Strengthening Primary Care and Improving Population Health: Nebraska’s Approach

Summary: In Nebraska — a largely rural state where leaders have been reluctant to impose top-down health care reforms — a cadre of independent clinicians, health plan administrators, and one state legislator partnered to strengthen the state’s primary care infrastructure. They are now working with a public health school dean to align health plans and providers around shared population health goals. To galvanize support, they are following a strategy that’s worked for them before: demonstrating the benefits of reform through pilot projects and promoting the results widely.

During the eight years he served in Nebraska’s legislature, Sen. Mike Gloor had a hard time convincing his fellow senators of the value of expanding eligibility for the state’s Medicaid program or bolstering its primary care infrastructure. He had seen the benefits of doing so firsthand in his prior job, CEO of a hospital in Grand Island, where he and his staff partnered with leaders of a local manufacturing plant to create a primary care clinic that was available to hospital and manufacturing plant employees.

Even though the manufacturer — a large, self-insured company — offered generous health benefits prior to the clinic’s launch its employees still struggled to find primary care. The group designed a primary care clinic that would make it easy for employees and their dependents to get preventive and chronic disease care, with lower out-of-pocket expenses and conveniences like same-day appointments and an onsite pharmacy. Clinic leaders also collected data to track how well clinicians were meeting quality and cost targets.

“Each physician received quarterly reports showing information such as the outcomes of their referrals and the cost of care,” Gloor says. From the point of view of the hospital and manufacturer as payers, it was a success: savings to them hovered around 10% to 15% annually, with the largest savings coming from having fewer diagnostic exams and adhering to the pharmacy’s formulary. Just as important, patient satisfaction numbers were higher among employees who opted to use the clinic, compared with those who saw other providers as part of the traditional insurance plan, according to Gloor.

To shape the pilot and develop performance measures, the legislation established an advisory council of primary care physicians and Medicaid agency staff, as well as Gloor and his staff. The clinics were given upfront funding to hire nurse care coordinators and technical assistance to form registries so they could identify patients who needed preventive screenings, assistance in managing their medications, and timely follow-up care after hospitalizations. Gloor also brought together physicians, hospital leaders, insurers, and other interested parties in a collaborative that met for three years to discuss patient-centered medical homes and other primary care-focused reforms, with assistance from the National Academy of State Health Policy and Milbank Memorial Fund, as well as other experts who offered insight into national health reforms then underway.

After two years, the pilot was evaluated by Nebraska’s Department of Health and Human Services. In 2013, the agency reported several measurable changes: significant decreases in emergency department (ED) visits, reductions in hospital admissions for ambulatory care–sensitive conditions, increased patient satisfaction, and some improvement on health outcomes as well as small cost decreases.

While the state declined to extend the pilot to practices statewide, it did encourage health plans to support patient-centered medical homes. Blue Cross and Blue Shield of Nebraska (BCBS of Nebraska), one of the state’s largest private payers with half of the commercial market, had already done so, launching its own medical home program in 2010 based on Gloor’s encouragement. The program offered practices financial incentives and technical support for expanding access, for instance by creating after-hours phone lines and weekend office hours. The health plan also gave practices care coordination fees, which were adjusted based on BCBS members’ medical conditions, to help them hire care managers to support people with chronic conditions and check on them after hospitalizations or ED visits.

“When we started, practices were struggling to keep their heads above water seeing patients in their offices and in hospitals. With support, they had more time to spend with patients grappling with serious illnesses and chronic conditions,” says Debra Esser, MD, BCBS of Nebraska’s chief medical officer. Today, 33 primary care practices are part of the insurer’s medical home program.

