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Medicine & Chronic Illness

PERSPECTIVE

Toyotas Or Hush Puppies? Physician Organizations And Chronic Care Management

As former head of the national association representing independent practice associations (IPAs), I have witnessed the challenges facing physician organizations. The comments in this Perspective reflect common themes gleaned from my discussions with physician organization leaders.

What Stands In The Way?

 
While most of these leaders believe that care management programs (CMPs) can lower costs "in the long run," they see no immediate financial incentive to invest in chronic care management programs. In fact, they have reasons not to do so. Unless it has at least a shared-risk arrangement for hospital services, the physician organization reaps none of the savings from reduced hospitalizations. Those who do have such a risk arrangement with one health plan will not see the savings from patients who switch plans. It is not a good business model to attract chronically ill patients who do not bring higher rates for their higher cost. Finally, capitation payments represent the minority of revenues for physician organizations; in some regions where capitation had been significant, it is decreasing or disappearing altogether. The alternative payment mechanism, fee-for-service (FFS), reimburses few chronic care management services.

So why does the topic of chronic care management merit discussion time for physician organization leaders? Because they believe that these programs can improve the quality of care. I have spoken with only one physician recently who used the term "cookbook medicine" to describe evidence-based medicine. This is a change from when I first met physician organization leaders in the mid-1990s. The message of evidence-based medicine and care management has "stickiness"—one of the key ingredients in "how little things can make a big difference" that Malcolm Gladwell describes in his bestseller, The Tipping Point.² His model is not one of industrial change, but rather one of an epidemic. He begins with the story of how a certain style of Hush Puppies shoes reemerged as a national phenomenon, as a grassroots movement. At this time, when the health care market cannot produce a business case, perhaps a look at how epidemics spread at a grassroots level can be useful in viewing physician organizations’ adoption of CMPs.

Motivations. The message that chronic care management can improve the quality of care is sticking. Physician organization leaders believe not that CMPs shouldn’t be done, but rather that they are difficult to do. What motivates and facilitates those organizations that initiate CMPs? Here I list three key ingredients: (1) Organizations need good information on their patients, on the best treatments, on how their physicians are doing. Timely, accurate, and accessible information requires good computer systems. (2) They also need leadership that embraces care management and quality improvement. This leadership comes in the form of clinician champions for specific programs and organizational champions who make care management a strategic priority and create a culture in which it is valued. (3) They need market forces that require physician organizations to be accountable for quality. Requirements (for example, the Health Plan Employer Data and Information Set [HEDIS] of the National Committee for Quality Assurance [NCQA] and Medicare’s Quality Improvement System for Managed Care [QISMC]) and initiatives (for example, the Business Roundtable’s Leapfrog and the Robert Wood Johnson Foundations’ Pursuing Perfection) have helped to stick the message that care management programs can improve quality.

How can the message stick with the individual physician organization? Physician organization leaders need information about their own patients and physicians so that they can improve and demonstrate their organization’s quality of care. They need to get information about patients to their doctors, so they can incorporate it easily into their practices. The belief in CMPs is there, but the ability to make them happen is limited.

Gladwell describes a "law of the few" who instigate and perpetuate change. This corresponds with the widespread perception in physician organizations that "champions" are essential drivers of care management programs. Finally, Gladwell’s "power of context" concept provides a way of looking at how market forces provide the context for a physician organization and how a concentration of market demands could "tip" an organization toward care management.

Impediments. Those same market forces demanding accountability on quality do not appear to want to reward it. Physician organizations identify the lack of a business case as the primary obstacle to adopting a CMP. In addition to the factors listed above, a critical limitation of quality reporting to date has been its inability to influence consumer choice. The primary criteria for delivery networks that purchasers still appear to use are the reputation of hospitals and the geographical reach of the network. Health plans are much more interested in patient satisfaction (or the absence of dissatisfaction) with physicians than in the quality of clinical care. Another obstacle is lack of good information, the converse of the above. Physician organization leaders bemoan bad data, redundant and contradictory health plan guidelines, and, most importantly, the unaffordability of good computer systems.

Finally, physician resistance impedes adoption. This includes not only unwillingness to change, but also lack of time as a result of increased productivity or increased paperwork. Physician organizations take pride in the quality of their physicians. Gradually, the definition of good quality is changing from "the best physicians" to measurable indicators of quality, and physician organizations know this. They may have condemned HEDIS as a measure of quality a few years ago, but today they identify it as a driver toward chronic care management. However, without a business case, most physician organizations will continue to react to reporting requirements one by one, resentful of the increased cost burden, rather than investing in the systems (both technology and human) essential for CMPs.

What Will It Take?

Top What Stands In The... What Will It Take? NOTES

 
What will it take for physician organizations to "tip" their care delivery for chronic conditions to a chronic care model? Here are five thoughts. First, attention must be focused on the "few." Champions must be understood, supported, rewarded, nurtured, acknowledged. There is more than one type of champion: the physicians who provide evidence to their colleagues and lead by doing; the nurses and pharmacists who do the teaching and the managing; the collaborators who pull different parts of the system (both within and outside of the organization) together to spread the knowledge and infect with energy and enthusiasm; and the chief executive officer who says that "it’s the right thing to do," allocating or creatively finding the resources. Without support, champions can burn out and CMPs fizzle.

Second, purchasers and health plans can help to create the market context by "paying for performance." Linking financial incentives with clinical improvements makes more of a business case. (Toyota purchasers pay more for a Camry than for a Corolla.) Third, the indicators for demonstrating quality improvement for chronic care in physician organization must be consistent. Chronic care management happens at the delivery system level, not the health plan level. Competing on quality is the domain of the physician organization, not the health plan. A few health plans are collaborating with purchasers and physician organizations to develop standardized measurements of quality improvement. These collaborations should be the rule, not the exception. Physician organizations respond to several contradictory health plan report cards on their quality the same way physicians respond to several contradictory health plan guidelines: putting them into the circular file.

Four, the focus must be on high-priority conditions for the patient population served. One well-designed and -implemented CMP lays the foundation for more. As baby boomers (notoriously well-informed and demanding consumers) age, the number of patients with chronic conditions will mushroom. Five, the information technology that supports CMPs must be investigated, and invested in.

The Institute of Medicine (IOM) has called for the health care industry to cross its quality chasm.³ The message is out there. If we focus our energy and resources on the "little things" that "make big difference," we may find the Tipping Point.

Editor's Notes

 
The author, now an independent consultant, was president of the National IPA Coalition from 1994 to 2000. She is a coinvestigator on the Robert Wood Johnson Foundation’s National Study of Physician Organizations and the Management of Chronic Illness. Health Affairs invited her response to the paper by Molly Joel Coye, which precedes this Perspective.

NOTES

Top What Stands In The... What Will It Take? NOTES

 

1. E.H. Wagner et al., "Effect of Improved Glycemic Control on Health Care Costs and Utilization," Journal of the American Medical Association (10 January 2001): 182–189.
2. M. Gladwell, The Tipping Point: How Little Things Can Make a Big Difference (Boston: Little, Brown and Company, 2000).
3. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001).

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