A growing number of primary group practices are taking a proactive approach to care management because they know coordinated care will be a linchpin driving impending changes in the care delivery system. Larger organizations especially are building the infrastructure they will need under new delivery and payment systems that are emerging for Medicare, Medicaid and commercial programs.
Medicare’s PGP Demonstration
Let’s look at the Medicare PGP program for example. The experiences of the 10 groups that participated in Medicare’s five-year physician group practice (PGP) demonstration show exciting examples of how these healthcare leaders took on the challenge of care coordination inside their practices and between sites of care to meet their goals.
Incentives for Innovation
The PGP pilot turned out to be a dry run for Medicare’s shared savings program for accountable care organizations (ACOs). Similar to what’s been proposed for the Medicare ACO program, the PGPs were eligible to split savings with Medicare if they met certain quality benchmarks and the savings exceeded 2 percent of expected costs.
In the demonstration project, participants could keep up to 80 percent of the savings they generated, depending on how well they did in meeting 32 quality goals, which is a powerful incentive for finding innovative and effective ways to better manage patient care.
Quality Improvements
According to the Centers for Medicare and Medicaid Services (CMS) report released in July 2011, in the fifth year of the five-year demonstration:
- All 10 groups achieved benchmark performance on at least 30 of the 32 measures.
- 7 groups achieved benchmark performance on all 32 performance measures.
- All 10 groups achieved benchmark performance on the 10 heart failure, 7 coronary artery disease measures and 2 preventive care measures.
Also for Year 5, four of the PGPs earned incentive payments based on the estimated savings in Medicare expenditures for the patient population they serve. The groups received performance payments totaling $29.4 million as their share of the $36.2 million of savings generated for the Medicare Trust Funds in performance Year 5.
Reasons for the Savings
The PGPs attributed their savings to a number of factors:
- Organizational structure
- Investments in care management and care redesign
- More intensive diagnostic coding
- Changes in market conditions
Each PGP that achieved savings used different care management strategies that may spark ideas for other primary care groups moving towards ACO models and similar population health models.
- The Dartmouth-Hitchcock Clinic in Lebanon, NH, focused on evidence-based care initiatives, including better use of care alerts, changing workflow for support staff, and using nurse case managers to work with high-risk patients.
- St. John’s Clinic in Springfield, MO, used a comprehensive patient registry, care alerts at the point of care, a case manager in the emergency department to plan transitions of care, and a care team dedicated to patients with congestive heart failure.
Conclusions
RTI International, the company that analyzed the PGP pilot for the CMS, drew these lessons from the test, many tied to the use of technology-based solutions:
- Medicare patients often have several comorbidities that need to be treated simultaneously. Therefore, group practices must address the need for complex care management that goes beyond traditional disease management for single conditions.
- Complex care management could be enhanced by combining disease-specific patient registries, or by using registries that encompass all patients.
- Planned visits can be facilitated through the use of data systems (e.g., registries and electronic health records) that analyze data and provide physicians and other clinicians with pertinent information about the patient prior to a visit. A visit planner report may, for example, provide a list of overdue tests for a patient that could be performed prior to a visit.
- Key change opportunities include increasing patient engagement, expanding care management, improving care transitions, and expanding the role of nonphysician providers.
The groups that were part of the PDP pilot demonstrated that technology, such as patient registries, plays a major role when adopting a proactive approach to care management.
What’s Next
In future blog posts, we will build on these takeaways, and talk about how the combination of technology and automation can foster even greater strides in population health.
Learn More
Listen to an on-demand webinar about Implementing Care Coordination within the PCMH Model.