Casey Health Institute: EVP/COO Tracey Gersh, PhD on Bridging Integrative Health into a PCMH and Accountable Care

Note: This article is part of a recent partnership between the Project for Integrative Health and the Triple Aim (PIHTA) and the Casey Health Institute (CHI) for which the Integrator is providing media support. The goal of the PIHTA-CHI partnership is to stimulate understanding of integrative primary care medical homes (PCMH) via a multi-faceted look at the model CHI is creating. PIHTA is an initiative of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

Other articles in the series:

• Cory Jecmen, MAc, LAc: An Acupuncturist/Tech Player in Casey Health Institute's Integrative PCMH
  
• Speed-Dating: A Casey Health Institute Method for Building a High Performing Interprofessional, Integrative Team (September 2015)
• Casey Health Institute: Marrying Integrative Health and Values-Based Medicine (June 2015) 
• Casey Health Institute Announces an Integrative Health Care PCMH as an Evolving Model of Practice (May 2012)

Tracey Gerch, PhD: CHI's EVP/COO

The Executive Vice President and COO of the Casey Health Institute (CHI), Tracey Gersh, PhD came to the  ground-breaking, Maryland-based integrative health center from roles as administrator and program developer at a nearby federally qualified health center (FQHC).

Asked to compare the two environments, Gersh immediately spoke to the mission and context in the FQHC "to bridge disparities for those who might not otherwise be able to access care." With the typical FQHC's dependence on grants from the federal government, the administrative environment was "one of the most regulated places she's ever seen." She adds: "Accountability and data collection are real."

Between CHI and an FQHC

Integrative PCMH joins an ACO

Much of this is not too far from Casey's patient-centered environment, according to Gersh. She speaks of a "parallel process." The tone of the work at CHI, she says, is a bit more "entrepreneurial - because we have to be." And though the payment environment at CHI is mostly fee for service with no federal funding, CHI has in common with the FQHC that "a lot of what we do is uncompensated."

Unlike many integrative centers, CHI offers a sliding scale to those who are uninsured or under-insured. For many of their patients, their insurance coverage either does not include or has limited coverage for services such as nutrition, chiropractic or acupuncture.

This means, as Casey acupuncturist Cory Jecman, LAc notes in an earlier interview in this project, many of the patients are integrative medicine naïve, in part because of their insurance coverage. Oftentimes, they arrive for treatment, said Jecmen, "because [their] primary care physician said to come" rather than because of an interest in acupuncture or an alternative approach or because their insurance company provides coverage.

Philosophy shift, breadth of services and "patient-centered care"

Comparing the FQHC and CHI environs

While both the FQHC environment and CHI aspire to make the philosophical shift to patient-centeredness, says Gersh, CHI has the distinct advantage in "the breadth and depth of what we offer." In CHI's patient-centered approach, she explains, "we are not doing something to patients - we are engaging them."  The shift is from provider-centric to patient-centered.

And CHI brings a great deal to patients:  "We have so many things that it is mind-blowing." She ticks off the services. First, the "best medical care, then the multiple practitioner types - MDs, nurses, chiropractor, acupuncturists, naturopathic doctor, massage therapists and coaches. These are all linked to "the continuum to wellness, including prevention and aftercare."

What does she mean by "aftercare"? She summarized: "We have a wellness center with a host of services, yoga, nutrition, and stress management. We provide ways to connect to the community. We have a care coordinator and an EHR [electronic health record]. Our nurses can help people navigate the system. We can help them stick to their care plans."

Gersh describes Casey Health Institute's concept of "patient-centered" as a work in progress: "No one is really trained in this." The Center's emerging model "is to engage patients in plans" for care along the way, beginning with pre-visit planning. The clinic focuses not only on bettering communications in and among diverse internal clinicians and staff but also with health resources in the community." All of this, Gersh said, "serves the Triple Aim."

