Read final_capg_spring_09.pdf text version

Spring 2009

VOL. 3, NO. 2

HMO vs. PPO Clinical Performance CAPG Member Spotlight Don Balfour, M.D.

The Healthcare Challenge: Modernize & Economize

Congresswoman Jackie Speier

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Contents

Nextgen, CaPg and the HITECH Stimulus Bill -- a Winning Combination

spring 2009 | VOL. 3, nO. 2

CaPg Organizational Members

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FEaTURE

Upcoming Events

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3 PaRT SERIES

HMO VS. PPO CLINICaL PERFORMaNCE 9 Part 1 -- Measuring the Effect of the Delegated Model in Humboldt County 23 Part 2 -- The UCLa Experience 24 Part 3 -- Coordinated Care Surpasses Entropy Care; It Takes a System

Smoothing the Path from Hospital to Home

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Developing Services for the Medi-Medi Patient

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Technology at the Point of Care

DEPaRTMENTS ON THE COVER Jackie Speier

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Healthcare Challenge: Economize and Modernize Congresswoman Jackie Speier represents portions of San Francisco and San Mateo counties in the United States House of Representatives and she writes a compelling article about today's healthcare challenges.

COVER STORY

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notes from the president

16 capg member spotlight 20 healthcare visionaries

Publisher: Valerie Okunami CaPg Health Editor-In-Chief: Don Crane Managing Editor: Lura Hawkins, M.B.A. Photographer: Paul Morigi (cover photo) Contributing Writers: Alan Glaseroff, M.D.; Jackie Speier; Sheila Lyzwa, R.N.; Dianne Glover, M.P.H.; Samuel A. Skootsky, M.D.; Wells Shoemaker, M.D.; Edward Kim; Dr. Careen Whitley For more information on advertising in CAPG Health, please call at (916) 761-1853 or e-mail [email protected] Please send press releases and all other information related to this issue of CAPG Health to [email protected] and /or c/o: CAPG Health 915 Wilshire Blvd., Suite 1620, Los Angeles, CA 90017 CEO: David McDonald President: Tony Young Chief Financial Officer: Webster Andrews Vice President of Market Development: Ken Minniti Publisher Development Manager: Teri Burke Director of Publisher Development: Howard LaGraffe Recruiting Specialists: Elisha Davis, Stephanie Michaud Manager of Sales administration: Cindy Maestas Vice President of Creative Services: Tyler Hardekopf Production Manager: Tanna Kempe Editorial Manager: Shannon Wisbon Production Specialist Manager: Brenda Holzworth Creative Services: Kenny Bump, Kristy Carns, David Drew, Gerry Dunlap, Breanna Fellows, Kristen Gantler, Amelia Gates, Tess Kane, Courtney Littler, Lana May, Jodi Nielsen, Si Robins Controller: Darrell Dragoo Financial Services: Lori Elliott, Allison Jeffrey, Sharon Lardeo, Christian Williams Manager of Human Resources: Carrie Hildreth Manager of Information Technology: Eric Hibbs CaPg Health is published by Sunshine Media, Inc., 8283 N. Hayden Rd., Ste. 220, Scottsdale, AZ 85258 Phone (480) 522-2900 | sunshinemedia.com Subscription rates: $36.00 per year; $62.00 two years; $3.50 single copy. Advertising rates on request. Bulk third class mail paid in Tucson, AZ. Although every precaution is taken to ensure accuracy of published materials, CAPG Health cannot be held responsible for opinions expressed or facts supplied by its authors. Copyright 2009, Sunshine Media, Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Postmaster: Please send notices on Form 3579 to P.O. Box 27427, Tucson, AZ 85726

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PHOTO COuRTESY OF GENTRY MAGAZINE

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Notes from the President

Integrated, multispecialty physician groups practicing in the delegated model, such as our CAPG members, are especially suited to serving seniors, who often benefit greatly from having a "medical home" and carefully coordinated services. That's why more than 11 million seniors nationally have chosen to enroll in Medicare Advantage HMO plans. In California, most Medicare Advantage HMO plans are implemented by such physician groups rather than by health plans. These groups assume full accountability or "risk" for patient care, including costs and outcomes. The combination of direct physician oversight and a predictable, per-patient-per-month fee structure, allows the groups to invest in such quality improvement measures as prevention, improved chronic disease management, more efficient IT systems and care coordination. Our experience shows that these health management techniques, plus quality-based incentive rewards, lead to better quality care as well as lower costs over time. That's why we believe so strongly that seniors must have affordable access to the quality and value offered by the best Medicare Advantage HMO plans. And it's why we have joined physician groups across the country to form a new coalition dedicated to help decision-makers in the healthcare reform debate understand the principles of coordinated care. This new coalition -- Physician Groups for Coordinated Care -- offers a strong national advocate for the idea that care management is at its best in the hands of accountable physician groups. I am so proud of our CAPG members, who have pioneered and led the development of this highly effective model. Regrettably, we are seeing decreased funding for the one system that has proven to successfully wed quality and longterm value. This issue of CAPG Health features a wide variety of thoughtful articles on subjects that are up for national discussion right now. Some of the topics include developing services for Medicare-Medicaid patients, technology at the point of care and the first of a three-part series on HMO versus PPO performance. The authors of these and other articles in this issue offer food for thought for all of us who are concerned about the quality and cost of healthcare in America. Some of these same authors will also be conducting educational sessions at the 2009 CAPG Healthcare Conference scheduled for June 25-28 in San Diego. I'd like to personally invite you to join us this year to hear such exciting speakers as former U.S. Secretary of Labor Robert Reich, former U.S. Secretary of Health & Human Services Donna Shalala and California Healthcare President and CEO Mark D. Smith. Please contact CAPG at (213) 624-2274 for further information or a registration form. I sincerely hope to see you there.

Donald Crane President and CEO

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Organizational Members

ORgaNIzaTIONaL MEMBERS Affiliated Doctors of Orange County Medical Group John Ernsberger, M.D., Medical Director, Chief Executive Officer Varsha Desai, COO Affinity Medical Group Richard Sankary, M.D., President AllCare IPA Randy Winter, M.D., Chairman, CEO Matt Coury, COO All Care Medical Group Samuel Rotenberg, M.D., Medical Director Craig Kaner, Administrator Allied Physicians of California Thomas Lam, M.D., CEO Kenneth Sim, M.D., CFO Alta Bates Medical Group* Richard L. Oken, M.D., President and Chairman of the Board James Slaggert, CEO AltaMed Health Services Corporation James Cruz, M.D., Chief Medical Officer Castulo de la Rocha, JD, President, CEO AppleCare Medical Management Surendra Jain, M.D., Chief Medical Officer Vinod Jivrajka, M.D., President, CEO Arta Health Network, APMC Baruch Fogel, M.D., President Karri Rodgers, CEO Bay Area Community Medical Group Bernard J. Katz, M.D., President, Medical Director Mark R. Needham, M.D., Chairman Bay Valley Medical Group, Inc. * Eric Kohleriter, M.D., President, Medical Director Shelley Horwitz, Chief Executive Officer Beaver Medical Group, L.P. * Dennis Flynn, M.D., M.B.A., Medical Director John Goodman, CEO Bright Health Physicians* William Stimmler, M.D., President, Physician Services Jennifer Jackman, President, CEO Bristol Park Medical Group, Inc. * Mark Schafer, M.D., Medical Director Patrick E. Kapsner, CEO Brown & Toland Medical Group* Stan Padilla, M.D., Medical Director Gloria Austin, CEO CareMore Medical Group Donald Furman, M.D., Chief Medical Officer Tom Tancredi, Director of Practice Operations Cedars-Sinai Medical Group* Stephen C. Deutsch, M.D., Chief Medical Director Thomas D. Gordon, CEO Centre for Health Care Lawrence Koenig, M.D., Medical Director Victoria Lister, CEO Children's Physicians Medical Group Tanya Dansky, M.D., Medical Director Susan Bantz, CEO Choice Medical Group IPA Manmohan Nayyar, M.D., President Anna Sugi, Executive Director, Administrator CMS CAP Management Systems Megan North, CEO · AKMMedicalGroup · AmviMedicalGroup · CapNetIPA · ExceptionalCareMedicalGroup · FamilyHealthAlliance · · · · · · HuntingtonParkMissionMedicalGroup MedicinaFamiliaMedicalGroup NobleCommunityMedicalAssociates PremierPhysicianNetwork SeoulMedicalGroup UnitedCareMedicalGroup

Community Health Center Network Ralph Silber, CEO Barbara Ramsey, M.D., Medical Director Empire Physicians Medical Group Steven Dorfman, M.D., President Yvonne Sonnenberg, Executive Director Facey Medical Foundation* Erik Davydov, M.D., Medical Director Bill Gil, President, CEO Golden Empire Managed Care, Inc.* Glen Singer, M.D., Medical Director Robert Severs, CEO Good Samaritan Medical Practice Association Glen L. Hollinger, M.D., Chairman, Board of Directors Kathy Hegstrom, Administrator Greater Newport Physicians Medical Group, Inc.* Dan Cusator, M.D., Chief Medical Officer Diane Laird, CEO HealthCare Partners* Robert Margolis, M.D., CEO Matthew Mazdyasni, CFO Heritage Provider Network* Richard Merkin, M.D., President, CEO Richard Lipeles · BakersfieldFamilyMedicalGroup · CaliforniaCostalPhysicianNetwork · CaliforniaDesertIPA · DesertOasisHealthcare · GreaterCovinaMedicalGroup · HeritagePhysicianNetwork · HeritageVictorValleyMedicalGroup · HighDesertMedicalGroup

