Provider-Based Population Health

In 2005, the Centers for Medicare & Medicaid Services (CMS) launched a physician group practice (PGP) demonstration designed to:

• Create incentives for physician groups to coordinate the overall care delivered to Medicare patient
• Reward them for improving the quality and cost efficiency of health care services
• Create a framework to collaborate with providers to the advantage of Medicare beneficiaries.

The successes of two PGPs that participated in the demonstration — the Marshfield Clinic and the Geisinger Clinic —depended largely on their well-executed coordinated care approaches and their effective use of technology.

Marshfield Clinic

The Marshfield Clinic, a 730-doctor clinic in Marshfield, WI, generated about half of the total savings in the demonstration that included 10 PGPs. The group has been using an electronic health record since 1985 and has long-running quality improvement programs.

For the demonstration project Marshfield:

• Focused on reducing hospital admissions, partly by expanding its telephonic case management program for patients who had heart failure and hypertension complications
• Expanded its anticoagulation drug therapy management program, designed to reduce costly complications of warfarin therapy
• Introduced partial open access scheduling and redesigned care processes for chronic disease patients to ensure they received all recommended care

Electronic tools are essential to population health management at Marshfield. The clinic’s EHR automatically generates an intervention list for each physician that identifies high-risk patients with multiple chronic conditions. Marshfield also uses electronic prescribing, a data warehouse for analytics, patient registries and care management software.

During its first year of participating in the demonstration, Marshfield reduced hospitalizations of patient in the anticoagulation management program by 29 percent. Satisfaction among patients enrolled in care management programs exceeded 85 percent.

Geisinger Clinic

Geisinger Clinic based in Danville, PA, is part of a health system that includes the Geisinger Medical Center and two other hospitals. The Clinic employs about 640 physicians in 41 practice sites.

Geisinger had disease management programs in place when it joined the PGP demonstration. The group wanted to extend those programs to Medicare patients. Additionally, Geisinger introduced a case management program for high-risk, complex patients.

In the pilot, Geisinger sought to reduce hospital admissions and readmissions through disease and case management, enhanced use of its EHR and an advanced medical home model. Geisinger emphasized patient-centered, team-based care across the continuum, transitions of care coordination, readmission risk screening and telephonic care management and/or device-based remote monitoring for CHF patients. It also redesigned its systems of care to reflect evidence-based guidelines.

Geisinger’s EHR can provides best practice alerts to providers at the point of care. Physicians can view a summary of the patient’s care, and they receive reminders about needed tests and other interventions. Equally important, they’re in close touch with the care managers who are handling their most difficult cases.

Coordinated Care Lessons Learned

Registries, care management software, and automated patient outreach—all used in conjunction with EHRs—are among the tools that these groups deployed successfully to manage their populations.

What if you were asked to take on the role of a primary care physician? Your objective would be to ensure that ALL of the patients you are responsible for receive the quality care they need at the right time and in a cost-effective manner. After all, isn’t that what you and I want as a patient? Let’s just walk through what that would be like. You would:

1. Identify who your patients are (the average primary care physician has about 2,500).
2. Research each patient and evaluate them against all the guidelines for their applicable conditions and risk factors.
3. Ensure they receive the recommended care needed during each visit, and if they are not active in their care, reach out and engage each patient.
4. Track and measure the quality of care you provide ensuring every patient gets consistent and high quality care, and since you are probably participating in multiple different quality initiatives (P4P, Meaningful Use, PQRS, etc,) capture the information to meet all the requirements of each initiative.

As reported by David Margolius and Thomas Bodenheimer in a 2010 Health Affairs article, “Transforming Primary Care: From Past Practice To The Practice Of The Future,” providers and care teams are increasingly challenged to keep up with all the activities surrounding patient care.

Many physician organizations have begun to solve the problem through a significant increase in the use of midlevel practitioners, care managers, care coordinators and health educators. Recently, I attended a conference at which a large medical group presented on how they were going to hire 50 data coordinators to help their care teams deliver higher quality of care.

Unfortunately, hiring your way to a patient centered medical home isn’t realistic. Most of these organizations see the future and are preparing to become an Accountable Care Organization (ACO). In an ACO, the cost of delivering care will be controlled and hiring large numbers of resources to manage the patient demand won’t be an option.

The Care Management Role

I am a firm believer in the critical role that a care manager will play in this new world of healthcare that is upon us. The care manager is responsible for making sure patients are having effective visits, providing one-on-one care for the highest risk patients and making sure at-risk patients stay healthy when they aren’t in the office.

In my experience, one thing is clear, the care management processes being implemented today tend to be very manual and touch only segments of the patient population, and often only those patients that have an office appointment.

How many patients can an individual care manager attend to using only manual processes?

Data suggests that the average physician has about 900 adults with chronic conditions.  Thirty percent of those, or 270 patients, are high-risk or complex and should be assigned to a care manager.

By extrapolation using this simple scenario, every physician with this size panel would require 1.35 care managers; 10 physicians would require 13.5 care managers and 100 physicians would require 135 care managers.

And still, only the highest risk patients would receive support from the care management team.

The Importance of Technology

Technology has become a ubiquitous part of almost every aspect of our lives:  online shopping with suggestions about what I would like to read, a text message telling me my flight changed gates, emails reminding me my car is due for a 60,000 mile checkup. Unfortunately in many areas, healthcare delivery can appear behind the curve.

The only way care management fulfills the design of its creation is leveraging the power, repeatability and scalability of technology.

What would the world look like if you combined the power of modern technology with the power of a care manager?

• ALL patients would receive personalized, systematic, and just-in-time reminders about an overdue test, a reminder for a cancer screening or the need for an office visit. The reminder would be in the patient’s preferred mode of communication.
• The care manager would receive a stratified and prioritized list of high-risk patients that will always need the personal touch of a care manager.

By applying technology to population health strategies that continually identify, assess and stratify provider panels, physician groups can use automation to augment the role of care teams, manage the patient population more effectively and efficiently, drive better outcomes and decrease overall cost as demanded by new delivery model payment incentives.