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President's Column: From Practice Variation to Practice Transformation
We know that health care expenditures will consume more than 20 percent of national GDP by 2018 if nothing is done to curb their growth. We also know that rapid adoption of new medical technologies is a primary driving force behind this growth. But what may receive less attention are the individual practice decisions that providers make every day -- the kind Gawande writes about above -- and their impact on national spending on health care and health care affordability. 
ACHP Patient-Centered Medical Home Collaborative: Strategies for Practice Transformation
While all eyes are on Washington watching how health care reform takes shape, ACHP member health plans are simultaneously implementing initiatives to transform how health care is delivered. More than a dozen member plans that form the ACHP Patient-Centered Medical Home Collaborative are helping practices in their service areas transition into patient-centered medical homes through financial and technical support, robust case management, process support and integration functions.
Geisinger Health Plan's Data Review Process
Reducing the rate of hospital readmissions has become a top priority for health system reformers since researchers revealed in 2005 that return trips to the hospital within 30 days costs Medicare $17 billion each year.
Priority Health Plan's Medical Home Grant Program
Transforming a practice into a patient-centered medical home often requires a re-directed focus from individual patients toward entire populations. It takes a re-educated staff that understands the importance of providing a spectrum of preventive, acute and chronic care services. And just as often, it takes money.
CareOregon Receives Medical Home Grant from Commonwealth Fund
ACHP member plan CareOregon is the recipient of a four-year, $500,000 grant from the Commonwealth Fund to expand and improve its patient-centered medical home practice model.
ACHP Member News
Read about the latest news from around the ACHP membership.
Upcoming ACHP Events for ACHP Member Organizations
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President's Column: From Practice Variation to Practice Transformation
From Atul Gawandes much-talked about report on the failures of the health care system comes this eye-opening exchange with a group of doctors in McAllen, Texas, which, at an average of $15,000 spent per beneficiary, is one of the most expensive Medicare markets in the country:
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that theres no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
"Oh, she's definitely getting a cath," the internist said, laughing grimly.
We know that health care expenditures will consume more than 20 percent of national GDP by 2018 if nothing is done to curb their growth. We also know that rapid adoption of new medical technologies is a primary driving force behind this growth. But what may receive less attention are the individual practice decisions that providers make every day -- the kind Gawande writes about above -- and their impact on national spending on health care and health care affordability.
What Gawande witnessed in McAllen was a cultural shift in how health care has been practiced. At some point, it became commonplace for doctors to perform more intensive and costly services for patients where before less was done. Unfortunately, more health care does not always mean better. States with higher rates of Medicare spending per beneficiary have been shown to produce lower quality care than states with lower spending rates. This perverse outcome has many origins, but the intensity and quantity of services that doctors today routinely provide are certainly factors. As Gawande writes: "The most expensive piece of medical equipment, as the saying goes, is a doctor's pen. And, as a rule, hospital executives don't own the pen. Doctors do."
How do we do better? There are no rules for reversing this culture of quantity, but ACHP member health plans work closely with their provider partners to support and encourage the kind of evidence-based medical care practices that produce excellent outcomes at lower cost. In this issue of ACHP's Bulletin, we look at three member plans that are part of ACHP's Patient-Centered Medical Home Collaborative and are reengineering their care management efforts to improve patterns of care and encourage best practices. For example, Geisinger Health Plan regularly examines performance and claims data with physicians and highlights opportunities for improvement. This program has lead in some instances to a 30 percent reduction in hospital readmission rates.
This level of engagement takes time and resources, but as visible members of their communities, ACHP plans have a stake in ensuring the health of the areas they serve. One way to encourage all health plans to implement innovative programs that improve provider performance and the quality of care is for Congress to reform Medicare payment mechanisms.
As Gawande discovered in McAllen, doctors are practicing high-volume medicine at an increasing rate because it pays to do so. If Congress is to pass meaningful and sustainable health care reform -- as its leaders have promised to do by the end of this year -- it is critical that Medicare payment policy become less volume-oriented and more value-oriented -- rewarding providers and health plans that succeed in lowering hospital readmission rates and preventing costly, emergency room medicine, for example.