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· RegalMedicalGroup · SierraMedicalGroup High Desert Primary Care Medical Group Ziad El-Hajjaoui, M.D., Medical Director Niki Balginy, CEO Hill Physicians Medical Group, Inc.* Tom Long, M.D., Chief Medical Officer Steve McDermott, CEO Inland HealthCare Group, Inc. Carey Paul, M.D., President Lisa Perko, Controller John Muir Physician Network* Mike Kern, M.D., Medical Director Paul Swenson, Interim CEO Lakeside Community Healthcare Marvin Kanter, M.D., CEO Joan Rose, COO Lakeside Medical Group, Inc.* Francesco Federico, M.D., President, CEO Kerry Weiner, M.D., Vice President Lakewood IPA Steven Villalobos, M.D., Medical Director Cynthia Guzman, CPA, Chief Operating Officer · AlamitosIPA · St.MaryIPA · BrookshireIPA Loma Linda University Health Care J. Todd Martell, M.D., Medical Director Jane Arden, Director, Quality Management Marin Independent Practice Association J. David Andrew, M.D., Medical Director Joel Criste, CEO MED3000 Gary Proffett, M.D., Medical Director Lynn Stratton Haas, CEO · NorthridgeMedicalGroup · SeaViewIPA · ValleyCareIPA

Med Point Management Rick Powell, M.D., Medical Director Kimberly Carey, Administrator · BellaVistaMedicalGroupIPA · ElProyectoDelBarrio,Inc. · GlobalCareMedicalGroup · MissionCommunityIPA · RiversideFamilyHealthMedicalGroup · WattsHealthCareCorporation Memorial HealthCare IPA* Ronald Zent, M.D., Medical Director Patty Page La Penn, M.P.H., CEO The Mills-Peninsula Medical Group* Brian Roach, M.D., President, CEO Kim Noon, Sr. V.P. of Financial Operations Molina Medical Centers Edward Kim, President Steve O'Dell, Regional Vice President Monarch HealthCare* Bart Asner, M.D., CEO Jay Cohen, M.D., President Muir Medical Group, IPA Steve Kaplan, M.D., President Ute Burness, R.N., CEO NAMM California* Leigh Hutchins, Senior Vice President, COO Elizabeth Haughton, Vice President, Corporate Counsel · CentralValleyMedicalGroup · CoachellaValleyPhysiciansof PrimeCare, Inc., · MercyPhysiciansMedicalGroup · PrimaryCareAssociatedMedical Group, Inc. · PrimeCareMedicalGroupofChino · PrimeCareofCitrusValley · PrimeCareofCorona · PrimeCareofHemetValleyInc · PrimeCareofInlandValley · PrimeCareofMorenoValley · PrimeCareofRedlands · PrimeCareofRiverside · PrimeCareofSanBernardino · PrimeCareofSunCity · PrimeCareofTemecula · RedlandsFamilyPracticeMedical Group, Inc.

Omnicare Medical Group Toni Chavis, M.D., President Ashok Raheja, M.D., Medical Director Pacific IPA Thomas Chiu, M.D., President Peder Lindblom, Executive Director The Permanente Medical Group, Inc. Oakland (North)* Sharon Levine, M.D., Associate Executive Director Gerard Bajada, V.P., Director, Financial Services Physician Associates of the Greater San Gabriel Valley* Bart Wald, M.D., President, CEO Physicians DataTrust Lisa Serratore, Vice President Maria C. Gonzalez, Director, IPA Administration · GreaterTri-CitiesIPA · NobleAMAIPA · St.VincentIPA Physicians Medical Group of Santa Cruz Marvin Labrie, CEO Nancy Greenstreet, M.D., Medical Director Pioneer Medical Group, Inc.* William Wong, M.D., President John Kirk, CEO Preferred IPA of California Mark Amico, M.D., Medical Director Zahra Movaghar, Administrator ProMed Health Care Administrators Jeereddi Prasad, M.D., President Kit Thapar, M.D., CEO Riverside Medical Clinic Steven Larson, M.D., Chairman Judy Carpenter, President, COO Riverside Physician Network* Timothy Mackey, M.D., President Howard Saner, CEO

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San Bernardino Medical Group Thomas Hellwig, M.D., President James Malin, CEO San Diego Physicians Medical Group James Cordell, M.D., President Joyce Cook, CEO San Jose Medical Group Dean M. Didech, M.D., Chief Medical Officer Ernest A. Wallerstein, CEO Sansum Clinic* Kurt Ransohoff, M.D., President, Medical Director Paul Jaconette, CEO Santa Clara County IPA (SCCIPA) Randall Frakes, CEO Jane Yieh, M.D., Medical Director Santé Health System, Inc* Daniel Bluestone, M.D., Medical Director Scott B. Wells, CEO Scripps Coastal Medical Center Louis Hogrefe, M.D., APC, Chief Medical Officer Elena Cresap, Senior Administrative Director Sharp Community Medical Group* John Jenrette, M.D., Chief Executive Officer Christopher McGlone, Chief Operating Officer Sharp Rees-Stealy Medical Group* Donald C. Balfour, III, M.D., Chief Medical Officer Donna Mills, Senior V.P., Chief Executive Officer Southern California Permanente Medical Group* Mark Bird, M.D., Sr. Physician Executive James Malone, Medical Group Administrator Sutter Health Foundations and Affiliated Groups* David Druker, M.D., CEO Palo Alto Medical Foundation

Tom Blinn, CEO Sutter Medical Foundation · PaloAltoMedicalFoundation · SutterMedicalFoundation · SutterNorthMedicalFoundation · SutterWestMedicalGroup · SutterNorthMedicalGroup · Sutter Medical Group · Sutter Region Medical Foundation · Sutter Independent Physicians · SolanoRegionalMedicalGroup · SutterGouldFoundation · CaminoMedicalGroup · SutterGouldMedicalGroup · Santa Cruz Medical Clinic · Sutter Medical Foundation ­ North Bay · Sutter Medical Group of the Redwoods · Physician Foundation ­ California Pacific Medical Center SynerMed, Inc.* S.Y. Wong, M.D., Chairman of the Board James Mason, President, COO · AngelesIPA · CommunityFamilyCare · EmployeeHealthSystems · HollywoodPresbyterianMedicalGroup · MidCountyPhysiciansIPA · MulticulturalIPA · PacificAllianceMedicalGroup · RedlandsIPA · SouthernCaliforniaChildren'sNetwork Talbert Medical Group* Keith Wilson, M.D., President, CEO Michael Gam, CFO Torrance Hospital IPA Norman Panitch, M.D., President Marc Moser, CEO U.C.L.A. Medical Group* Sam Skootksy, M.D., Medical Director David Hartenbower, M.D., COO Vantage Medical Group Kevin Tyson, M.D., Chief Medical Officer Robert Lonardo, Chief Executive Officer

CORPORaTE PaRTNERS Abbott Amgen Inc. Anthem Blue Cross of California Bayer Healthcare Pharmaceuticals Boehringer Ingelheim Pharmaceuticals, Inc. Health Net of California Hill-Rom Johnson & Johnson Family of Companies Novo Nordisk Roche Diagnostic Diabetes Care SCAN Health Plan Westcliff Medical Laboratories, Inc. aSSOCIaTE PaRTNERS AstraZeneca Pharmaceuticals Cooperative of American Physicians, Inc. Eisai, Inc. EMPI Forest Laboratories, Inc. Genzyme Corporation GlaxoSmithKline Kindred Healthcare, Inc. MEDEM Mercer Human Resource Consulting Merck & Co. Novartis Pharmaceuticals Pfizer, Inc. Providence Medical Institute sanofi-aventis Schering-Plough Affiliate Partners Altura Ascender Software, LLC DPS Health Freed & Associates King Medical Supply Lumetra MedVentive, LLC MZI HealthCare, LLC OakRidge Consultants, Inc. pmpm Consulting Group, Inc. Redlands Community Hospital Renta-CEO, Inc. Sullivan/Luallin, Inc. The Centennial Group University Childrens Medical Group Unlimited Innovations, Inc. Ventegra, LLC

*

Indicates 2009-2010 Board Members

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Upcoming Events

Techniques to Engage Physicians in Improving Care Date: Thursday, April 2, 2009 Time: 8:30 a.m.-12:30 p.m. (Networking lunch at 12:30 p.m.) Location: Hilton LAX Cost: FREE Register online: EffectivelyEngagingPhysiciansConf_April2.kintera.org La/OC Regional Network Session 2: Engaging Physicians to Improve Patient Care -- The La/OC Experience Date: Thursday, April 2, 2009 Time: 1:00-3:30 p.m. (Networking lunch at 12:30 p.m.) Location: Hilton LAX Cost: FREE Register online: LAOCNetworkRegionalMtgApr2.kintera.org California Council on gerontology & geriatrics (CCgg) 2009 annual Meeting It Takes a Village: Toolkits for Effective Practice Friday, April 3, 2009 California State university, Northridge (CSuN) university Student union ­ Grand Salon Room For more information or to request a brochure, please contact the CCGG Executive Office at [email protected] or call (310) 312-0531. CaPg Medical Policy Meeting ­ Southern California April 7, 2008 Los Angeles CAPG office* Using Measurement for Quality Improvement (offered through CHCF) Date: Wednesday, April 8, 2009 (A session will be held in Southern California in July) Time: 8:30-4:30 p.m. Location: Nile Hall, Preservation Park 1233 Preservation Park Way, Oakland, CA Cost: FREE To register, contact Nandi Brown at [email protected] or (510) 587-3115. Improving Organizations Performance Series Workshops 1 and 2 Date: April 16, 2009, and June 10, 2009 Time/Location: TBD Cost: $500 for both workshops Register online:ImprovingOrganizationalPerformanceSeries.kintera.org CaPg Public Relations Committee Meeting April 21, 2009 Los Angeles CAPG office* Ostensible agency Theory: Recent developments April 21, 2009: 8:30-10:30 a.m. Luminaria Restaurant, Monterey Park, CA Register online at www.scahrm.org. CaPg San Diego Regional Meeting April 22, 2009 San Diego, CA* `get Smart': Risk Management in Turbulent Times The Southern California association for Healthcare Risk Management May 6-8, 2009 Rancho Mirage, CA Register online at www.scahrm.org. CaPg Southern California general Membership Meeting May 12, 2009 Los Angeles CAPG office* CaPg Inland Empire Regional Meeting May 13, 2009 Riverside, CA* CaPg HR Committee Meeting May 19, 2009 Los Angeles CAPG office* CaPg Contracts Committee Meeting ­ Northern California May 21, 2009 Hilton Oakland Airport Hotel* CaPg Disparities, Culture & Language ­ Special Conference May 21, 2009 Conference call* CaPg Pharmaceutical Care Committee Meeting May 26, 2009 Los Angeles CAPG office* CaPg Northern California general Membership Meeting May 28, 2009 Hilton Oakland Airport Hotel* CaPg Contracts Committee Meeting ­ Southern California June 4, 2009 Los Angeles CAPG office* CaPg Medical Policy Meeting ­ Northern California June 9, 2009 Call CAPG for location* 2009 CaPg Healthcare Conference June 25-28, 2009 San Diego, CA To register or for more information, go to www.capg.org*

