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Free Help to Perform Unpaid Labor?

Nurse taking blood pressure

Like most in the improvement science field, I’m constantly on the lookout for new insights – either from projects or initiatives I’m working on or from reports and analysis of other initiatives. So, I was interested to see a recent special supplement to the Annals of Family Medicine1 describing early findings from the Agency for Healthcare Research and Quality’s (AHRQ) program – EvidenceNOW: Advancing Heart Health in Primary Care.

Briefly, EvidenceNOW targets key practices for heart disease management, the ABCS – aspirin use in high-risk individuals, blood pressure control, cholesterol management and smoking cessation. Beyond the clinical focus, EvidenceNOW seeks to understand how best to build and support the capacity of primary care practices to receive and incorporate new evidence and models of care. EvidenceNOW is a $112 million effort, the largest single initiative in AHRQ’s history.

As I reviewed the research articles in the Annals supplement I was impressed by the thoughtful approach to the design of the initiative. AHRQ implemented EvidenceNOW through funded regional cooperatives. Applicant cooperatives were allowed to propose their own implementation design strategies and to provide evidence supporting those choices.

EvidenceNOW is ongoing. AHRQ reports that seven regional cooperatives have enrolled 1,500 small to medium-sized primary care practices with approximately 5,000 clinicians serving 8 million patients, launched their implementation interventions, and collected baseline ABCS data. The supplement includes research articles reviewing topics such as baseline practice characteristics and the experience of regional cooperatives in recruiting practices. It is too early for reporting on project outcomes.

The Annals supplement also includes two invited commentaries. Both hold important lessons for health care systems improvement.

The first commentary is by Lawrence P. Casalino, M.D., Ph.D., of the Department of Healthcare Policy and Research, Weill Cornell Medicine New York-Presbyterian Hospital. Dr. Casalino provides a provocative perspective titled:

Technical Assistance for Primary Care Practice Transformation:
Free Help to Perform Unpaid Labor?

Dr. Casalino outlines the critical function of primary care in an effective health care system and reviews the health care policy drivers supporting primary care transformation. He also notes that:

“Physicians and staff…may or may not believe that transforming their practice will improve their work lives, help them take better care of their patients, and lead to a positive return on investment— or at least not be a financial negative for the practice.”

Indeed, the early results that Dr. Casalino reviews from EvidenceNOW suggest that even the best designed and most expertly executed technical assistance, quality improvement and practice transformation programs may have difficulty gaining traction if financial drivers are not addressed in parallel (and not only through the prospect of uncertain future shared savings returns).

The second commentary, by Asaf Bitton, M.D., MPH, of Ariadne Labs, has a somewhat different focus, but includes this observation:

“Primary care practices simply cannot be asked to improve care, avoid burnout, reduce costs and achieve system targets while also wondering whether in so doing they will reduce their income.”

What is HealthInsight doing to help?

At HealthInsight, we have become increasingly concerned about the burdens health care quality improvement place on primary care providers. We have been working on a strategy for supporting primary care providers that advances care quality goals without sacrificing provider and staff well-being or the financial viability of the practice. Recent changes in Medicare payments, combined with experience from practices that have successfully adapted to these changes, offer the possibility that many more practices can, if not have it all, at least have a pathway that brings them closer to their goals.

This strategy involves process redesign and, potentially, increasing clinical (non-provider) staffing to increase wellness, preventive care and chronic care management services. In just the last few years, through policy changes intended to strengthen the primary care foundation in the United States, these services—such as Annual Wellness Visits (AWV) and Chronic Care Management (CCM)—have become directly billable and payment levels sufficient that many providers will now find there is a solid business case for expanding their practice offerings to include them.

We are interested to hear your experience with the use of these services. Please let us know if you’d like to talk further about how this might work in your practice.


Local EvidenceNow Collaboratives

HealthInsight New Mexico and Qualis Health are both participating in EvidenceNow cooperatives. Contact us to learn more.

EvidenceNow Southwest:

Healthy Hearts Northwest: 


1AHRQ’s EvidenceNow: Early Findings. Ann Fam Med 2018;16(Suppl_1).

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