that we are among a select group of institutions to test Centers for Medicare and Medicaid Services’ new GUIDE model for dementia, a program that was based partly on work done at UCLA and that will make it possible for patients and their caregivers to access resources that dramatically improve their quality of life.
However, there are many other initiatives that are being led by DoM faculty such as a new innovation in ambulatory care that is reducing strain on the emergency department and hospital wards as well as progress in implementing preventive medicine in primary care and managing kidney disease. These represent a few examples of programs focused on promoting our patient's health and wellbeing.
Richard Leuchter, MD and Team Open Next Day Clinic in Westwood
Let's examine the Next Day Clinics (NDCs), which Dr. Skootsky views as an illustration of value-based care in action. NDCs aim to decompress the ER and hospital wards by diverting eligible ER patients to the outpatient setting as well as enabling already-hospitalized patients to be discharged several days sooner than they would be otherwise. The Next Day Clinic model was designed and launched at Olive View-UCLA Medical Center in July 2023, and due to its success there was implemented at the Ronald Reagan Medical Center this past July. Another is slated for Santa Monica early next year.
“This is a perfect example of a value-based care program because it reduces costly admissions and substitutes much lower-cost care — office care — but the value is the same or greater,” Dr. Skootsky explained. NDCs are also relatively inexpensive to launch because they’re integrated into Immediate Care clinics, sharing space, staff, medications and more.
“This ‘clinic within a clinic’ model is a strength because it allowed us to launch at a relatively low cost since we could harness existing infrastructure,” Richard K. Leuchter, MD, who founded the UCLA NDC program, said. “This also makes the NDC much easier to disseminate to other healthcare systems, since almost every health system has immediate care or urgent care clinics that would be able to hold an NDC — it doesn’t require launching a whole new clinic from scratch.”
Here's a quick example of how care flows in an NDC. Let’s say an elderly patient presents at the ER very ill with pneumonia. After a decision is made to admit them to the hospital, an automated algorithm uses EHR data, real-time labs and vital signs to predict their length of stay. If it’s greater than 48 hours, they’re admitted as usual. But if it’s less, the patient’s electronic health record (EHR) flags them as a candidate for NDC care.
At that point, they are screened first by a case manager, then by an ER physician. If both find the patient eligible for the NDC, they’re discharged home with an appointment for the NDC within 12 to 24 hours, along with IV antibiotics and anything else they’ll need until then such as home oxygen or nebulizers. The case manager will follow up with them at least once daily in the interim to check on their status, and they will return to the NDC daily — typically twice — until they are out of the acute illness phase. For patients who live far away, the NDC can house patients in Westwood at the Tiverton Health and Wellness Hotel at no cost to them, and also offers no-cost Lyfts for patients who live closer but do not drive.
This streamlined referral system required the creation of special Smart Sets in the EHR system, an undertaking by Information Services & Solutions that took more than 900 hours to complete. The Smart Sets serve as one-stop-shops for ED providers to identify NDC candidates, order medications and tests within the ED, prescribe post-discharge medications, place specialty referral orders and prescribe special medical equipment, like oxygen tanks.
“This level of functionality was a first for UCLA and made it such that referring patients to the NDC was equal or even less effort than admitting them to the hospital,” Dr. Leuchter said. “Making NDC referral the path of least resistance was critical to its adoption.”
NDCs also save money for UCLA, he added. UCLA cares for thousands of patients with insurance plans that are structured as fully capitated models, meaning the health system receives a fixed amount of money to care for those patients regardless of how many health services they utilize. For those patients, hospitalization might cost the UCLA Med Group between $7,000 and $17,000 depending on their diagnosis and length of stay. Replacing a hospitalization with far less expensive clinic visits might offer large cost savings — in some cases, as much as $10,000 per referral. Patients benefit financially as well.
