Another year, another glowing report
CMS trumpets PGP demonstration successes
The 10 groups participating in CMS’ Physician Group Practice (PGP) demonstration project received a total of $16.7 million for improving quality and efficiency of care during the project’s second performance year, according to CMS. Four groups—Dartmouth-Hitchcock Clinic in Bedford, NH, The Everett (WA) Clinic, Marshfield (WI) Clinic, and the University of Michigan Faculty Group Practice in Ann Arbor—earned a combined total of $13.8 million in performance payments. However, even with that windfall, groups involved in the project say the bonuses do not offset the costs associated with the program.
PGP, the first pay-for-performance initiative for physicians under Medicare, creates incentives for groups to coordinate care delivered to Medicare patients and rewards them for improving quality and cost efficiency.
The 10 physician groups represent 5,000 physicians and 224,000 Medicare fee-for-service beneficiaries.
(For a complete list of participating groups, see “Physician Group Practice participants” on the PDF.)
All of the groups improved quality of care for chronically ill patients by achieving benchmark or target performance on at least 25 out of 27 quality markers for patients with diabetes, CAD, and CHF. Five of the groups reached benchmark quality performance on all the quality measures, according to CMS. (For a list of the 32 measures in the project, including measures that are being implemented in year three, see “Quality measures for the Physician Group Practice demonstration project” on the PDF.)
Additionally, all 10 groups increased their scores on at least 19 of the 27 measures in year two. The groups placed their incentive payments at risk for performance on all the 27 quality measures under CMS’ pay-for-reporting Physician Quality Reporting Initiative (PQRI). Five groups earned 100% of their PQRI payments, and the others received at least 96%.
CMS is so pleased with PGP’s results, it has extended the project to a fourth year.
“We are paying for better outcomes, and we are getting higher quality and more value for the Medicare dollar,” Kerry Weems, acting administrator of CMS, said in a prepared statement.
“And these rules show that by working in collaboration with the physician groups on new and innovative ways to reimburse for high-quality care, we are on the right track to find a better way to pay physicians,” Weems says.
For the second consecutive year, Marshfield (WI) Clinic met quality measurements and saved CMS money. Because of its successes in year two, Marshfield Clinic will gain $5.78 million. (CMS will withhold 25% of that amount until the end of the project.)
Theodore A. Praxel, MD, medical director of quality improvement and care management at Marshfield Clinic, says Marshfield’s programs are based on getting the right care at the right time at the right place. “The clinic as a whole is quite proud of the results of meeting all the quality metrics and the performance payment. I think it speaks well for the physicians and staff efforts to further improve the quality of care we give our patients,” Praxel says.
As part of the project, Marshfield Clinic expanded its anticoagulation care management program across the entire 43-site system, developed a heart failure care management program, enhanced its electronic health record (EHR) to expand care management and coordination, promoted its 24/7 nurse advice line, and developed clinical practice guidelines and monitored population-based clinical performance through clinic storyboards.
“The goal is to support the providers’ practice and make it easier for the patient and the provider to accomplish the care needs the patient has,” Praxel says.
During year two, Marshfield Clinic also rolled out electronic provider reminders (called iList, for intervention list) that flag patients who need monitoring. For example, if the system did not contain records of a recent foot exam or A1C test, the system would notify the provider of the gap in care.
“This allows the practices to reach out and proactively contact those patients,” Praxel says, adding that the program promotes a better use of physician and patient time.
Marshfield Clinic has had an EHR for more than 20 years, and the network is now completely paperless. Praxel says physicians bring a tablet computer to patient visits and can make notes, review lab results, and see x-ray images and interpretation on the tablet computer.
The nurses have the same access to records as the physicians, which allows them to view the patients’ medications and review their full care. This provides the nurse with a view of the whole patient and not just a particular disease, Praxel says.
The EHR is one reason for the project’s success. Marshfield Clinic has improved efficiency by reducing the number of retests. Going paperless helps providers avoid communication breakdowns.
For example, the technology is also used in the anticoagulation program, Praxel notes. “For those care management programs in which nurses interact with the patients, those notes are almost real-time transcribed and updated to the record, so when the patient comes in, the provider has the record. In addition, there is an e-mail notification to the provider so they can look at the entry to see if there was any change, which promotes a continuous healing relationship,” he adds.
Praxel says one issue is that many of Marshfield’s care models, such as the anticoagulation and heart fail-ure management programs and 24/7 nurse line, are not reimbursed by CMS, despite their importance for care coordination between office visits.