* For more information, contact CAPG at (213) 642-CAPG. n If you have an event to submit for this column, please do so at [email protected] and please include the name of the event, the date, location and where to get additional information.

HMO vs. PPO Clinical Performance

By Alan Glaseroff, M.D.

Measuring the Effect of the Delegated Model in Humboldt County Part 1 of a 3 Part Series

SUMMaRY A comparison of clinical performance for a subset of HEDIS process measures (IHA P4P measure set) was performed for approximately 10,000 patients receiving care under the delegated model (HMO and local self-funded PPO insurance) versus approximately 30,000 PPO patients receiving care from the same practices for measurement year 2007. The analysis revealed an approximate 15% difference, with higher performance scores for the patients receiving care under the Delegated Model. Potential explanations for the discrepancy are analyzed, and implications for health policy discussed in this article. THE CaLIFORNIa `DELEgaTED' MODEL "Delegation" is the core principal of the California Model. While the rest of the U.S. predominately finds health plans dealing with physicians as individuals, California has developed a system to allow organized groups of clinicians (medical care organizations or MCOs) to locally gain the control of the delivery of health care services (which includes credentialing, quality management, care management of at-risk patients and utilization management). Generally, these MCOs come in two forms: large multispecialty groups and IPAs. While fully integrated multispecialty groups can deliver a single system of care for both HMO and PPO patients via contracting through a single tax ID number, IPAs often manage only a fraction of the patients within a given practice, and are generally shut out of the PPO business due Federal Trade Commission antitrust regulations. It is fair to say that the driving force for care innovation in California historically has been the Kaiser Permanente Medical Group, with the Delegated Model itself an alternative response to Kaiser Permanente's integrated system of insurance, hospital and clinician group that is specifically designed to serve the HMO market. HUMBOLDT DEL NORTE IPa: BaCkgROUND Humboldt County is a rural county on the north coast of California near the Oregon border. The Humboldt Del Norte IPA (HDNIPA) has contracted for HMO business via the delegated model since its inception in 1995. HDNIPA's membership includes virtually the entire clinician community, including physicians, advanced practice clinicians (NPs and PAs), podiatrists and behavioral health professionals (LCSWs, MFTs and Ph.D. psychologists). Given its geographic isolation (Redwood Curtain), and the inclusive nature of its membership, HDNIPA has consistently approached its mission with a view towards providing care to the entire county's population, rather than limiting efforts to the 7% with HMO insurance. It is a long-held belief in the IPA that no effective system of care could be successfully implemented that only applied to 7% of the population. Hence, the IPA's business model is to serve as the care integrator for the region, and has sought grant funding to support the expansion beyond the limited HMO population and serve as model for other regions. QUaLITY IMPROVEMENT Beginning in 2003 with the Humboldt Diabetes Project, improving chronic disease care has been the major focus of system development, with the Chronic Care Model as the blueprint. Through a series of grants (from the California Healthcare Foundation and more recently from the Robert Wood Johnson Foundation) and participation in multiple collaboratives (including with DQIP and BCCP), HDNIPA has built and maintains a communitywide electronic registry for diabetes (approximately 95% of all patients with diabetes in Humboldt County), and has completed successful improvement projects in breast medicine, hypertension in diabetes, selfmanagement support, end-of-life care and the spread of standard treatment protocols for chronic conditions. Currently, the IPA is running a collaborative to redesign systems in primary care, called "Primary Care Renewal (PCR)" that includes teams from 13 of 25 primary care practices in the county, including the safety net. PCR is modeled on a similar effort by Care Oregon, a Managed Medicaid community-owned health plan in the Willamette Valley. The IPA also employs a part-time nurse practitioner to coach practices in the various aspects of the Chronic Care Model. The IPA also performs care management for high-risk patients, has established a community-based and ADA recognized chronic condition self-management education program (Health Education Alliance) and works extensively with a multistakeholder organization (Community Health Alliance) that offers peer-led community chronic disease workshops based on the Stanford Model. The IPA has self-reported results to the Integrated Health Care Association's Pay-for-Performance program for the past several years. This has led to several years' reporting of performance data at the community and practice level, evolving into the current series of unblinded comparisons that are shared amongst all clinicians (individual data available within the

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cover story

The Healthcare Challenge: Modernize and Economize

By Congresswoman Jackie Speier

Healthcare is expensive. There's no getting around that. And, as better treatments and innovative therapies are developed, the costs are only likely to rise. How, then, do we improve healthcare delivery and expand access to every American at a time when our country is facing the most severe financial climate since before the invention of a polio cure? The answer: modernize and economize. MODERNIzE Medical technology advances at a rate much faster than most industries, yet record keeping and data collection is still stuck in the days of little black bags and house calls. Fully modernizing our country's health information technology is a daunting task, but the benefits are enormous. Once implemented, a national health IT system would allow comprehensive management of medical information and provide a secure exchange between healthcare consumers and providers. Modernizing this crucial system would prevent medical errors, reduce costs, increase administrative efficiency, decrease paperwork and expand access -- all of which will lead to a higher quality of healthcare. Modernizing the way we keep records will also benefit public health by helping with early detection of infectious diseases, tracking the spread of outbreaks and enabling better statistical analysis of the quality and value of care in different regions of the country. Expanded health IT will also enable individual patients to better maintain their health by gathering their health information in one place so they can more easily monitor their personal information and communicate more effectively with healthcare providers to ensure that care fits their individual needs. ECONOMIzE While costly at first, updating our record-keeping system will save money in the long run. Combined with other efficiencies, the goal is to create a more economical and less cumbersome healthcare system for our country. A recent report by the Dartmouth Institute for Health Policy estimated that 30% of U.S. healthcare spending, or $700 billion, could be eliminated without negatively affecting the

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quality of care. One area where there is room for savings is Medicare Advantage. A column in the Winter 2009 issue of this publication acknowledged that Medicare Advantage rates are, on average, 14% higher than traditional fee-for-ser v ice Medicare, wh ile Jackie Speier White House Budget Director Peter Orszag told a conference sponsored by America's Health Insurance Plans in March that the government spends $1.30 for each dollar it spends in traditional Medicare. "I believe in competition," the director told the conference. "I don't believe in paying $1.30 to get a dollar." Many physicians provide coverage to Medicare Advantage patients and the system has proved beneficial for millions of Americans, but we all must admit that inefficiencies exist that can and must be addressed. The leading cause of personal bankruptcies in our country is healthcare expenses. For many of these people, it is one aspect of healthcare that drives them off the cliff: prescription drugs. Any comprehensive healthcare reform must find a way to make prescription drugs more affordable. A recent study of the "doughnut hole" provision in the Medicare Part D prescription drug plan revealed that beneficiaries on brandname medications decrease their use by 14% upon reaching the coverage gap, while those taking generic drugs reduce use by 3%. Certainly, any patient making pharmaceutical decisions without their doctor is a recipe for disaster, and we must recognize the role that cost plays in these very unhealthy health decisions. For all the work that lies ahead of us in reforming our healthcare system, I am confident and encouraged that this is the noblest of pursuits. I look forward to hearing from CAPG members -- as I do often -- with ideas on how we can make sure that the world's most advanced democracy is providing its citizens with the most advanced and cost-effective healthcare. n

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practice). Self-reporting has led to ongoing dialogues between IPA administration and primary care practices, as the IPA sends each practice a list of patients requiring services on a quarterly basis and practices respond by either supplying missing data or the needed service itself. Monthly meetings with the office managers of the independent practices in each city in Humboldt County (Arcata, Eureka and Fortuna) have

greatly enhanced these efforts. Practices have, to varying degrees, accepted the concept of responsibility for populations of patients, and anecdotes are emerging of preventive screenings producing early diagnoses of cancer that would have been missed without the reminders sent by the IPA. Spread of the concepts of team care and the use of the chronic disease registry have been aided by these meetings, in

addition to the work done by the coach and within the collaboratives. aLIgNINg FORCES FOR QUaLITY Humboldt County was one of 14 regions in the U.S. included in the Robert Wood Johnson Foundation's "Aligning Forces for Quality (AF4Q)" Initiative in 2007. The goals of this long-term national project are to widely measure and publicly report clinical and patient experience performance data while using the data to drive improvement and engage consumers in the subject of quality, and patients in their own self-care. Wide reporting of data requires a sufficient denominator to produce reliable results. As the population covered by HMO insurance is small (and declining), the IPA approached the largest insurer in the county, Anthem Blue Cross, asking for access to PPO claims data. HIPAA issues were overcome via new business associate agreements, and in late 2007 the IPA had received claims on 30,000 additional PPO patients, and was able to expand the Patients Assessment Survey to allow for aggregated clinical and patient experience reporting at the county, practice and frequently individual clinician levels. Although the IPA has been able to report diabetes measures communitywide for some time, this effort has been limited to a single disease and by varying degrees of participation in the registry functions (data largely comes from the point of care, and is hence subject to practice's relative efforts to enter complete data). Efforts to automate lab data entry into the registry have proven only partially successful. Periodic chart audits have shown up to a 20% gap between chart (often paper) and registry in certain practices, hampering efforts to report widely and fairly. Hence, getting access to PPO claims was very attractive to the IPA. While data issues remain (accurate patient attribution to a given practice and clinician is the biggest issue to resolve), the

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it's totime feel better.