“Sixty-five percent of personal bankruptcies in America are due to medical debt, and the #1 contributor to medical debt is hospitalization,” Dr. Leuchter said. “As providers, we often don’t realize how the financial toxicity of healthcare impacts our patients, and the NDC offers a high-quality acute care alternative to hospitalization that can have 80% lower out-of-pocket costs for patients.” Dr. Leuchter points out that the NDC also has other benefits to patients, such as allowing them to sleep in their own bed, be with loved ones and avoid things like hospital-acquired infections.
The NDC at Ronald Reagan has seen 41 patients since it started in July and avoided more than 72 hospital bed-days. Many of the patients are acutely ill and require two or three NDC visits in a row, Dr. Leuchter said, so the total number of visits is about twice as high. Thanks to the work of designated case manager Angela Jaymalin, RN, the Ronald Reagan NDC has a 100% show rate to appointments. Other critical members of the day-to-day operations team from the DoM are Michael Yashar, MD; Karin Kessey, PA; Danielle Seiden; Will Turner; Eric J. Curcio, MD; Giselle Duran, RN; and Claudia Flores. The NDC also has strong partnerships with numerous ER stakeholders.
The new Santa Monica NDC opening next year will increase patient volume by 125 to 150%, Dr. Leuchter estimates. He also expects the clinic will expand the types of conditions it can treat. We look forward to building upon our commitment to value-based care and giving more patients access to this innovative resource!
Value-Based Care Programs Report Progress
The next initiatives I would like to highlight are Primary Care First (PCF) and Kidney Care First (KCF), both of which are Centers of Medicare Services (CMS) Innovation Center models that were launched within the past five years by the Faculty Practice Group’s Office of Population Health & Accountable Care (OPHAC).
The PCF, a Model Home program, went live at UCLA Health in January 2021 with 43 participating UCLA Health primary care practices and around 39,000 Medicare Fee-For-Service beneficiaries enrolled in the program. It is designed to reward value and quality by offering a payment structure that supports the delivery of advanced primary care, emphasizing the importance of the clinician-patient relationship and care for patients with complex chronic needs. Participating practices must meet standards that reflect high-quality care to be eligible for a positive adjustment to primary care payments. Measures include performance on health care system utilization, patient experience; blood pressure and Hb A1c control; completion of colorectal screenings; and advance care planning.
“What is great about Primary Care First is that it aligns with our organization’s five key tactics to succeed in value-based care: avoid unnecessary utilization, improve quality of care through care gap closure, improve diagnosis coding accuracy and completeness, enhance patient experience, and ensure annual wellness visits. These tactics closely align with what primary care providers and primary care clinics are already doing every day,” Sarah Meshkat, director of OPHAC, explained. “Additionally, it is worth noting that there have been a lot of multi-disciplinary efforts over the years to lay the organizational infrastructure that facilitates accomplishing these key tactics, including but not limited to EMR enhancements, centralized ambulatory care management programs and provider quality incentives.”
The KCF model launched in January 2022 with 22 participating UCLA Health nephrologists and around 1,100 Medicare Fee-For-Service eligible beneficiaries enrolled in the program. It is designed to incentivize better management of kidney disease through financial incentives that are adjusted for clinical quality, utilization, and health outcomes, with the goal of encouraging providers to provide care that meets patients’ health needs through the course of their chronic kidney disease (CKD) stage 4 or 5 or end-stage renal disease. In particular, the KCF model focuses on delaying the progression of CKD to ESRD, managing the transition into dialysis, supporting patients through the transplant process, and keeping patients healthy post-transplant.
Using KCF as a catalyst, OPHAC brought together a collaborative, multidisciplinary design team with primary care physicians, nephrologists, clinical operations, IT, Quality, ambulatory care management, and population health to launch a redesign of kidney care. The resulting UCLA Kidney Medical Home program includes many innovations that exemplify our commitment to value-based care, including early identification and referral of primary care patients with CKD; a comprehensive CKD patient education program; identification and stratification of high-risk patients using a UCLA-developed machine learning predictive model; and a complex care management program for patients with CKD and heart failure with remote patient monitoring and support of an RN care manager to prevent avoidable hospitalization and ED visits.
