Leadership Message and Joint Venture Announcement
Colleagues—By now I’m sure you’ve heard our news announcing the joint venture between UCHealth and Intermountain Health, creating a statewide, clinically integrated network. The C3 team is eager to share our excitement about all the possibilities this will bring to your practices and patients.
I wanted to start off by revisiting the importance of clinically integrated networks (CINs) in changing how we deliver health care. We all are well aware that health care, as it exists today, is not achieving the results we aspire to reach. In fact, we spend more money for lower-quality care than any other developed country. In the U.S., health care is fragmented and inequitable. Clinicians operate in silos, and important social, behavioral and economic drivers are often not factored into a patient’s care.
Simply put, a clinically integrated network (CIN) is a partnership of clinicians and administrators across the care continuum working to deliver high-quality, evidence-based, patient-centered care that is both cost-effective and equitable. A high-functioning CIN embodies a new business model of health care that supports the quadruple aim. A CIN is an attempt to transform health care delivery from a reactive, to a proactive, process. In its most advanced form, under a capitated payment model, it can enable clinicians to take ownership of our role in keeping patients healthy, make care more affordable, and ultimately keep us connected to the reasons we entered the healing profession in the first place.
So, what does this mean for you, and your practice, as members of this new network? In other words, what can you expect from the network, and what does the network expect of you?
Network practices can expect help with the following:
- Contracts that support the transformed practice model and reward clinicians for healthier patients and lower costs of care.
- Help focusing your efforts on the most impactful measures using a single scorecard driven by data and analytics.
- An expanded care team to help you care for your patients in the “in-between” spaces.
- Collaborative relationships with specialists and community organizations to support your patients’ care across the continuum.
- Streamlined data sharing between organizations to ensure that clinicians have a full picture of their patients’ health journey and their needs along the way.
And, as partners, here is what we need from you:
- A commitment to providing the highest-quality, evidence-based care.
- A focus on keeping patients at the center of your practice operations.
- Engagement in learning how to be a clinician in a transformed health care delivery model.
This will mean holding ourselves accountable for the health outcomes we deliver, taking more ownership for making the care we offer more affordable, and leading the teams of caregivers working with us.
Ultimately, we all went into health care to provide patients with the means to live their healthiest life. A clinically integrated network, the payment models that support it, and the tools and teams for collaboration it can provide, offer us a way to do just that.
Amy Scanlan, MD
Moving Upstream Using the Annual Wellness Visit
As we move from a volume-based system of care to a value-based system of care, we need to make a fundamental shift in how we care for patients. That means, instead of just treating the sick, we need to get better at preventing sickness from happening in the first place. This will involve elements of practice redesign and learning to use novel approaches in how we care for patients.
The Annual Wellness Visit (AWV) is an excellent example of a novel approach by taking a comprehensive look at all your patients’ needs for the upcoming year. The visit can build trust between the patient and the care team, identify risks that contribute to deteriorating health, and guide future interventions and efforts. Physicians can perform these, but they can also lean on their teams for help. Working together upstream, teams will quickly realize the benefits to both patients and their care teams as patients live longer and healthier lives.
We have developed a playbook for AWVs that offers ideas and workflows for how to make these visits work for your practice. Feel free to reach out to the care management team for more ideas about which workflows are best for your team.
C3 has a centralized team of nurse care managers to provide support to our practices. Recently, Champions Family Medical practice manager Rich Lane let us know how helpful one of our care managers had been with one of their more complicated patients. The team had reached out to this patient and enrolled them in our longitudinal care management program. The patient had a complex medical history, with multiple hospitalizations and ED visits in the previous 6 months. The care manager discovered that the patient’s family felt overwhelmed by the care required, and they were often unable to provide transportation to all the follow-up medical appointments. As a result, the patient was ending up back in the ER or hospital. The care manager worked with the home health care RN to apply for a Medicaid waiver, which would allow them to pay for additional assistance with everyday care needs. She was also able to communicate with the home health team so they could reinforce the importance of follow-up visits with the patient’s PCP. The care manager communicated with all members of the care team, including the PCP, and created a seamless experience and the best possible outcome for the patient and family.