Independent Primary Care Physicians Step Up

While the Medicaid agency’s foray into value-based payment was short-lived, many of Nebraska’s primary care clinicians remained committed. Members of the South East Rural Physician Alliance (SERPA), an independent physician association, saw an opportunity in Medicare’s Shared Savings Program, which enabled them to form an accountable care organization (ACO) in 2013 and reap some of the savings they achieved by improving health outcomes and reducing hospital use. “A lot of people told us it wasn’t possible to have an independent, rural, primary care–led ACO,” says Bob Rauner, MD, MPH, then the chief medical officer of SERPA. “After we ran it successfully for a few years, that sort of opened people’s eyes that this could be done.”

Nine participating clinics used $2.1 million in advanced payments available to physician-led and/or rural ACOs from the Centers for Medicare and Medicaid Services (CMS) to invest in infrastructure, including care coordinators and data tracking capacity. The SERPA ACO has since grown to include more clinics, serving more than 18,000 beneficiaries across much of central and southern Nebraska.

Today, there are nine Nebraska-based ACOs, with contracts covering half of the state’s population. All achieved high levels on the most recently available ACO performance measures from Medicare and four earned shared savings.

Physicians also encouraged BCBS of Nebraska to join Comprehensive Primary Care Plus (CPC+), a federal program designed to encourage public and private payers in particular regions or states to form value-based contracts with primary care providers. BCBS of Nebraska was the only private payer to do so, enabling the 33 participating primary care clinics to receive per member per month fees (PMPM) from both Medicare and BCBS of Nebraska for achieving certain performance benchmarks. The state’s Medicaid program does not participate in the program. Esser says performance bonuses for 139 practices participating in the plan’s PCMH and ACO programs received $34 million for the last fiscal year.

A Path Forward for Payers and Providers

In 2014, Nebraska’s physicians and health plans gained a new partner in their efforts to promote delivery system reforms: Ali S. Khan, MD, MPH, an epidemiologist and former director of the Office of Public Health Preparedness and Response at the Centers for Disease Control and Prevention (CDC), who was appointed dean of University of Nebraska’s College of Public Health that year. Khan came to Nebraska because he saw an opportunity to rethink health. “Nebraska is the right scale for a novel statewide approach to reunite public health and health care in a way that could improve quality of care, decrease costs, and ensure equitable health,” he says.

As part of a listening tour to get to know the state, Khan met with Lancaster County’s medical society and shared his vision of Nebraska as one of the nation’s healthiest places. He noted one clear opportunity: Nebraskans had higher colon cancer rates and less colon cancer screening than national rates. This caught the attention of Rauner, who worked through the nonprofit he ran in the Lancaster County seat, Partnership for a Healthy Lincoln, to encourage the region’s primary care providers to increase screening for colon as well as breast cancer. Rauner appealed to providers’ competitive nature, their desire to prepare for value-based contracts, and their drive to help patients (all while earning CME credit). After two years, most participating clinics were screening 80% or more of their patients and the success of the project convinced some of the highest-performing providers to launch an ACO.

Buoyed by the success of the program, Rauner and Esser approached Khan about expanding its reach and focus, with the College of Public Health acting as a neutral convener to encourage health care providers and payers to think about how they can partner to promote public health. That effort, co-led by Khan and known as ALIGN/Nebraskans for Better Health was designed to help the state’s three major commercial insurers, its public health and Medicaid agencies, and several ACOs and other health systems come to an agreement on a set of shared targets for population health improvement. “We wanted to put the public health people in the same room with the health care providers and the insurers to see what happens if we all are rowing in the same direction,” Khan says.

Most of the targets — pediatric immunizations, diabetes and hypertension control, timely prenatal care, and postpartum depression screening — are common. However, screening for unhealthy alcohol use and brief counseling, is not, although nearly 22 percent of Nebraskans report excessive drinking, placing Nebraska 44th out of 50th among the states on this measure.

What’s significant about the effort is that participants have agreed to harmonize their measurement approaches and work with local providers and other community leaders to promote best practices for improvement. “We have buy-in from everyone at this point,” Khan says, noting that the process took two to three years; the next step is enlisting large employers, who can help hold insurers and providers accountable for achieving results.