Fully integrated care settings and staff providers is one way to ensure quality of care, but there are others. Similar results are achieved by ACHP member plans whose providers are under contract in a network. Another model is the Accountable Care Organization (ACO), which rewards providers who work together on a spectrum of care for individual patients with a portion of the shared savings they are able to produce. Dr. Mark McClellan, former CMS administrator and a widely recognized proponent of ACOs, briefed ACHP plan leaders this month on the ACO concept and initiated a discussion on how this structure could support their mission of delivering quality health care to the communities they serve.
Payment reforms and delivery system restructuring hold the promise of reversing the trend toward more McAllens. As Congress heads into the final stretch for passing health care reform, ACHP will continue to make the case that rewarding quality, coordinated care should improve health, prevention, affordability and value.
Patricia Smith
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ACHP Patient-Centered Medical Home Collaborative: Strategies for Practice Transformation
While all eyes are on Washington watching how health care reform takes shape, ACHP member health plans are simultaneously implementing initiatives to transform how health care is delivered. More than a dozen member plans that form the ACHP Patient-Centered Medical Home Collaborative are helping practices in their service areas transition into patient-centered medical homes through financial and technical support, robust case management, process support and integration functions.
To demonstrate cost savings, better outcomes and a better patient experience with care, participating health plans have begun reporting to ACHP specific metrics that describe the quality and efficiency of care provided under the medical home model and how satisfied patients are with that care. First quarter results were reported this month and participating plans will be working together this summer to refine the measurements, and identify best practices connect to the results reported.
As they measure the progress of their efforts, ACHP member plans are also taking concrete steps to provide leadership and additional resources for practices and primary care physicians to help them transform the quality of the care they provide. Below are three examples of how ACHP member plans are collaborating with provider communities to build patient-centered medical homes.
Independent Health's Practice Redesign Exercise
One challenge to physician practices becoming true patient-centered medical homes is reorienting traditional practice patterns to a team-based approach to providing care. The medical home model of care asks practices to delegate care responsibilities to all members of the practice staff in the most efficient manner and to tap into external, community-based resources.
Independent Health Plan of Buffalo, N.Y. uses an exercise to help the 22 practice sites in its patient-centered medical home pilot program adopt a team-based approach. In this exercise, Independent Health graphically displays which providers are responsible for diabetes services and which services dont get performed at all. The exercise allows practices to envision themselves as a fully functioning medical home using as many resources as possible, says Dr. Tom Foels, medical director at Independent Health.
The exercise starts with a practices physicians, nurse and administrative supervisors and plan representatives gathered around a bulletin board with a pyramid divided into four parts. Starting at the base, the parts are labeled "Preventive Care," "Low-Risk Population," "Medium," and "High." (See chart below.)
Participants then work their way through a stack of post-it notes on which are written services for diabetic patients. They are assigned to the correct section of the pyramid and to the provider who is responsible for providing the services: front-desk administrators, nurses, mid-level providers, primary care physicians, specialists, health plan and community. For example, "Mammography" would go under the "Preventive Care" section. Screenings for "Depression" might go under "High Risk." There is also a "parking lot" outside the pyramid where services that the practice doesnt provide are placed.
"What we saw was, all the preventive services were going to the nurse practitioner (NP) or the PCP (primary care physician), not to a nurse," Foels says. The same was true for the Low-, Medium- and High-risk services: all were falling to the primary care providers. Ancillary services like using a health plan case manager, asking a pharmacy specialist to review medication records or contacting the American Diabetes Association -- "all that went to the parking lot," Foels says.
The exercise shows how physicians who spend much of their time performing low-intensity services -- diabetes a1c tests, eye exams, smoking cessation -- have less time to help diabetic patients with complex and high-risk conditions. Seeing how underused (or overburdened) some staff are helps practices identify ways to delegate services down and make more efficient use of the physician and mid-levels time and expertise.