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feature

NextGen Healthcare Information Systems, CAPG and the HITECH Stimulus Bill -- A Winning Combination

Over three years ago, CAPG initiated a group purchasing program to benefit members in obtaining practice-related goods and services that would aid in improving their quality and efficiency at a discounted price. NextGen Healthcare Information Systems was the first company to join the program, making NextGen Healthcare Information Systems a preferred business partner for computer-based healthcare information tools and systems. Since 2006, several CAPG members have taken advantage of the program and benefited from the advanced, fully integrated ambulatory electronic medical records (NextGen EMR) and practice management solutions (NextGen EPM). Now, fast-forward to 2009 and the recently enacted federal government HITECH stimulus bill. Beginning in 2010, physicians can benefit from an estimated $40,000 per physician in federal cash payments over a five-year period for the meaningful use of an EMR. Couple those federal payments with the CAPG Group Purchasing Program discount on certified NextGen Healthcare Information Systems and you have a win-win combination that benefits CAPG physicians, patients, NextGen Healthcare Information Systems and CAPG. For early adaptors of EMR, the federal government is rewarding their initiatives with stimulus payments as well. NextGen Healthcare Information Systems along with Medem/iHealth, Ven t e gra a n d Sulliva n Luallin Consulting are participants in the CAPG Group Purchasing Program. For more information about NextGen Healthcare Information Systems, please visit www.nextgen.com or visit the NextGen Healthcare Information Systems booth at the upcoming CAPG Healthcare Conference in San Diego June 25-28. For information regarding the CAPG Group Purchasing Program, contact Rick Swanson at [email protected] n

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capg member spotlight

Growth of a Multispecialty Group Practice in a Large Integrated System

Donald C. Balfour, M.D.

In 1977, Donald C. Balfour, M.D., joined Rees-Stealy Medical Group in San Diego, CA, specializing in hematology/oncology. Rees-Stealy Medical Group, at that time, had 27 physicians and two facilities and had been operating as a multispecialty group practice since 1923. The group grew over the next eight Donald C. Balfour, years to 53 phy- M.D. sicians and three facilities until the group affiliated with Sharp HealthCare through a 1206(l) foundation in 1985. Rees-Stealy Medical Group embraced managed care in the mid-'70s, and by 1985, 83% of the practice was full-risk capitation. Q: Why did rees-stealy Medical group join sharp HealthCare? A: We needed capital to expand our practice. In caring for the increasing number of managed care patients,

New Sharp Memorial Hospital

New facility at Scripps Ranch

we needed to increase the number of facilities and primary care and specialty physicians. On October 1, 1985, we accepted our first senior HMO patients. The community physicians thought we were foolish for accepting the risk for seniors, but history has proven otherwise. FFS Medicare patients realized the value of senior HMO programs and joined our senior products at a rate of over 1,000 patients per month. Q: What did sharp HealthCare think about accepting risk? A: They had minimal exposure to managed care prior to the acquisition, but they had been watching managed care grow in San Diego in both the commercial (65% of the insured) and

senior (one of the highest percentages of HMO penetration in the country) markets. Recognizing the need to participate in managed care, Sharp HealthCare supported the growth and development of the infrastructure of the Sharp Rees-Stealy Medical Group [SRSMG]. Sharp's willingness to accept risk on both the professional and hospital side has enabled SRSMG to become one of the most successful groups in the state. Q: How do you measure success for your group and sharp HealthCare? A: We have grown to 400 physicians in 30 different specialties serving 18 clinical locations. We have been AAAHC accredited since 1981, and we were recognized by the Integrated Healthcare Association in October 2008 as the No. 1 group in the state for the pay-for-performance program. Sharp HealthCare has grown to four acute hospitals, three specialty hospitals, two nursing homes, home health, hospice, a commercial health plan and three charitable foundations. In 2008, they were the recipient of the Malcolm Baldrige National Quality Award and were recognized by the readers of the San Diego union as the No. 1 hospital system in San Diego. On January 14, 2009, they opened the first new hospital in San Diego in 15 years. The 334-bed tertiary hospital has all private rooms with overnight accommodations for family members.

Dr. Charles Schuetz, otolaryngologist, Vice President of the SRSMg Board of Directors, and Dr. Ostrander, cardiologist

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CaPg HEaLTH

spring 2009

Smoothing the Path from Hospital to Home

By Sheila Lyzwa, R.N., Director of Case Management, Brown & Toland Physicians

Brown & Toland's Discharge Follow-up Program

The patient had suffered a heart attack. After cardiac catheterization, he headed home with a stent lodged in his heart, but no solid plans for a follow-up appointment. Brown & Toland Physicians case manager Janet Kimball, R.N., called two days after his release and encouraged the patient and his wife to head back to the doctor to check in. Medical staff discovered that his anticoagulation medication dosage needed to be changed dramatically. " It's a good t h i ng he went i n," Kimball said. Her phone call -- a part of Brown & Toland Physicians' new discharge followup program -- may have saved the man's life or prevented a costly trip to the emergency room. Too often, patients are discharged with the wrong type or dose of medication, poor discharge instructions, no physician In response, Brown & Toland Physicians established a discharge follow-up program that blends coordination of care and the personal touch while remaining cost effective. The goal: to identify senior patients at high risk for readmission, reduce their unscheduled hospital visits and improve patient satisfaction with inpatient care. There could be many explanations for an increase in discharge errors. The number of senior patients, many with chronic conditions, has increased because people are living longer. Paradoxically, seniors may have fewer resources to manage the transition from the hospital back home than in the past as families have become more fragmented. Sometimes patients are given discharge instructions but do not follow them, Kimball said. "By the time they get home, they've forgotten what they've been told or they didn't

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Linda Johnson, Janet kimball and ann Longley

follow-up appointment or appointments made far too long after hospitalization, according to our review of the literature.

capg member spotlight

Sharp is the predominant provider in most health plan narrow networks. This is attributed to the quality and cost effectiveness of coordinated patient care provided by Sharp Rees-Stealy and Sharp HealthCare. Q: What keeps you up at night? A: Short term, I am worried about the current economic situation and the impact on healthcare coverage. A decrease in enrollment and increase in bad debt can have a significant financial impact to our practice. Longer term, I am worried about the lawmakers in Washington who are on a quest to reduce the funding for MAPD. A decrease in funding would potentially reduce physician compensation until either we can no longer financially afford to stay in the program or decrease benefits until our seniors choose to return to fee-for-service Medicare. Q: What can CApg do to help? A: CAPG can continue to tell our story in both Sacramento and Washington of the improved patient outcomes provided by the groups and IPAs in California. Hopefully, working together we can preserve the highquality, cost-effective delivery systems that have existed in our state for the last three decades.

Dr. Balfour has been the President of SRSMG since 1985 and served as Medical Director from 1993 to present. He has served on the Sharp HealthCare board of directors since 1985.

Dr. Balfour has served as a member of the CAPG governing board since 2003 and was a member of the CAPG Executive Committee from 2003 to 2008. Dr. Balfour was governor of the American College of Physicians for the Southern California Region III from 1997 to 2001. He served as president of the American Group Practice Association from 1995 to 1996. The group is currently known as the American Medical Group Association. Dr. Balfour is a founding member and current secretary for the Council of Accountable Physician Practices. He was chairman of the Blue Cross of California Physician Relations Committee from 1996 to 1998. n

CaPg HEaLTH spring 2009 | 17

Continued from Previous Page

understand the instructions because they're so focused on getting home," Kimball said. And at the hospitals, discharge planners are under increasing pressure from payers and their own hospital administrators to move patients quickly across the continuum of care. With these factors in mind, we chose to focus on medical management interventions that ease the transition from the hospital to home by enhancing the communication between stakeholders and ensuring patients more timely and appropriate ambulatory care with the primary care physicians in the network. CHECkINg IN As a first step in developing the program, Brown & Toland Physicians created a patient survey that would assess senior patients following discharge from two of the major admitting hospitals. The preliminary results from the survey indicated that the most critical time to intervene in order to prevent a rehospitalization is within 14 days of discharge. Given this key finding from our study, we established processes that would allow for timely interventions by a nurse case manager. Case managers first call patients within 48 hours of discharge and then call again within the next seven days. When speaking to patients, case managers go over discharge instructions and evaluate the medication list to make sure it is appropriate. They also check to see if the patient has a timely follow-up appointment. This intervention is critical: Patients often skip follow-up appointments because they do not realize the value, said case manager Nancy Clark, R.N. "If they're feeling good, they think, `Oh, I won't go,'" she said. If no appointment has been made, case managers will help arrange one and even facilitate transportation, if necessary. In order to prepare for the follow up after discharge, each case manager obtains pertinent clinical data including the hospital progress notes, discharge summary, copy of the discharge instructions and a current medication list. There is also data available through the integrated electronic medical record system that tracks ambulatory care