Esser, Khan, and Rauner envision having a state organization, similar to Partnership for a Healthy Lincoln, facilitate work with providers and community leaders to help them share data and best practices for improving performance on these measures. Its success will depend on securing funding and establishing an organizational structure to provide technical assistance to practices, and on enlisting sufficient numbers of employers to ensure these measures are included in health plan contracts throughout the state.

Lessons

In states like Vermont and Rhode Island, governors or other legislators have played an active role in convening health care stakeholders or mandating health care delivery reforms. But in Nebraska, networks of independent clinicians, health plans, and other advocates have been the driving force for reform. For example, after the legislature declined not to expand Medicaid, Nebraskans themselves voted to expand the program to more low-income people in a 2018 ballot initiative.

This has meant that changes depended on individual champions and the reform efforts that played out in fits and starts over the years as leaders opportunistically piloted new approaches to demonstrate their benefits to skeptics. “One or two people have to try out something new and show that it works, then the rest will follow,” says Rauner.

It helps that Nebraska is a small state. Many health care leaders know each other and cycle among leadership positions, making it easier to share information and stories of success. Gloor first heard about the patient-centered medical home model from a physician friend; Esser of BCBS of Nebraska formerly worked at one of the Medicaid managed care organizations that joined the Medicaid pilot.

This has also meant reform efforts can falter when their champions leave key roles. Fortunately, after Senator Gloor left the state legislature due to term limits, Khan took up the role of championing population health improvement. He has forged partnerships with state and local health departments (in part by staffing them with people who hold joint appointments at the College of Public Health and state health departments) and has sought to educate state legislators and administrators about opportunities to improve health and control costs.

ALIGN/Nebraskans for Better Health leaders are betting the creation of 11 shared performance measures will keep up the momentum for change. “We’re hoping as this rolls out and people look at its success from year to year, it’s selfigniting and catalyzes itself,” Khan says.

Takeaways

While federal programs help, ensuring their alignment with other value-based contracting initiatives is important.

Federal programs and private payers provided critical funds to help small and independent practices make the transition from fee-for-service to value-based contracting. According to Rauner, Nebraska clinics that joined SERPA’s ACO as well as CPC+ benefitted from the complementary funding streams from Medicare and BCBS: the advanced payment ACO funds enabled them to make upfront investments in staff and infrastructure, while PMPM fees helped sustain them over time. Most small and independent primary care providers do not have the financial cushion to invest or take risks in new payment models; at the same time, many — particularly in rural regions — serve patients who are older and sicker than the general population and will require more support.

Rauner is concerned that the new Primary Care First program, the follow-up to CPC+ in which primary care practices can receive both fee-for-service and PMPM payments as well as performance-based incentives and penalties, is not going to work for Nebraska practices because the PMPM rate does not sufficiently take into account patients’ risks. “I’m hoping the new federal administration will fix that,” he says.

Partnerships among public health and practicing clinicians are key to advancing population health goals.

The pandemic has made Americans aware of the country’s patchwork and underfunded public health infrastructure. In addition to helping reduce coronavirus infection rates at hotspots like meatpacking plants, Khan has worked to bridge the worlds of public health and practicing clinicians, which he sees as key to moving forward. Nebraska has already realized benefits from uniting public health and medical practice; not only did participation in the breast and colon cancer screening campaigns prepare clinicians for value-based contracts, but it also whetted their appetite to do more.

To succeed, champions for health care delivery and payment reform must find allies.

Nebraska has a term-limited legislature, which means efforts to convince legislators of the need for reforms must be repeated often. Having a governor who isn’t interested in health reform can also be a challenge. Rauner and Khan are looking to the election of a new governor in 2022 as an opportunity to find an ally and funding for their efforts to improve population health. Having examples of what works in Nebraska and similar states will help. “I think you need red-state examples to be successful in a red state,” Rauner says.