Independent Health's Practice Redesign Pyramid Exercise
 Changing provider roles that have long been established is not easy, Foels says. Nurse and administrative staffs familiarity with diabetes may not be strong and investing in education materials may be necessary.
But once training is complete, its a good idea to begin with a small step. "Start with mammographies. Make sure all the staff understand the guidelines, and then delegate it down," Foels says. After a week, reopen the charts and see if women over 40 years were scheduled for the exam.
When a practice looks at one patient at a time, its easy to overlook service opportunities and underuse staff. Independent Healths exercise gets practices on the road to becoming population managers. "If you ask a physician how many diabetic patients they have, they can only guess," Foels says. "Only half of their diabetic patients were seen in the last year. Only one-third have had an a1c test this year. When you look at one patient at a time, you don't think about these things. When you think in terms of populations, you see opportunities and take a proactive approach. You pull the names of diabetic patients from the claims file and send post card reminders for a flu shot."
Team delegation and clearly identifying responsibilities are one of Independent Healths major themes for its patient-centered medical home program. Health plans are uniquely suited to helping practices connect with additional resources -- case managers, pharmacy and behavioral specialists -- and providing a population-based perspective.
Foels does not expect significant practice transformations for at least one year -- its patient-centered medical home pilots and "pyramid" exercises began in January. But the pilots have responded positively to the exercise and have continued using the boards. "We think some seeds have been planted," Foels says.
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Geisinger Health Plan's Data Review Process
Reducing the rate of hospital readmissions has become a top priority for health system reformers since researchers revealed in 2005 that return trips to the hospital within 30 days costs Medicare $17 billion each year.
Cutting hospital readmission rates is one of the goals of Geisinger Health Plan of Danville, Pa. and its patient-centered medical home program. To successfully prevent readmissions, information is key. Each month, Geisinger Health Plan (GHP) staff meet with doctors, nurses, case managers and administrative staff at the 25 participating practice sites. This team reviews records of patients who were admitted or readmitted to a hospital and asks: Was this a preventable hospital admission? What could have been done differently?
These discussions help the providers and office staff examine what happened to the patient prior to hospitalization. If a patient was admitted for heart failure, did she have a diuretic protocol? Was she weighing herself at home? Did the provider know her weight was going up? Did she call into the clinic before going to the hospital? Is she in the tele-monitoring program for heart failure?
"If we can get at it upstream, teach them to weigh themselves, adjust the diuretic if they see weight gain - we can prevent the big weight gain that leads to hospitalization," says Janet Tomcavage, vice president of health services at GHP, referring to exacerbation in heart failure patients.
Even with serious cases, medical home practices can head off hospital use. For example, clinics can keep antibiotics for pneumonia, administer them on site and arrange home care and a follow-up visit by a case manager. "Improving access and thinking differently about managing acute medical conditions -- there are many things that can be done in the office that don't have to be done just in the ER," Tomcavage says.
Using patient data and records to prevent hospital readmissions is just one way Geisinger Health Plan improves health outcomes, lower costs and enhances patient satisfaction. Each quarter, health plan staff meet with every pilot practice to review 8 to 12 quality metrics that measure the practices performance on diabetes, coronary heart disease and other common chronic conditions. In addition, the health plan also performs a baseline assessment of a participating practices office design and workflow to help improve scheduling appointments and identification of high-risk patients.
The results of these data-driven interventions are promising. Several of the participating practices have reduced their hospital readmission rates by 20 - 30 percent, Tomcavage says. And more improvements are planned. With a deeper level of data recorded and analyzed -- specific diagnoses and reasons for a hospital readmission -- Tomcavage believes the health plan and pilot practices can identify patterns that will help them drive down primary admissions and readmission rates even further.
"If we see that 50 percent of readmissions are happening within the first five days, maybe they can be prevented with an office visit on day three," Tomcavage says.