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key Interventions after Discharge

· Phone contact within 48 hours of discharge · Follow-up call within seven days from the initial call · Coordination of resources and review of discharge instructions · Medication reconciliation and medication management · Assessment of timely physician follow-up appointment

given to patients by physicians in the network. Having all the relevant data allows the nurse case managers to make more informed decisions, hold meaningful conversations with patients and troubleshoot problems that arise. An essential element to building a successful discharge follow-up program was promoting it to patients, their families, caregivers and hospital staff. In addition to creating a brochure that describes the program, Brown & Toland Physicians spoke to as many seniors in person as possible. Brown & Toland Physicians felt that seniors would be hesitant to speak with strangers over of the phone (and that they are often not the best historian of their health care). To put patients and staff at ease, nurse case managers introduce themselves to patients prior to discharge. During this time, they ascertain who will act as the primary caregiver, confirm a contact number and inform all parties that they should expect a call several days after discharge. This approach helped increase the response rate and promote the program to the membership and the physician network. "It puts a face with a name," Clark said. "It makes people feel more connected." METHODS aND CHaLLENgES During the pilot phase, we conducted a second study to determine which group would benefit the most from this program. This approach allowed for program redesign as needed, identification of contributing factors related to readmission, additional data collection and reporting on program impact. Brown & Toland Physicians chose to pilot the program at

two hospitals where it had close working relationships with hospitalists and noted a high volume of senior admissions. Implementing this program within two different hospitals systems proved to be advantageous because it highlighted institutional variability that later enhanced its ability to promote change. One challenge Brown & Toland Physicians encountered during the pilot phase was accessing clinical information in a timely manner. For example, discharge summaries were sometimes not available at the time of discharge. Providing its two hospital partners with this feedback helped improve medical record documentation and led to a new policy regarding the timeframe for communicating a discharge summary to the primary care doctor. The outcomes differed between the two hospitals, presenting Brown & Toland Physicians the opportunity to do performance improvement with its hospital partners and the physician community. It has since held discussions with its hospitalists and hospital administration. Those discussions lead to new perspectives on inpatient management that Brown & Toland Physicians anticipates will reduce unscheduled readmissions in the future. In the end, this collaborative patient care initiative further strengthened its relationship with its hospital partners and physicians. However, the most rewarding aspect of the program is knowing that we are improving patient care. As the nurses visit seniors at the hospitals and talk with them by phone, it is clear they are making a difference. Clark said the feedback from patients has been overwhelmingly positive. "They just appreciate the concern, that we took the extra step to make sure that they have what they need," Clark said. "The personal touch goes a long way." For more information on the discharge follow-up program, contact Sheila Lyzwa at [email protected] or (415) 972-4220. Lyzwa will be presenting a breakout session at the 2009 CAPG Annual conference. For more information, go to www.capg.org. n

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majority of the P4P measure set is quite accurately reported via claims in a PPO, fee-for-service environment (submitting a claim is how practices are paid, and getting paid is a core value in virtually all practices). Additionally, the idea of comparing HMO (and the small amount of self-funded PPO managed by the IPA) to PPO performance within the same practices, for care delivered by the very same clinicians, could serve as a measure of performance of the delegated model itself. The comparison provides performance measurement for three basic categories of patients: 1. Anthem-Blue Cross PPO patients -- care provided for approximately 30,000 patients by a panel of Humboldt PCP practices (virtually all IPA members) that individually contract with Anthem. Deductibles and copays vary by patient -- generally 80/20 plans. 2. IPA California Care patients -- classic HMO care provided for approximately 7,500 patients by capitated IPA PCPs, with the IPA delegated for claims payment, credentialing, medical management, quality management, care management and behavioral health credentialing. IHA P4P program participation with the IPA self-reporting. 3. All-IPA Plans -- also includes approximately 2,000 local self-funded PPO lives that receive care from the IPA panel (fee for service), and also are managed by the IPA, which is delegated for the full menu of services (claims, credentialing, medical management, quality management, care management and behavioral health). Copays and deductibles generally similar to commercial PPO benefits. IPA P4P program includes data for this population as well as for the HMO patients. Here is what was found. (See graph.) The data on childhood immunizations may underestimate PPO rates due to access to free public health vaccines for patients with high deductibles and copays.

DISCUSSION Humboldt County affords a rare opportunity to study the effect of the Delegated Model side by side with traditional, unmanaged PPO care within the same practices. Each practice has its own system to manage population health for non-IPAmanaged patients -- some with EHRs, many with paper "tickler files," but none supported by a local quality and population support infrastructure. In contrast, the HMO (and IPA-managed PPO) patients are part of a database that is actively managed as a core function of IPA work.

While the discrepancy between HMO and PPO results varies by measure, the care received by IPA-managed patients is roughly 15% better than the care received by patients with Blue Cross PPO insurance. Benefit differences between HMO and PPO coverage (deductibles and copays) do not explain the difference, as HMO- and IPA-managed performance measures show little difference. What might explain the difference in performance? The answer appears to be fairly straightforward: The IPA, which

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healthcare visionaries

CAPG Health Visionary Alain Enthoven

By Dianne Glover, M.P.H.

Alain C. Enthoven is the Marriner S. Eccles Professor of Public and Private Management, Emeritus, Stanford university. He has published in the fields of economics, organization, management and public policy of healthcare in the united States and united Kingdom. Hi s r e s e a r c h focuses on the causes of unsus- alain C. Enthoven tainable growth in national health expenditures, the costs of health insurance and strategies to inhibit growth while improving quality of care. Enthoven holds degrees in economics from Stanford, Oxford and MIT. He has served numerous presidents; while serving as a consultant to President Jimmy Carter, he designed and proposed the Consumer Choice Health Plan, a plan for universal health insurance based on managed competition in the private sector. He also was an early contributor to the Clinton health plan. He joined the Stanford faculty in 1973, where he has taught business policy, microeconomics and healthcare. Q: Let's start with a bit of your history. You have worked extensively throughout your career advising former administrations on health reform. What were your greatest lessons learned in this arena? A: My greatest lesson learned is that healthcare is incredibly complex. There is little understanding or agreement on just what is the problem, much less about the solution. It is the problem from hell. For example, people talk about "reform" without agreement about what the term means.

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Many people, starting with Governors Romney and Schwarzenegger and now with President Obama, by health "reform" they mean changing to a system in which everyone has been brought into the health insurance system. I use the term "reform" differently to mean a system in which we have wallto-wall reformed delivery systems that are integrated, responsible, efficient, competing and accountable for quality and cost. When I hear "reform," what I am thinking that should mean is something like what we have here at Stanford, where we have the Palo Alto Clinic and Kaiser Permanente competing to serve Stanford employees. They are both working to improve the quality of service and the quality of care. They both have excellent information technology and they are improving. I think what we need is greater costconsciousness across America and organized delivery systems such as those mentioned. So, it's hard to talk about healthcare reform when people have such different ideas as to what it means. Q: Were you called upon to contribute to the Obama plan? A: Not so far. Q: Our economy is currently in rough shape right now. some experts have said that the recession could deplete funding for Medicare in as few as three years. Do you believe that now is the right time for the president to be discussing comprehensive health reform? A: Yes, I do, but again, as to what I understand reform to be. I think it is very important that we reform the healthcare system now because it costs way too much and it's pricing itself out of reach. Last year, I did an op-ed piece for Forbes.com, which began with the

sentence, "In 2008, healthcare is draining the federal budget by more than $1 trillion a year." That's a huge amount of money. Traditionally, federal tax revenues have been about 18% of GDP. A trillion dollars is 7% of GDP, so it's looming very large in public finances at both the state and federal levels. What I'm worried about as we pour out this vast amount of debt with our stimulus package is that somebody out there must be willing to buy our debt and hold it. I think that if the administration and the Congress show themselves to be unable to get this trillion-dollar outlay under control, then we look forward to perpetual serious fiscal deficits. And who's going to want to buy our debt if we can't even take serious actions towards balancing the budget? So, I do think it's very important now that we get underway with reform of the healthcare system. Q: so, you believe reforming our healthcare system is necessary to keep America viable in the global economy. To narrow the scope further, president Obama was quoted recently in The new York Times as saying, "We can't solve Medicare in isolation from the broader problems of the healthcare system," and "comprehensive healthcare reform is the best way to strengthen Medicare for years to come." Do you agree with that statement? A: Yes, I completely agree with that statement. You can't solve Medicare in isolation. You have to address the whole healthcare system. The same doctors and hospitals who take care of Medicare patients, of course, take care of others as well. Moreover, as I just referred to the trillion dollars, Medicare is only about 460 billion of that; there's also Medicaid and other programs, such as programs for health

