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October 2, 2006
Employers from the Cincinnati Children’s Hospital Medical Center to Home Depot and Verizon are experiencing something they haven’t seen in years: stability in the face of rising health insurance premiums and improved employee health. Even smaller companies can enjoy stable premiums. At a time when the nation’s average premium increase is 15%, these and other savvy companies are saving billions of dollars. How? Employers, struggling to provide good healthcare for their employees while managing the high cost of healthcare, have found a new ally in local physicians. The savings accrued become physician performance bonuses, ranging from $350 to $35,000 per year. At the core of the relationship is assurance that the employees are getting better and physicians have access to data to measure improvement. “The key is using a third party to measure performance. When physicians actively participate, it’s a very strong driver to change,” said Francois de Brantes, national coordinator of Bridges to Excellence (BTE), in a recent audio seminar that offered physicians guidance on how electronic health records (EHRs) are used to measure quality improvement. BTE is a nonprofit organization developed by employers, physicians, healthcare services researchers, and other industry experts with a simple mission “to create significant leaps in the quality of care by recognizing and rewarding health care providers who demonstrate that they have implemented comprehensive solutions in the management of patients and deliver safe, timely, effective, efficient, equitable and patient-centered care.” This mission is accomplished by paying bonuses to physicians who meet standardized, expert-based performance measures developed or codeveloped by the National Committee for Quality Assurance (NCQA), the Physicians Consortium for Performance Improvement, medical boards, and expert panels. BTE also includes an optional patient component that provides support tools and an incentive model for patients to align patient behavior changes with physician standards of care. In bringing employees and physicians together, BTE pays the participating physician up to $50 per patient per year for top performance, up to $80 per diabetic patient per year (paid to primary care physicians [PCPs] and endocrinologists); and up to $160 per year for cardiac patients (paid to PCPs and cardiologists). Through BTE’s measurement tools, employers have identified annual savings of approximately $110 per patient, $350 for diabetics, and $360 for cardiology patients. At the core of this relationship are three quality improvement tools: • standard performance measurements; • independent third-party organizations to measure performance; and • better systems of care, including HIT, to systematically improve the delivery of care. BTE engaged Towers Perrin to conduct a study of the relative impact on clinical quality and cost of more than 90 ambulatory measures. As a result of the study, Community Care Physicians, an independent physician association (IPA) in Albany, N.Y., for the first time was able to identify the top three chronic conditions in its area. It created standards, protocols, and programs to manage patients within and across practices: cardiovascular disease, endocrinology, and neurology. It also launched four diabetes care improvement programs to track employees with the disease, provide follow-up care, and assign disease and case managers. The IPA created a diabetic registry, conducted process audits, benchmarked data, developed interventions, and remeasured patients for improvement. Within one year, employees with diabetes averaged a 1.5% decrease in A1c levels. “Clinical and financial information would have been very difficult to measure and improve without a way to measure results both clinically and financially,” de Brantes says. “Performance bonuses exceeding $400,000 helped the doctors invest in better technology, such as EHRs.” Taking Quality Improvement to a National Level Rita Graves, administrator at Sandhills Physicians, and her colleague, Tina Wise, RN, director of medical management, understood their doctors’ intent and were asked to facilitate building a proprietary clinical integration system that would be accessible to all physicians in the IPA. During days off and evenings, teams of physicians under Wise’s leadership pored through standard clinical protocols from medical associations, disease management organizations, and quality improvement organizations such as the NCQA. Through careful examination and comparison, Sandhills adopted 140 protocols that met or exceeded those already in place. With clinical guidelines in one central database, the IPA’s leaders presented its practice patterns, along with a pay-for-performance plan, to its physician members to fine tune it into a formula for success. A promising business opportunity emerged when a regional employer showed interest in using the protocols to improve employee health. The theory between employer and doctors was that if the doctors could confidentially identify the top 5% of covered lives that created 75% of the employer’s costs, a case manager could build a healthy relationship with these high-end users and help them manage their chronic illnesses. It was the beginning of that first—and now long-standing—employer relationship that led Sandhills to incorporate Doctors Direct Healthcare (DDHC) as a wholly owned subsidiary. Initially designed to provide medical management for self-funded employers in its community, the DDHC has evolved into a national presence for physician-driven medical management. Now at 505 physicians, the IPA has relationships with doctors in 26 states. “Don’t let the numbers get in the way of the secret to success,” Sandhills President Michael Bryant, MD, FACS, cautions. “It all boils down to one physician providing care to one patient, one day at a time.” Its challenge to manage large amounts of clinical and financial information sent Sandhills on a search for a partner that understood the cost drivers, could analyze the data and apply it to a clinical setting, and help provide evidence-based medicine. Ideally, all the physician members would agree on one system that would allow them to electronically exchange health information. But in early 2000, EHR software hadn’t fully matured; the software return rate was still too high and it was still expensive. Besides, it needed a partner that could crunch some serious numbers and spit out immediate results. Graves, Wise, and Bryant, with help from other IPA members, searched 18 companies and found a partner in InforMed, a quality-improvement, payor-based health record system in Annapolis, Md. The InforMed system centers around a payor-based health record, a hybrid of sorts between an EHR and health claims records. As a data management and financial reporting company, InforMed provides quality improvement strategies to health systems, physician hospital organizations, utilization review organizations, as well as employers and third-party administrator payors. For Sandhills, InforMed serves as a data manager, a data-scrubbing agent, and a watchdog of data that arrives from approximately 150 payor sources—and in just as many formats. Physicians require only Internet connectivity to access the secure data. Once securely logged on, a physician can select various views. “The system allows us to develop baseline and benchmark data on length of stay, trending of claims cost, and clinical outcome measures. We can drill down to one physician treating an individual patient and identify high-cost users and high-performance physicians, rendering the results indisputable,” Bryant said in an address at the Quality Colloquium at Harvard University on healthcare. “We also use the data as a mechanism of communication between the employer group and healthcare providers,” he continued. “From a quality and value perspective, we meet our commitment to keep the healthcare decision between the physician and the patient, while focusing on the optimal treatment plan.” The clinical decision arm of the DDHC conducts precertification with the intent of finding a way to deliver healthcare to the patient, rather than routinely rejecting a procedure. When a call is necessary to the doctor of an employee, a Sandhills physician in the same specialty contacts the doctor directly and discusses strategies to deliver the best care for that employee. “We try to find every possible way to approve the treatment prescribed by the employee’s doctor,” Bryant said. In addition to precertification, the DDHC also participates in case management and disease management strategies, helping employers reduce costs and employees improve health. A fourth proactive component, wellness management, has become the defining difference between a solid medical management program and data that helped the DDHC prove it was on the right track. In conducting precertification evaluations for a large employer, 80 employees qualified for gastric bypass surgery as a treatment plan for morbid obesity. Recognizing the need for benefit changes, the DDHC physicians designed an exercise and nutrition program for the employer. One hundred percent of the eligible members signed up for the 12-week lifestyle management program consisting of strength training and educational programs, with a follow-up 15-month health maintenance program. The lifestyle changes netted the employer a $2 million premium savings. Creative Billing to Finance
Technology As a group, the DDHC is looking to build a lifetime patient record in the communities it serves. — Carolyn P. Hartley is president and CEO
of Physicians EHR (www.physiciansehr.com)
and lead author of EHR Implementation: A Step-by-Step Guide for the
Medical Practice.
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