The health plans case managers are a crucial component of this process. They are responsible for contacting patients recently discharged from a hospital and arranging a follow-up visit with the primary care physician if necessary. But rather than working from a distant Geisinger Health Plan office, the case managers work in the pilot sites and are fully integrated with the practices. This allows the case managers to introduce themselves to patients as someone who works directly with their doctor, Tomcavage says, and not with an insurance company.
The transition to this brand of data-driven care management has not been entirely seamless. Busy doctors who already believe they are delivering good care are sometimes reluctant to embrace Geisinger Health Plans review sessions. But most providers quickly see the value the review sessions provide.
"If you talk to the leadership, they would tell you that they were flying blind prior to the reporting we now provide," Tomcavage says. "Once you get past the notion that a health plan is only interested in costs, you teach them to balance experience and quality and efficiency. And they start to think: 'How can we manage this wound differently -- can we give IV antibiotics at home as safely and effectively as we can in the hospital? Does the patient have the support services in place to do this? Would the patient prefer to stay at home and continue their recovery?' We need to effect health care system change at that level, and data is critical to getting providers and their team to understand where the gaps are as well as the opportunities to make changes."
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Priority Health Plan's Medical Home Grant Program
Transforming a practice into a patient-centered medical home often requires a re-directed focus from individual patients toward entire populations. It takes a re-educated staff that understands the importance of providing a spectrum of preventive, acute and chronic care services. And just as often, it takes money.
Priority Health of Grand Rapids, Mich. understands the upfront costs associated with creating a patient-centered medical home. Thats why last year, it began a grant program that provided $750,000 for programs at 16 pilot practice sites to help increase access hours, coordinate services for diabetes care and improve patient engagement.
The first year-long phase of the grant program will end in October, when a second round of grants will go out and cover an 18-month period. "One year is not enough time to really transform a practice. We were overly optimistic on that," says Mindy Olivarez, senior administrator for patient-centered medical home at Priority Health. Olivarez expects about 8-10 practice sites to receive grants starting in October for amounts varying from $100,000 to $250,000.
Below are examples of how practices in Priority Health's medical home program are putting the health plans grant money to good use:
Access: Patients want access to their provider at the time they need care. In most practices, patients are seen on the same day they request an appointment. But providers are often double- or triple-booked, which address only acute issues, not necessarily the whole person, Olivarez says.
One way to improve scheduling is through a capacity analysis of providers schedules. By examining supply and demand of providers, and adjusting schedules and patient loads, some doctors can have 50 percent open access. "This means that if a patient calls in to get an appointment that day, half of the physician's schedule will be unbooked. That's unheard of for most physicians," says Olivarez.
Increasing access to physicians also helps with care coordination. If patients are more often seen by their own physician, the physician will get a better idea of the patients progress, medical events or other concerns. More advanced practices have used funds to create a secure log-in portal for online appointments. This allows patients who dont want to take a day off from work to get their questions answered.
Care Coordination: All of Priority Health's grant recipients are focused on care coordination for diabetics. Some practices use the funds to hire additional nurses to manage their high-risk patients (rather than rely on the health plan to send case management resources to the practice). Others perform time studies on their process for creating care plans. This helps practices determine the most efficient way to assess the risks, needs and self-management ability of patients and to connect them to available resources.
Patient Experience: A hallmark of the patient-centered medical home model of care is paying attention to what happens to patients outside the office. Some plans use the Priority Health grants to engage patients in better lifestyle choices through care plans, setting goals and doing follow-up visits. "It's important to encourage practices to better engage patients," Olivarez says. "If a patient's chart says they committed to walking two days a week, someone ought to ask, 'How's that going?'"
One of the Priority Health pilot practices has focused on pediatric asthma by partnering with community-based services. The practice is able to track enrolled kids and knows when they missed a day of school or were admitted to the hospital.
To track the progress of the grant recipients, all 16 practice sites receive a dashboard report that shows how theyre performing on HEDIS diabetes measures month-to-month and makes their progress transparent. The reports also look at ER use, generic-brand drug use ratio and the total cost of diabetes care. Priority Health compares the results to the plan average to identify improvement.