Meshkat told us that UCLA Health is generally doing very well in both Primary Care First and Kidney Care First models in comparison to national and regional benchmarks, meeting or exceeding the required thresholds for performance. And the suite of initiatives under the UCLA Kidney Medical Home program have led to a statistically significant trend in reducting hospital admissions and emergency department visits.
Programs like these represent a paradigm shift in the way we think about value-based care, putting a greater emphasis on integrated care that highlights the importance of quality of care, patients experience, and provider performance.
These are just some of the many ongoing efforts we have implemented to support patients across the care continuum as we move towards value-based care, and we are excited to be at the forefront of this exciting new era in medicine.
Celebrating the Legacy of Proceedings of UCLA Health
Last week we announced that the Proceedings of UCLA Health — a medical journal that for nearly three decades has disseminated scholarly work authored by DoM faculty — will soon debut on its own channel on Cureus, an open-access medical journal platform. The publication will also be renamed Proceedings of UCLA Department of Medicine. Michael Lazarus, MD, will serve as editor-in-chief.
Our journal would not be possible without the dedication of Robert K. Oye, MD, who co-founded the publication under direction of former Chair of the Department of Medicine Alan M. Fogelman, MD. Their goal was to ensure that faculty in the clinician educator series would be able to “document creativity,” a requirement for promotion. At that time, creativity was often interpreted as conducting and publishing research, which was a major challenge for faculty providing full-time direct patient care.
“It was unrealistic to expect all faculty providing direct patient care eight to nine half days a week to have the time or energy to participate in traditional research” Dr. Oye explained. He and Dr. Fogelman reasoned that a publication of “clinical vignettes” based on select patients of teaching interest would be a practical solution, especially given that faculty were accustomed to case-oriented clinical teaching.
“Traditional published 'Case reports’ featured very uncommon examples and were not necessarily the most educational,” Dr. Oye said. “We wanted faculty to identify examples of situations that experienced clinicians would find educational.”
Thus, the Proceedings of UCLA Health Network, as it was initially titled, was born. Volume I of the journal debuted in print during the summer of 1997. Articles in the first edition focused mainly on clinician education — Anita Agzarian, MD and Alice Agzarian, MD co-authored an article on integrating a teaching program into a community medical practice, for instance, while Peter Galier, MD wrote about creating a balance between a physician’s role as a community practitioner and medical educator. Future volumes would include clinical vignettes on everything from herbal tea-induced liver injury to brain abscesses due to a sinus infection to a case of imatinib toxicity, potentially caused by an interaction with blood oranges.
“These vignettes were the exact kind of situations that clinicians with trainees would select to teach,” Dr. Oye explained.
To print physical copies of each issue “cost way more than my wedding,” Dr. Oye joked, which eventually led him to take it online. But that didn’t stop him from editing each submission the old-fashioned way — on paper using a red pen. He lends the same meticulous copy-editing process to UCLA Health’s quarterly consumer publication “Vital Signs” as a member of its editorial board.
When asked why he remained at the helm of the publication for so many years despite his many other clinical and leadership responsibilities — and has continued even after he retired in 2021 — Dr. Oye offers a practical answer.
“There weren’t a whole lot of others looking for this job,” he said. But that made it no less rewarding, and not just because it helped faculty get promotions and disseminated knowledge to other clinicians. Patients with uncommon problems have found the publication useful from time to time as well, he noted, reaching out to him via email to see if they could connect with the author of a paper.
Dr. Oye is looking forward to passing the reins on to Dr. Lazarus as he continues Dr. Oye’s legacy of excellence. The UCLA Department of Medicine would not be what it is today without his dedication to our success, and we are deeply grateful for his service! Be on the lookout for more details about our new Cureus channel in the coming months.
Dale
P.S.
I know that there are many in the DoM who enjoy flower gardens. Let me share a few pictures from a recent visit to an orchid garden.
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