healthcare visionaries

insurance for public employees There are tax subsidies for employer-paid health insurance that comes to well over $250 billion. That's a big part of the drain of the federal budget, so all of those have to be addressed. Q: And do you agree with the Obama plan to use the existing care system to achieve this reform? A: I think we have to start with what we have and start from where we are. But I see a reformed delivery system as made up of accountable care systems. Q: so how do we get there from here? A: I believe the way that we get there from here is to make sure that every American is offered a cost-conscious choice of health plans, meeting certain standards of adequacy in quality and coverage. I think that would accomplish a lot because of what I observe at employment groups like my own here at Stanford. When people are offered such choices, then in very high percentages they choose group practice-based HMOs or [those] that are pretty good approximations to an integrated delivery system. If people were offered choices of value for money, they would migrate to what they see as value for money, and I think we have good evidence that such systems can provide very good care for 30% less than the cost of the open-ended, uncoordinated fee-for-service sector. Q: president Obama has made a large financial commitment to information technology for healthcare. Do you believe that more robust information networks are a necessary precursor to health reform? A: I think healthcare IT is very important. Kaiser Permanente and the Palo Alto Clinic are able to use it constructively to make great improvements in the efficiency and quality of care. But the IT is not the key. Information technology in healthcare is primarily a matter of physician organization, culture and incentives. I think we need to reform the system; the way to get to everyone using excellent healthcare IT is by using competition to drive us to efficient, organized delivery systems. Then they, in turn, would adopt IT and want to use it. But IT without that [integrated systems and competition] would be a waste. Some people seem to engage in magical thinking; they say the most efficient systems use IT, so let's buy IT for all doctors. I think that is a mistake. That is, the reason the systems that I mentioned and many others in multispecialty group practices and also some IPAs like Hill Physicians Group are using IT is because they want to, and because the leadership has persuaded the doctors that it is very much in their interest to do it. They have incentives and motivation to use IT to improve quality and cut costs. If doctors are in the present dominant system that does not have incentives to improve quality and cut costs, they won't use IT for those purposes. Q: Tell me a little more about the competition that you mention. A: First, we do need systems to improve quality and cut costs. It takes systems to organize all of the different resources and point them in the right direction. Competition should be at the level of the delivery system. The world would look the way it does for Stanford employees or state of California employees. The employer makes a fixed-dollar contribution towards the plan of your choice. At Stanford and the university of California, the fixed-dollar contribution is at the price of the low-priced plan, and then people make a costconscious choice. And at Stanford and university of California, 81% choose HMOs that are based on integrated systems, mostly multispecialty group practice and some IPAs that have integrated and coordinated care. Q: preventative care is another cornerstone of the Obama plan. Does the Obama plan include enough preventative care commitment to be effective in bringing down overall healthcare costs? A: I think it is not entirely clear that preventative care can reduce costs all that much. I have an article by Louise Russell who is a research professor at Rutgers university. She says, "It is impossible to generalize preventative interventions as if though they were all alike. The evidence does not support the commonly accepted idea that prevention always or even usually reduces medical costs; although, sometimes it does. Most prevention interventions add more to medical costs than they save at the same time that they improve health." It's a little like IT. People look at Kaiser Permanente and say they are one of the most efficient systems out there, they do a lot of prevention, so prevention must be a key to saving money. It's not entirely clear -- even to them -- that prevention saves money. They do it because it improves the health of their members. I'm talking about the type of preventative intervention that the healthcare system does. The evidence is at best equivocal, as far as interventions in the medical arena. I think there are many other types of intervention, such as healthy lifestyles. If we got every teenager in America to do vigorous exercise regularly and continue that through their lives, it would reduce obesity, diabetes, hypertension, heart disease and so forth. The healthcare system can try to get people to exercise and lose weight, but I think it is beyond what doctors learned in medical school. For example, if tomorrow someone invented a pill to cure cancer, I doubt it would have a big effect on healthcare expenditures. In the open-ended system with fee for service, the now-displaced oncologists would find other ways to make themselves useful and well paid. So, this pill would not necessarily produce cost savings. What drives healthcare costs is the supply. But if Kaiser, with their closed-ended system, started dispensing this cancer-curing pill, they would be able to stop hiring oncologists and possibly retrain their current oncologists to primary care or some other useful area. That would produce savings. There are two different problems:

CaPg HEaLTH spring 2009 | 21

healthcare visionaries

one is healthcare expenditures and the other is poor health. Prevention may help improve health, which is important. In an open-ended financing system, it is not at all clear that prevention will actually reduce healthcare costs. I would not look to preventative care as a major source of savings. Q: so, bottom line, what do you think works about president Obama's plan? What works and what needs to be changed? A: With all due respect to the president -- this is not a partisan statement and I have positive feelings towards him -- but I don't think he has a plan or even a concept. I have been listening carefully, but what he has put forward so far is just general goals. I regret that. I wish that he would get up and say we need to make sure every American has a costconscious choice of plans and make sure that we have lots of private plans in there competing. Then, he needs to lay out a concept like managed competition. I don't think that he's done that so far. To my understanding, he's turning those "details" back over to the Congress. In some way, it's an overreaction to Hillary Clinton's mistake. Hillary invented the whole 1,342 pages in her back room, then sprung it on Congress and it went nowhere. So then, it seems Obama's idea is to let Congress do it all. A better example to learn from is Lyndon Johnson with Medicare. I am told by Philip Lee that Lyndon Johnson called in Wilbur Cohen, the secretary of HHS, and gave him a concise description of what we now call Medicare. He even favored a particular bill. President Johnson said, "You go sit down with Wilbur Mills, the Chairman of the Ways and Means Committee, and see if you can negotiate agreement to a plan that meets my general specifications. If you can, we'll join hands, go forward and enact it." That was not a matter of turning the whole problem over to Congress, which is, after all, the home of all kinds of narrow special interests. It was a case of presidential leadership working with Congress. I think

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that would be better. I think President Obama really needs to take the lead and describe in broad outlines what he sees as the best kind of plan. I would add that the president has said in other areas he is going to put behind us the partisan divisions. I think in this case, it's important that we have a plan that attracts strong bipartisan support, so that we don't go back to the situation in which the party in power puts in their plan, then the other party tears it up and starts over. We need to have a lot of Republican fingerprints on the legislation as well as Democratic fingerprints. Q: Any major overhaul plan needs to have established measures of success and checkpoints to see if it is being effectively executed. What would you say are the measures of success and how could they be measured? A: One intermediate outcome along the way would be what percentage of our population has the opportunity to make cost-conscious choices between competing delivery systems. Eventually, measures of success would include bending the curve of expenditure growth and bringing health expenditure growth close to being in line with the growth of the GDP. Then, measures of success would include quality indicators. We are building up now a suite of healthcare quality indicators with HEDIS and the Integrated Healthcare Association's pay for performance. The measures would be cost, quality and access -- the traditional three ways of measuring. A key measure would be success in driving down the number of uninsured people. Q: On a more personal note, how would you answer this sentence? people would be surprised to know ... A: People might be surprised to know that my one and only dear wife and I have 17 grandchildren from six children of our own. Also, my wife and I still ski. We do cross-country and downhill skiing. We are so grateful that we can still do it. We have been married for almost 53 years.

Q: Congratulations! That is fantastic. so, do you have any final thoughts or advice for CApg members? A: I think that it is important for us toge ther to educate the American people to the fundamental importance of organized, accountable, integrated delivery systems. unfortunately, so many people that I talk to just don't get it. They think that the way God made medical care and the way that it will always be is with solo doctors practicing autonomous, fee-for-service, uncoordinated, unintegrated care. Especially in the East, so many people don't have a concept of what this is. I think that we have a big job of educating the American people, and I think CAPG members could be an important part of that by continuing to do an excellent job. You can teach people by example. Now, unfortunately, when you go to the East, people say what you are talking about could only happen in California. So, I say, "No, no. There are several fine, large multispecialty practices in Massachusetts; Kaiser is in the mid-Atlantic states and in Georgia. There are integrated delivery systems in rural Wisconsin, Pennsylvania, Texas, utah, Montana, etc. It can happen there and in the Midwest. It can happen in a lot of different places -- rural as well as urban settings. People think it can only be in urban settings. We have the Marshfield Clinic in Wisconsin, the Scott and White clinic in Texas and the Billings Clinic in Montana. These systems have to adapt to local conditions, but they can and do exist in all parts of the country. And I think we have a huge education job ahead of us in educating the country to the value of these systems. Please say to all the doctors in CAPG, when you talk to or write to your friends in the East, tell them what you are doing and make them feel they wish that had that too! Q: You are singing our song. Truly, thanks so much for your time today. n

HMO vs. PPO Clinical Performance

THE uCLA Experience and Commentary Part 2 of a 3 Part Series

By Sam Skootsky, M.D., Medical Director, uCLA

Editorial comment: UCLA's experience in a markedly different practice environment corroborates the differences between coordinated, systematically measured, accountable care and the less integrated care typically experienced by people with PPO coverage. While the magnitudes of difference were similar to those reported by Dr. Glaseroff in this edition of CAPG Health, Dr. Skootsky offers some reservations regarding validation. Dr. Skootsky's editorial comments come from one of California's leading quality crusaders and achievers. W. Edward Deming liked to point out that it is not enough to do your best. You must know what to do, then do your best. In 2001, the Institute of Medicine formulated 10 rules for the redesign and improvement in care in the now legendary "Crossing the Quality Chasm." About the same time, Edward H. Wagner's Chronic Care Model emerged from the Seattle mist. Together, these two documents define the characteristics of high-quality and efficient care.