Praxel suggests changes to the reimbursement system to pay for these kinds of services.
Although Marshfield will receive $5.78 million for performance year two, Praxel says the bonus does not cover the program’s costs. He says it’s difficult to determine the project’s full costs because the network has spread the program through its entire patient population.
Praxel echoes those who spoke glowingly of the demo’s learning opportunities through partnerships with the other PGP projects.
The groups met for a monthly phone meeting to discuss effective care processes and review standards and approaches. The clinic learned from other PGP groups about risk stratification of patients and using care management approaches to take care of patients with complicated diseases.
“There has been a sharing between the groups of the different formats that people might use, different data displays, different ways to help educate the providers and the patients, and that has all been very educational,” Praxel says.
Praxel and others involved in the project say CMS does not provide information in a timely manner. For example, CMS did not release data from the demo’s second year until midway through performance year four. “We really can’t do anything about performance year three. That’s done already,” he says.
Praxel adds that without actionable rapid information, the network can’t intervene. “I think that’s one of the things I have learned for our own providers as well. The sooner we can give them actionable information, the more useful it is to them,” he says.
St. John’s Health System
St. John’s Health System, a Springfield, MO, faith-based integrated health system that includes six hospitals, a health plan, and 70 locations in southwest Missouri and northern Arkansas, scored 100% on the quality measures during year two. St. John’s used a patient registry that is designed to track information, identify gaps in care, and ensure that appropriate and timely care is provided to the 31,000 Medicare beneficiaries in its 62,000-patient system.
The registry includes a visit planner that allows physicians to track a to-do list for each patient visit, such as reminders about tests and interventions. The planner includes one-page summaries for each patient with demographic and clinical information.
Although the registry is not an EHR per se, James T. Rogers, MD, St. John’s primary care department chair, says the homegrown product has some of the same characteristics as an EHR.
Rogers says the healthcare system created its own database because it was unable to find an EHR it could use for the demonstration project.
Rogers says St. John’s avoided the temptation to develop a complex database and instead created a program that physicians, providers, and office staff members could integrate into their work flow. St. John’s information technology staff built a system that feeds laboratory, scheduling, and billing data into one database.
The database was limited to the 32 quality measures in the PGP and allows report generation so the system can review data long-term. “As opposed to a lot of price tags, we built this for a lot less than finding something out there and trying to retrofit it,” Rogers says.
The system also implemented a case manager in the emergency department to collaborate with the system and community services to provide transition planning; a heart failure team that coordinates heart failure care, provider education, and improve outcomes; and groups that focus on diabetic retinal eye exams and mammography and colorectal cancer screenings.
Rogers says St. John’s almost backed out of the PGP project. When the project was first announced, CMS initially issued fewer quality measures and did not put limits on savings, he says.
“The reason we decided to continue is that it forces us to do better in quality,” Rogers says, adding that the system realized there might be a chance it would not gain any bonuses at all. “We’re putting in about a half-million a year on our budget to try to make this thing successful, and we haven’t recouped any of that investment yet,” Rogers says.
The Everett Clinic
The Everett (WA) Clinic scored 96% on quality for management of diabetes, CAD, and CHF in the PGP project’s year two and will receive $250,000, after reportedly saving CMS nearly $1.6 million.
Through the project, The Everett Clinic offers electronic patient reports to PCPs to use with diabetes, heart disease, and hypertension patients, as well as mammogram, Pap smear, and colonoscopy screening, provides on-site coaching for hospitalized patients and caregivers to help them through the healthcare system during and after hospitalization, implements a program in which physicians see patients within 10 days after unplanned hospital admissions, and partners with local providers to deploy palliative care programs in PCPs’ offices to improve end-of-life care.
James Lee, MD, assistant medical director at Everett, says the clinic moved from paper to full EHR during the second performance year of the PGP project. Lee says Everett Clinic did not use outside vendors, but instead created its electronic programs and performed DM functions within the network.
Lee says having an outside vendor can add a layer of complexity and might delay care. He says the most important thing he has learned about the demonstration is that to deliver high-quality, efficient care, a system needs to use a common platform through an EHR.
“A systematic approach to disease management and preventive services is crucial. In addition, a coordinated care model, irrespective of the care setting, prevents unnecessary hospitalizations,” Lee says.
The EHR is the glue of the project’s integrated process, he adds.