Family Clinic of Fort Collins joined the ACO in late 2021 as an Epic Community Connect practice. As a network practice, they have access to a dashboard tool that helps them keep track of their performance in the value-based care quality measures. The office manager reached out to the C3 network engagement team to better understand the dashboard. She wanted to know how they could use it to improve the care they were providing to their patients. The practice transformation coordinators were able to help her use the dashboard tool to identify patients who were due for preventative screenings or follow-up visits for chronic issues. The clinic used these lists as part of an outreach process so that these patients could be scheduled with their PCPs. The network engagement team was excited to be able to help the practice better utilize the tools at their disposal.
Value-based Medication Management: New Ways to Help Patients with Medication Costs
Medication costs are an increasing problem for both patients and the health care system. From 2009 to 2018, the average price of a brand-name prescription more than doubled to over $350.1 Fortunately, there are some developments that can help lower your patients’ out-of-pocket medication costs and improve medication spend in value-based contracts.
Understanding Medicare Updates
The 2022 Inflation Reduction Act (IRA) includes several measures to help decrease medication costs for Medicare patients.2 Become familiar with how these changes can help your patients:
- As of January 2023, Medicare Part D insulin costs will be capped at $35/month. This is for all coverage phases (including the “donut hole” coverage gap), and any deductibles do not need to be met first:
- This applies to any formulary insulin product, including combination GLP1-RA/insulin products (Soliqua, Xultophy).
- The patient cost will be the same at both preferred and non-preferred pharmacies.
- Insulin administered via pump has historically been covered under Medicare Part B. Starting July 1, 2023, insulin for pumps will also be capped at $35/month.
- Vaccines recommended by the Advisory Committee on Immunization Practices are now available with no deductible or cost-sharing:
- This applies to adult vaccines covered under either Part B or Part D. Be aware
that administering Part D vaccines at a provider office may result in additional patient costs.
- Part B covers influenza, pneumococcal, hepatitis B and any other vaccines used to treat injuries and exposures.
- Part D covers other vaccines used to prevent illnesses.
- Other changes to come that may help reduce costs include:
- Expanded eligibility for the low-income subsidy program (also known as LIS or Extra Help) starting in 2024.
- Decreased caps on out-of-pocket Part D costs for patients, leading to a $2,000 annual cap starting in 2025.
- Increased ability for Medicare to negotiate prescription drug costs and potential rebates for Medicare if medication price increases outpace inflation.
- Where to learn more:
- How the IRA affects Medicare: Inflation Reduction Act and Medicare | CMS
- FAQ on insulin cost-savings changes under the IRA: Frequently Asked
Questions about Medicare Insulin Cost-Sharing Changes in the Prescription
Drug Law (cms.gov).
Vaccines recommended by the Advisory Committee on Immunization Practices are now available with no deductible or cost-sharing.
Helping Patients Maximize Pharmacy Benefits
Both commercial and Medicare prescription insurance benefits are now offering more incentives to improve adherence and decrease costs. Help your patients get the most out of their pharmacy benefits using these tips:
- Does your patient have a preferred pharmacy?
- Out-of-network pharmacies can have elevated prices when compared to preferred pharmacies.
- Does their insurance offer mail order pharmacy services? Not only is it convenient for patients, it may also be lower cost than other pharmacies.
- Does your patient have a 90- or 100-day supply of medications?
- Utilizing extended day supplies for maintenance medications can reduce trips to the pharmacy and help with adherence.
- Some Medicare Advantage insurance companies will cover up to 100 days of medications in one fill at the same cost as a 90-day supply.
- Also consider providing 4 refills on prescriptions with extended day supplies. Not only does it help with adherence, it can cut down on patient calls to your clinic. Learn more about extended prescription duration in this American Medical Association article.
- Has your patient talked with their insurance?
- There may be other cost-savings benefits they don’t know about. Some companies offer free over-the-counter medications, general medication cost assistance programs, gift cards for groceries, or discounts on transportation.
- By calling the phone number on the back of their insurance card and asking for help with saving money, they can find out how to get the most of out of their pharmacy benefits.
- Congressional Budget Office. (2022). Prescription Drugs: Spending,
Use, and Prices. https://www.cbo.gov/publication/57050.
- Centers for Medicare & Medicaid Services. (2023, January 10).
Inflation Reduction Act and Medicare