The best practice of primary care occupies a central focus in both. 1. A continuous, committed and accessible source of care 2. Attention and respect for patient preferences and choices 3. Individualized support for patient self-management, including use of resources in the broader community 4. Information technology and registries to support evidence-based decisions, timely care, completion of preventive and chronic care tasks and recognition of dangerous patterns 5. Team-based care, planned visits, with concern for both the individual and the health of the larger population 6. Coordination of care between all involved professionals This is not easy for a single provider or small office to do, but is done every day in the well-organized medical groups and IPAs for their HMO populations. There aren't many opportunities to accurately compare the performance of an organized system of care with a

relatively "nonsystem" care from the same providers. But the accompanying article by Dr. Glaseroff is one such opportunity. He describes services received by a rural and relatively isolated patient population from a single set of providers in an IPA setting in Humboldt County. One group of patients had HMO insurance or a locally self-insured PPO both coordinated by the IPA in a system of care along the same lines of best practice. A third group had typical PPO care from the same providers without formal, local care coordination. His findings simply put are that, in every measure except one, the patients in the system-based care received more of the evidence-based indicated care. UCLA has a delegated model medical group embedded within a large multispecialty group practice in an urban environment in West Los Angeles. We have a primary care-based system of care along the lines of best practice for our HMO members, and the same primary care providers also care for nonsystem PPO patients. For both HMO and PPO patients, the medical care tends to be at UCLA, although the PPO patients can go elsewhere as they please. We have our own in-house clinical laboratories generally used for all patients. We did a small exploratory study of two diabetes measures looking at the differences between system-based HMO and nonsystem PPO care in 2007. We used a modified HEDIS measure limited to ambulatory visits and looked at only the care we provided from all our providers (not limited to primary care). Also, we did not get data from the health plan for the PPO patients. In short, we also found that our nonsystem

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CaPg HEaLTH spring 2009 | 23

HMO vs. PPO Clinical Performance

By Wells Shoemaker, M.D., Medical Director, CAPG

Coordinated Care Surpasses Entropy Care; It Takes a System Part 3 of a 3 Part Series

The national health care reform debate has reached a fever pitch, but national policy leaders seem reluctant to take California's temperature. It is true that California is the only state where prepaid, comprehensive care has survived as a dominant model, using medical groups delegated by health plans to deliver locally coordinated, regularly measured, accountable, publicly reported care. California's HMO care model serves 16 million people -- more than the total population of all the New England states in sum, with vastly greater diversity, too. Our experience is not

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trivial, and we want to contribute what we have learned. East of the Sierras, however, there appears to be an axiom that "capitation is bad." Accordingly, most of the reform models are toying with tweaks on the fee-for-service mantra that has so miserably damaged health care affordability and perpetuated embarrassing disparities in clinical care. One of CAPG's frustrations over the years has been the dearth of data to credibly compare the performance of our delegated groups in HMO care to PPO care. This data vacuum has allowed detractors to quip that

we cannot prove the superiority we intuitively claim. At long last, that is changing, but the superiority of prepaid, comprehensive HMO care over loosely overseen PPO may not be the most important message to policymakers. It's the systems of care that HMO built that we desperately need to preserve. Elsewhere in this issue of CAPG Health, Alan Glaseroff, M.D., Medical Director of the Humboldt Del Norte IPA, used a uniquely complete data set from an insular community in Northern California to demonstrate

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PPO patients received less evidence-based care than the system-based HMO care. The trend was similar to what has been described in Humboldt County, although some details differ. Some caution is warranted in interpreting these results. 1. One potential flaw in both studies is that we don't know to what extent the differences might be related to better reporting for the system-based care and/or incomplete data from the PPO health plan for their respective populations. Self-reporting medical groups/IPAs in California have learned to collect data for HMO patients who receive care out-of-network in order to fulfill requirements for self-reporting

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for the annual P4P submissions. For PPO patients, any lack of data relative to the HMO group (e.g., services obtained under another insurance plan or provider, or poor health plan data integrity) would make the nonsystem PPO care appear worse. 2. The availability of the paid claims from the PPO, a unique feature for the Humboldt RWJ grant and not generally available widely, does improve confidence that non-network care in that PPO population was captured. And in Humboldt County, because of geographic isolation, there are apparently few feasible out-ofnetwork alternatives. 3. At UCLA we did not have access to health

plan data at all, and we used only lab data results actually done at UCLA. 4. For both studies, a chart review validation of a sample of patients would have helped ensure that the differences are real. CONCLUSION Both Humboldt IPA and UCLA have systems of care that are generally aligned with best practice as we know it for their HMO patients. The data from both suggests that systems of care are superior in ensuring that patient receives appropriate evidence-based care. Strategies to fund the spread the best practice of primary care to all patient populations are needed. n

that HMO model care resoundingly surpassed the chronic and preventive care performance of typical PPO care delivered by the same providers. The margins were staggering: 10%, 15%, even 20% deltas. While this result does not surprise most insiders, Dr. Glaseroff's article added an important twist. Patients using a self-insured PPO reimbursement structure, but relying upon the full-bore care coordination of the local medical group instead of remote health plan contacts, equaled the HMO clinical care metrics. The message: It is the application of an effective system of local support -- respectful engagement with community providers, accurate information and continuous feedback, good listening and administrative agility, ethical decision making plus population thinking, not the reimbursement mechanism per se -- that makes a difference for our patients. Is the Humboldt result generalizable, or is it attributable to one-of-a-kind leadership, or is it merely a statistical fluke? Certainly, HDNIPA has the luxury of engaging nearly every health care provider in the delivery system, and Dr. Glaseroff's leadership, indeed, surpasses "visionary." The series of prestigious foundation grants (CHCF and RWJ) in this ideal community study crucible has brought exceptional financial and intellectual resources to a small county, so the Heisenberg Principle could be active. Is this result reproducible? F rom t he m i st y redwoo d s of Eureka to the swaying jacarandas of Westwood, the answer seems to be yes. Sam Skootsky, M.D., professor of medicine and Medical Director of the UCLA Medical Group, probed

UCLA's 2008 data and found the same pattern, albeit with slightly less eyepopping margins. Sam and A lan are exceptional Medical Directors and their groups are perennial high performers. How about elsewhere? Thanks to the California Cooperative Healthcare Reporting Initiative (CCHRI), we now have additional corroboration, this time using statewide aggregate scores. In December 2008, for the first time, CCHRI reported HMO versus PPO comparisons side by side, along with NCQA national averages and 90th percentiles. The report is 103 pages long, with sophisticated displays, drill-down exhibits and robust documentation. The full report is readily available as a downloadable PDF through the PBGH website. The first 19 pages are a goldmine. Visit www.cchri. org/reports/PowerPoint _ PDFs/ CCHRI2008_QR.pdf. kEY TakEaWaYS FROM THE CCHRI REPORT: 1) Using plan-based data*, HMO surpassed PPO in nearly every clinical measure in commercial care where comparisons were available, but fell slightly short in patient satisfaction. 2) Clinical diabetes care and cardiovascular care measures showed striking superiority HMO over PPO in every single category, often by 10% to 20% deltas in absolute performance. a. All-plan HMO** equaled or surpassed national averages, but i n no case su r passed nat ional 90th percentile. 3) The preventive care measures showed the same consistent superiority, with smaller yet highly

significant margins (5-10%). a. All-plan HMO hovered around national averages, but in no case surpassed national 90th percentile. 4) Medicare: CA plans with Medicare Advantage contracts consistently, and often strikingly, surpassed national averages in clinical, preventive and chronic care. a. Diabetes and cardiovascular care. Across-the-board, California superiority over national mean, with 9-12% differentials in six out of 12 measures. Interestingly, not one single plan fell significantly below national mean in even one out of 12 categories. 5) Kaiser-Per manente perfor med ahead of other California health plans in nearly every measure, and in multiple categories exceeded the NCQA 90th percentile. *Reporting is done by statewide plan HEDIS averages, subject to the limitations of blending all California's diverse regions into a single figure derived from a relatively small denominator. In the IHA's annual P4P scoring exercise, medical groups' internal data registries have larger denominators, more carefully vetted accuracy and report generally higher performance. **Cross-plan averages make the most sense as an overall barometer, as the medical groups and individual doctors in the frontline delivery system do not generally differentiate patients based upon insurance company. Since the insurance companies have only minimal direct clinical interaction with patients, CAPG's conventional wisdom is that the non-Kaiser plan to plan differences are largely factitious, reflecting avidity of data capture more than bona fide differences in care. n

CaPg HEaLTH spring 2009 | 25

Developing Services for the Medi-Medi Patient

By Edward Kim, President of Molina Medical

For over 28 years, Molina Healthcare has been ensuring access to medical services for low-income and ethnically diverse families and individuals through government-sponsored programs like MediCal. When Molina Healthcare developed its Medicare programs, it targeted this same population. These seniors were the grandparents of the Medicaid children whom we've cared for since Molina Healthcare opened its first clinic in 1980. These individuals faced the same challenges when it came to accessing healthcare services, and frequently they even lived in the same neighborhoods as our MediCal members. They were the low-income seniors who qualified for both Medicaid and Medicare -- the Medi-Medi population. Unlike some managed care companies, our Medicare programs target seniors with incomes up to 200% of poverty. This special patient population requires us to deliver medical care differently. We are doing just that. TRaNSFORMINg MOLINa MEDICaL gROUP OFFICES FOR THE MEDICaRE POPULaTION In order to better accommodate our growing Medicare population, we began to think about how we could make our offices more accessible. As a result, this year we are transforming our larger minor treatment rooms in six of our offices to provide better accessibility for our patients. They are equipped with exam tables that adjust to 17" off the floor. This will make it easier for patients to transfer from their wheelchair to the exam table. For patients who are not strong enough to self-transfer from their wheelchair to the exam table, we are installing a Hoyer lift to aid in transferring patients. We are also adding a 1,000-pound-capacity scale so that patients