Everett Clinic created a real-time electronic database that includes hospital admissions and discharges so that care coordination could take place. Nurses and office staff members can use this information to arrange discharge follow-up. While the patient is in the examining room, DM prompts and reports from the EHR remind physicians and staff members about any overdue preventive screening services or necessary laboratory tests. This allows staff members to order these items and frees up physician time.
“The whole care model revolves around electronic health records gluing different clinical pieces together to enhance face-to-face experience during an office visit,” Lee says.
The clinic also added a hospital coach—a nurse with 30 years of experience—who visits Medicare patients at a local hospital. She speaks with them about barriers or challenges that could cause a problem during the transition from the hospital to home.
Lee says the program has been a tremendous help for patients. “On an emotional level, patients really appreciate someone from their doctors’ office visiting them at the hospital. Patients feel connected and are more willing to talk about their challenges and difficulties,” he says.
And there are other added benefits to the hospital coach program. Lee says the nurse can identify whether patients understand why they are hospitalized, their medications, what to do after discharge if problems arise, and whether they have scheduled a doctor’s appointment after discharge.
“Those are the four key educational components we can introduce into these visits that are elements of good care transition, and I believe a robust discharge process prevents unnecessary visits back to the hospital and the emergency room [after discharge],” Lee says, adding that a key to the project’s success is having an open and constant dialogue among all stakeholders in the local care delivery system.
This is important not only in the PGP project; DM could learn from the success. Any dialogue to improve chronic care should center on patients and explore both medical and social challenges.
“The community partnership is so important. Physician offices should use all available community resources to improve patient care,” Lee says, adding that Everett Clinic lost $7.6 million caring for its 25,000 Medicare patients in 2007.
The $250,000 that Everett Clinic will receive via the second year’s success is not enough to make up for this loss of revenue, Lee says.
Billings Clinic and Park Nicollet Health Services
Pharos Innovations, LLC, a Northfield, IL–based technology company that offers chronic care management programs, assists Billings (MT) Clinic and Park Nicollet Health Services in St. Louis Park, MN, in the heart failure portion of the demonstration. In year two, Pharos worked with 500–600 patients for each network.
Pharos’ telephonic Tel-Assurance program captures daily patient information, identifies which patients need interaction, and feeds the data back to physicians and care managers.
This allows them to catch potential health problems before they spiral out of control.
Randall Williams, MD, CEO of Pharos, says the biggest challenge was getting the patients engaged. In year two, Williams says Pharos staffed enrollment and retention efforts. He says keys to engaging the HF population are getting physician buy-in and connecting with patients while they are in the hospital.
“Part of the magic is that by helping co-opt the physician in endorsing the program to the patient, we have a running start in getting the patient in the program,” Williams says. “Secondly, we capture some of these patients during hospitalization, so they are a little more motivated in not making that happen again.”
Williams adds that Pharos has worked with behaviorists and social workers to effectively reach people. The outreach team tells the patient they are calling from the provider organization rather than a DM com-pany or health plan, which helps the patients feel a closer connection.
Pharos has also used local mail distribution and phone number banks help connect with people. Williams says Pharos’ work paid off, as Billings and Park Nicollet promote 85%–90% participation rates.
“Both of our clients experienced consistent and compelling reduction in all-cause hospitalization for the patients who were enrolled in our programs. They were able to reduce admissions by about one patient admission per enrollee per year,” Williams says.
One challenge is that provider organizations are often not equipped to perform chronic care coordination, so Pharos has helped them develop processes for this, he says.
“We learned the power of cooperating or collaborating with provider systems to do care management. We have also learned about the challenges of doing that. From the standpoint of the power of doing it, we have found that the robustness of clinical information goes dramatically beyond what is available by claims data to target the right patients for intervention,” says Williams.
An issue cited by those involved in the PGP project is CMS’ bonuses. Williams says the delay in getting paid by CMS prevents individual networks from expanding their services in the project. He says it can take up to three years from the time the networks incur costs to receive their CMS bonuses.
“It’s a pretty brutal financial arrangement, though on the surface it sounds great,” Williams says of the $16.7 million CMS paid in bonuses for year two.
Pharos is talking to the two networks about expanding its Tel-Assurance program to COPD and diabetes patients, and a third project site, Forsyth Medical Group in Winston-Salem, NC, signed up Pharos to perform heart failure interventions following the end-of-performance year two.
Although there have been recent questions about the effectiveness of DM (most notably in the Medicare Health Support demonstration project), Williams says DM works if it’s delivered in the right way, such as the programs in the PGP.