Payment bonus as a Care First PCMH

One place where Gersh as COO is particularly happy in the Casey Health environment relates to payment. As a qualified patient centered medical home (PCMH) with Care First, Maryland's Blue Cross Blue Shield plan, CHI routinely receives an enhanced medical payment rate. This jumps routine payments by 12% in consideration for a PCMH's commitments to a broad delivery of services.

Recognizes CHI as PCMH

For CHI, Care First's new rate began July 1, 2015. This coincided with a process on which Care First mentored them to identify high risk and high cost patients: "A major influence on outcomes is how you do with these [high risk] patients." She adds, however, that it is CHI's goal to apply a similar thoroughness and individuation "across the board."  She shares that Care First has some outcomes incentives awards, on top of the advanced payment rate.

CHI co-founder David Fogel, MD noted in a prior article in this series that he bets that the data-based outcomes from CHI's experience will be a significant boost for the integrative care field: "Integrative medicine is team-based collaboration. I think we will blow values-based metrics out of the water with our outcomes using a team-based staff model of care."

Has CHI any data to share yet? 

Gersh confirms that CHI got off to a poor start in this department. They had an EHR vender they fired. "Most of the data yet is in aggregate," says Gersh and they have only just begun to contact patients after their first visits: "We want their feedback." The ability to analyze significant data over time is yet a ways off. Yet Gersh is convinced that now they are set with a system and strategies to discover "who needs more care" and strategies "to get the outcomes we want at lower costs."

Entering into an accountable care organization

ACO formed of 5 primary care clinics

The most recent step toward fulfillment on the CHI founders' plan to implant these integrative services into the new era boosted by the Affordable Car Act is a recent decision to join an accountable care organization. For CHI the path began with some connections to an ACO named Aledade and particularly the business's CEO, Farzad Mosteshari, MD a colleague of a CHI board member. The firm's pitch to primary care practices on its website as to why to "embrace primary care" is as follows:

• "An ACO lets primary care physicians capture the value they create for the health care system through improved care coordination, chronic disease management, and prevention.
• "In an ACO, primary care physicians continue to receive payments for their services - and get a share of any savings from fewer avoidable emergency room visits, hospitalizations, and unnecessary and potentially harmful procedures.
• "Most of all, joining an Aledade ACO will help keep independent primary care practices flourishing, and prepare them for the future as health care payment shifts from a system based on volume to one based on value."

Mostashari: Aledade founder

Gersh credited CHI co-founder Fogel's ability to "invite conversation" as what got the dialogue with Aledade rolling. Leaders of the two s did a deep check in on philosophy and values in a series of conversations. One outcome was that, according to Gersh, Aledade "thought Wow! How interesting to have a model like ours in this environment. They really wanted us to be successful. They also thought we could offer a different perspective."

In joining, CHI linked with five other conventionally-oriented primary care practices that formed the basis of the ACO. Workgroups were organized to link teams in different work areas across the practices. No big surprises, according to Gersh: "The initial conversations vetted them."

Now it's wait and see on what can be learned from the EHR and other experiences and outcomes as Casey Health Institute, starting January 1, 2016, becomes the first integrative primary care home partnered in an ACO.

Betting on CHI's outcomes

Comment:  I have the feeling of being involved in a kind of gamble here. Terrific outcomes can be a huge advertisement for an integrative model implanted in the center of the most progressive organization of primary care in operation in the United States. Good comparative outcomes will be a boost. Poor outcomes will likely produce the kind of surprise that the seemingly endless series of negative botanical studies from the NCCIH produced.  

The bet from Gersh and Fogel and CHI is that when the data come in, the case for integrative primary care will be made. Like a veteran betting person at the track, I've done my analysis of the racing form. I've a good feeling for this horse. Better yet, for a bettor: I know the trainer - Fogel and many on his team - and have an idea through this series of interviews about how well the horse is being cared for and handled. (I like, for instance, that both