26 | CaPg HEaLTH spring 2009

in wheelchairs can roll onto the scale to be weighed. Counters in all new offices will be wheelchair accessible as well. All these adaptations complement the entrance ramps to our doorways, restrooms and parking that are already modified for our patients with special needs. In addition, we provide transportation of all members unable to get to the offices or who do not have their own transportation. CULTURaL aND LINgUISTIC CONSIDERaTIONS In addition to physical changes in the MMGs, Molina Healthcare has a history of providing culturally and linguistically competent care for patients. We know that culture and language are crucial factors in the delivery and reception of healthcare services. The patients who receive

care through the MMGs are ethnically and culturally diverse. The top language preferences are English, Spanish, Russian, Hmong, Vietnamese and Armenian. To address the cultural, ethnic and linguistic needs of patients, many medical groups have developed programs to assist their patients. Molina Healthcare is no exception. The staff is bilingual, as is the appointment scheduling center, and health education materials have been translated into several languages. We have also centrally located our medical offices in the communities that we serve. Molina Healthcare has the added advantage of being associated with a health plan that offers many diverse programs. Molina Healthcare patients have access to Molina Healthcare's 24-hour Nurse Advice Line, which provides nurse advice in over 20 languages. Since 2004, Molina Healthcare has offered TeleSalud to its members, allowing them to speak directly with a registered nurse and receive a medical opinion about a physical or emotional problem. Patients have timely access to nurses who are able to direct each caller to the most appropriate level of care. In addition, Molina Healthcare trains its staff through the Molina Institute for Cultural Competency, which was established in 2005, to increase cultural knowledge and sensitivity. The institute conducts internal and external cultural trainings, provides accredited continuing medial education courses based on cultural education, distributes cultural resource manuals to key Molina Healthcare departments and distributes monthly cultural notes informing staff of traditions and health practices of various cultural and ethnic groups. As our patient population changes, so will we. Our patients require us to deliver medical care differently. We'll continue to evolve to meet those needs. n

Continued from Page 19

self-reports P4P data to the Integrated Healthcare Association's P4P program, is a local trusted entity that has been built via long-term relationships. Within the delegated model, clinicians work with their group to ensure the accuracy of data, and have opportunities to supply missing information for P4P reporting. The IPA sends out quarterly patient-specific reports on missing services for HMO and self-funded PPO patients to practices that have become customized to either provide missing data or contact the patients regarding the missing services directly. IPA staff meets with office managers monthly in each of the three Humboldt Bay cities (Arcata, Eureka and Fortuna). The IPA listens to the needs and issues of its member practices, and responds to such feedback in a timely manner, and with collegiality. Members are proud of their history of quality improvement. Within the statewide medical group community, HDNIPA is not "exceptional" in any way other than by being rural and not having many HMO-covered lives; otherwise their approach is fairly representative of what delegated groups do around the state. What does "a 15% improvement" actually mean in human terms? In statistical terms, the percentages for given chronic care and preventive services serve as measures for real events in patients' lives. In human terms, stories may be a better way to look at this comparison: "A vigorous 80-year-old woman regularly schedules an annual periodic exam with her PCP, at which her health status is reviewed, and preventive screenings ordered. However, she suffered a small stroke in 2007 that led to the cancellation of that appointment, although she was seen within the practice two times following her stroke. Her recovery has been gratifying to the patient and her husband, who have resumed their daily walks on the beach. Those visits focused on the problem at hand, namely her stroke, her recovery and her psychological reaction to the event, which threatened to change her life to a great extent. She was extremely pleased with the sensitive, caring approach taken by her care team, and especially pleased with her eventual near-full recovery of

function. However, she didn't realize at the time that her health was under threat from another direction entirely. She has Medicare for her insurance, and a commercial PPO `gap' insurance as well. Neither provides routine population management. As a result of her local IPA's efforts to introduce population management into common practice, her lack of a mammogram in 2006-7 was brought to the attention of her PCP, who had been entirely focused on her stroke. The missed mammogram was scheduled, and a locally invasive ductal carcinoma was found at an early stage and a lumpectomy performed. She underwent subsequent radiation therapy, and her chances for cure are > 95%. With a very low likelihood of a second stroke (now on Warfarin), and no other major health risks, she is looking forward to what she expects to be a full decade of walking on the beach, watching her grandchildren become young adults, and enjoying the continuing company of her husband of 56 years." While it is not inherently impossible for small independent practices to develop internal systems to track population health, in fact few do so (including those with EHR systems). The small practice mentioned in the patient vignette above does utilize a paper "tickler file" that reminds patients to schedule their periodic visits and other forms of follow up. However, that system broke down when the patient cancelled her appointment as a result of the stroke (the reminder had already been sent and the appointment scheduled, but no system existed to review all woman patients > 40 years for mammograms). This is fairly typical in the independent practice environment. The IPA's efforts includes a Primary Care Renewal collaborative based on five principles (and is combined with the IHI Model for Improvement): 1. Team-based care 2. Patient-centered care 3. Population-based care 4. Barrier-free access 5. Integration of behavioral health into primary care The population reporting by the IPA, developed in response to a commitment to caring for the population of Humboldt

County and supported by capitation and P4P, functions as a "safety net" for missed preventive services at the practice level. In the more fully integrated multispecialty group-delegated model, this function is likely delegated to the QI staff, and not left to the individual clinician to remember who needs what. Within Kaiser-Permanente, which operating entirely within the HMO environment, the medical group removes this function from the clinician and makes it a system function (care managers responsible for population health). The office visit serves as the "safety net" for care not completed by the care managers, the reverse of what happens in the independent practice environment. Both models view population health as a system function that is integrated into the care for the individual patient. Population health makes economic sense within a capitated model. PPO feefor-service reimbursement actually provides a disincentive for spending money on such a system, which only increases overhead and reduces the bottom line. Practices operating outside of the delegated model (and outside of safety net clinic networks, which also view population health as a system function due to a heightened sense of mission and support by the federal and state governments) generally are still practicing within the acute care model, being paid fee for service and defining their work as "completing today's schedule." There are of course exceptions to this generalization, but in Humboldt County, the difference between the two models of care and reimbursement is measurable (approximately 15%). The Delegated Model saves lives. As the HMO product declines in California, the health of the population is threatened due to a lack of organizational support for individual practices within the PPO environment. Extending the benefits of the Delegated Model to all patients is critical to insuring the health of our citizens. This can be accomplished by increasing the number of patients with HMO insurance, and by PPO "value-based" contracting with delegated groups for population health. n

CaPg HEaLTH spring 2009 | 27

Technology at the Point of Care

EHR Solution Improves Hill Physicians' Disease Management and Health Maintenance Efforts

By Dr. Careen Whitley

Disease management and health maintenance are about diagnosing and treating small health problems before they become serious ... and expensive. Even with the best paper-based health records, however, details that could have a profound impact on medical care are likely to be missed. To make sure our patients don't fall through the cracks, Hill Physicians Medical Group implemented electronic health record (EHR) technology from NextGen Healthcare Information Systems that includes extensive disease management and health maintenance modules. EHR PROMPTS COMPLIaNCE WITH CaRE MaNagEMENT EFFORTS When caregivers first access a patient record, a customized template containing both health maintenance and disease management "monitors" indicates what actions may be necessary during that visit. Protocols built into the template allow our medical assistants to order the appropriate tests, such as a blood draw or X-ray, even before the patient is evaluated by the physician. Offloading these administrative tasks enables doctors to spend more quality time with their patients. For patients who require ongoing disease management, caregivers are prompted with regular questions to ask and tests to order. The template will automatically pull relevant information such as recent results from other sources within the health record. And the advantage our EHR offers is the ability to see all this information on one screen rather than having to look in several different places within a paper chart. These templates and protocols are not static. We are able to update and modify screens and prompts in response to changing payer policies and quality measures. Historically, for instance, payers have provided reimbursement for Pap smears on an annual basis. More recently they have come to realize that performing these screening exams every two or three years is just as beneficial. We have been able to adjust our system to remain in synch with payer guidelines.

28 | CaPg HEaLTH spring 2009

REaPINg THE BENEFITS OF EHR Our practice reaps care management benefits even prior to the patient's visit. When a patient calls to make an appointment for the evaluation of a fever, for example, the receptionist sees a summary of critical information on the computer monitor, including recommended health maintenance tests or treatments. Rather than waiting for her physician to bring it up during the exam, office staff can inform Mrs. Smith that she is overdue for her mammogram and immediately initiate steps to schedule the test. We are now also able to improve patient care and satisfaction beyond routine health maintenance and disease management reminders. We visually engage patients by graphing data related to their health issues. For instance, we can show a diabetic the results of his lab tests over time, with a baseline indicating his optimal range. This is an infinitely more helpful tool for including patients in their care than simply reciting data to them. Plus, it provides patients with a greater sense that we are genuinely concerned about their health and well-being. Though still early in our adoption process, we have realized financial gains -- including a decrease in overhead through reduced staffing and supply expenses, as well as improved dictation practices -- which more than justify the hard work and upfront investment an EHR requires. CURRENT VaLUE SETS STagE FOR FUTURE BENEFITS We are confident that the system will produce long-term dividends, like increased reimbursement resulting from health information technology (HIT) adoption. Federal programs currently are promoting timely deployment of HIT in practices large and small. Likewise, pay-for-performance initiatives are employing a "carrot and stick" approach to HIT implementation to support reporting on quality measures. Currently, they are holding out a carrot in the form of bonuses to practices that collect, extract, aggregate and report on specific performance standards. In 2009, for example, Medicare reimbursement will increase up to 5% -- 2% for e-prescribing, 2% for PQRI and 1%

in the form of a general increase -- to all providers who comply with program requirements. Soon, however, this carrot will become a stick, as payers simply penalize practices for failing to submit required reports and analysis. We also stand to benefit financially with the Medicare Care Management Performance (MCMP) Demonstration Project in California, which creates incentives for reporting clinical quality measures and utilizing an EHR. The annual incentive for reporting clinical quality measures is up to $10,000 per physician per year ($50,000 maximum per practice) for three years. And we receive a 25% bonus for use of a CCHIT-certified EHR and electronic submission of data to CMS. In the future, we aim to maximize the value of the medical data we collect, and use it for population health trending and studies. This is one area in which we physicians need additional functionality, and we are excited about the possibilities that this information will provide at the point of care. Careen Whitley, M.D., is a board-certified family physician who has been in private practice for more than 20 years. She works with Hill Physician Medical Group as a clinical liaison to promote the adoption and ongoing improvement of its EMR strategy. n

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