One area in which Olivarez says Priority Healths medical home practices would like to improve is accessing community-based services -- ancillary providers, behavioral health services, and programs by the United Way, for example. A review of provider and patient experience surveys by Michigan State University showed this to be an area of opportunity. "If we can improve access to care, care coordination and patient engagement efforts, then we hope that will naturally lead to appropriate community-based service use," Olivarez says.
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CareOregon Receives Medical Home Grant from Commonwealth Fund
ACHP member plan CareOregon is the recipient of a four-year, $500,000 grant from the Commonwealth Fund to expand and improve its patient-centered medical home practice model.
The Commonwealth Fund's National Medical Initiative for Safety Net Clinics supports health centers that provide patient-centered medical home services for disadvantaged populations. CareOregon, which serves about one quarter of the Medicaid population in its state, will partner with the Oregon Primary Care Association and Qualis (Washington State's quality improvement organization) to provide technical assistance and training programs at 13 clinics across the state.
Since March 2007, CareOregon has operated a patient-centered medical home pilot program that serves about 20,000 patients. The clinics participating in the new grant program will provide a medical home to 189,000 patients, including 16 percent of the states Medicaid population and 12 percent of its uninsured patients.
The goal of this new program for CareOregon is to build and expand on the success of its ongoing medical home efforts. "We've been successful with the safety net model," says Dr. David Labby, medical director for CareOregon. "We see this collaboration as a way to spread the medical home model to any practice."
Specifically, the grant will allow CareOregon staff to serve as mentors to participating clinics as they begin to transform their practices into medical homes. Key to successfully implementing medical homes, Labby says, is to recognize that there is no single model and to focus instead on core principles. For CareOregon, these include providing team-based, patient-centered care, integrating behavioral health services with primary care and removing barriers to access.
"We start with a set of principles and figure out how to apply them to individual practices," he says. "We're not taking the approach that there's a single medical home model. It's about improving outcomes based on principles."
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ACHP Member News
Medical Home Investment Pays Off for Group Health
An evaluation of a Group Health Cooperative Patient-Centered Medical Home program shows significant success and rapid return on investment. The data led to a decision to invest in these best practices in all of Group Health's 26 medical centers by 2010.
In one year, Group Health's Patient-Centered Medical Home pilot, compared to controls:
- Broke even on its primary care staffing investment through reduced downstream utilization costs. Emergency room/urgent care visits were 29 percent less and inpatient hospital stays for patients with conditions including diabetes, chronic obstructive pulmonary disease, congestive heart failure, and asthma were 11 percent less.
- Improved indicators of quality of care. Overall improvements were 1.6 times greater across 22 measures than in controls. In seven out of 22 measures, the proportion of people meeting their target went up by more than 5 percent over one year. One example is cholesterol management (LDL less than 100mg/dl) for people with heart disease.
- Enhanced patients experience, including better bonding between patients and their physicians and care teams as well as better care coordination.
- Improved care teams' work satisfaction and reduced their emotional burnout.
Group Health increased its primary care staff by 30 percent to reduce physician-panel size and expand multidisciplinary clinical teams: doctors (family doctors and general internists), physician assistants, nurses, medical assistants, and clinical pharmacists.
Proactive staff-to-patient outreach increased, including clinical team analysis of each patient's needs, communication with the patient days before appointments, and detailed follow-up after it.
Use of e-health technology was maximized, including electronic medical records and increased contact with patients through secure e-mail and phone.
HealthPartners Behavioral Health Program Wins Honors
A HealthPartners-administered program that provides psychiatric medications to low-income patients received a 2009 Community Leadership Award honorable mention from Americas Health Insurance Plans. The Mental Health Drug Assistance Program provides 24/7 access to stop-gap psychiatric drugs to low-income patients with severe mental health conditions such as major depression, schizophrenia and bipolar disorder. MHDAP includes more than 25 local public- and private-sector organizations.
The program prevents psychiatric crises that lead to emergency hospitalization and incarcerations which cost an average of $12,000-15,000 compared to the average cost of $165 for a psychiatric prescription. A 2007 study of Twin Cities found that 40 to 50 emergency room patients with serious mental health conditions are admitted every month to hospitals in the Minneapolis/St. Paul metro area because they do not have access to community resources.
In the first year, MHDAP provided prescriptions to 300 patients. In a survey, patients reported that the program reduced the need for hospitalization by 26 percent. These results and the potential savings to the community have prompted the MHDAP collaborative to explore expanding the program locally and to explore potential national applications.
Independent Offers Members Vitamins, Supplements, Natural Products
Independent Health will begin offering them name-brand vitamins, supplements and other natural products at competitive prices via an online store effective immediately.
Thomas Foels, M.D., medical director at Independent Health, said there is growing evidence within the medical community regarding the many positive benefits of taking supplements, ranging from multivitamins, calcium and vitamin D, to omega-3 fatty acids, fiber, probiotics and zinc. He said such products are an important component of healthy living currently being embraced by approximately 150 million Americans and nearly 9 out of 10 (89 percent) of the health plans members.
The new product offering is consistent with other initiatives underway at Independent Health designed to engage members in activities to improve their health and change the health care paradigm, making it a more proactive and collaborative effort. The products will be available at www.yournaturaloptions.com through Lighthouse Naturals, LLC, a company headquartered in North Palm Beach, Fla. Lighthouse Naturals is a subsidiary of Independent Health Corporation, which in turn is a wholly owned for-profit subsidiary of Independent Health.
Tufts Health Plan Sponsors Community Activities
Tufts Health Plan has teamed up with a local Rhode Island radio station to provide local youth agencies with the opportunity to enjoy local professional and collegiate sports through the Tufts Health Plan - WEEI Community Bench.
Through the Tufts Health Plan -- WEEI Community Bench program, WEEI-FM listeners will nominate a local youth charity or civic organization to receive complimentary Community Bench section tickets at 12 local games, including the 2009 Pawtucket Red Sox and 2009-2010 Providence Friars Basketball.
One youth agency per available game will be chosen at random to receive 24 free tickets and Community Bench t-shirts, courtesy of Tufts Health Plan and WEEI-FM. For more information, nomination guidelines, and complete contest rules, please visit www.communitybench.com.
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Upcoming ACHP Events for ACHP Member Organizations
Practice Transformation Subcommittee -- PCMH Collaborative
This Subcommittee of the Patient-Centered Medical Home Collaborative was formed to help define the necessary processes of transforming practices into medical homes.
This Web conference is for members of the Practice Transformation Subcommittee. If you are interested in joining this Subcommittee, please contact Naveen Rao at nrao@achp.org.
Thursday, July 8
2-3:00 p.m.
Patient-Centered Medical Home Collaborative July Pilot Program Update
As part of ACHP's ongoing series of Patient-Centered Medical Home Collaborative pilot reports, ACHP's two Minnesota member plans -- HealthPartners and UCare -- will brief participants on their current practice pilots and discuss strategies for fostering flexibility for practices while assuring accountability. They will also provide an update on the Minnesota Health Care Home legislation, and HealthPartners will review the evolution of their care model process into the medical home.
Thursday, July 30
1-2:00 p.m.
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Copyright 2009 Alliance of Community Health Plans
Editors: Brendan Armbruster; Contributors: Patricia Smith, Brendan Armbruster
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ACHP is a national leadership organization that brings together innovative health plans and provider groups that are among Americas best at delivering affordable, high-quality coverage and care in their communities. The non-profit, community-based and regional health plans and provider organizations from across the country that make up ACHPs membership provide coverage and care for approximately 15 million Americans. These health plans focus on improving the health of the communities they serve and are on the leading edge of patient care coordination, patient-centered medical homes, accountable health care delivery, use of information technology and other innovations leading to improvements in affordability and the quality of care. To learn more about ACHP, go to .
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