Ohio Collaborative Reduces Hospitalizations, Costs

A primary care collaborative in the Cleveland area uses best practices to avert nearly 6,000 hospitalizations over five years, with cost savings estimated at about $40 million.

The Better Health Partnership, a primary care-led regional health improvement collaborative operating in the Cleveland area since 2007, identifies and shares best practices for patients with chronic conditions such as hypertension, heart failure and diabetes.

A study in Health Affairs estimated that the collaborative saw 5,746 fewer hospitalizations for ambulatory care-sensitive conditions from 2009-14, and generated savings of nearly $40 million.

Study co-author Randall Cebul, MD, an internist affiliated with MetroHealth Medical Center, and a member of the collaborative, spoke with HealthLeaders Media about the findings. The following is a lightly edited transcript.

HLM: Why does primary care lead the collaborative?

Cebul: When the opportunity came about through for a national foundation grant, it was primary care physicians who signed up. That’s how it's grown from reporting 34 clinics and 26,000 diabetics in 2008 to now we are reporting those conditions plus some pediatric conditions plus colorectal cancer screening, which we don't report on here, on more than 400,000 patients, in more than 100 practices, and more than 1,000 docs.

Part of the secret sauce has to do with physicians taking ownership of the care of their patients and if that requires engagement of services that are outside the community health center that's what we recommend. We are using the data to document the best practices. The positive deviance approach we use identifies who does best, and if we can determine that there is something replicable, that is presented at twice-yearly annual meetings and we provide either consultation or coaching to practices.

HLM: How did the collaborative save $40 million?

Cebul: It's all reductions in hospitalization costs for cardiovascular conditions; diabetes and diabetes complications, high-blood pressure and heart failure. Heart failure is not the most prevalent but it clearly saw the most cost-savings for hospitalizations. About $20 million was the heart failure part of the $40 million and the other savings were related to diabetes. Hypertension, even though it is very common, doesn’t require hospitalizations that often.

HLM: Why did you target these chronic conditions?

Cebul: We chose these prevention quality indicators from the ambulatory care-sensitive conditions compiled by the Agency for Healthcare Research and Quality. There are a lot of conditions that, given proper outpatient care, should avoid hospitalizations.

Our collaborative was founded in 2007 and immediately chose to use diabetes as one of our conditions and use clinical measures that are familiar to all doctors for the care and the outcomes of patients with diabetes. That was vetted by the clinical advisory committee, which established the measures we should use. Heart failure hypertension followed on the tail of that.  

HLM: Is there potential for more savings if you target other chronic conditions?  

Cebul: Of course! You'll see that you’ve got chronic obstructive lung disease, and cancer and other chronic diseases that are costly in and of themselves.

This is also cost and not charges. We were able to identify the charges for hospitalizations and then reduce the costs multiplying the ratio of costs to charges.

In any case, what we have done since 2007 is provider led. It is not led by insurance companies or non-physicians who are looking for cost reductions. This is an organization that seeks to create a safe space for competitors to collaborate.

HLM: Who are these competitors?

Cebul: They are mostly doctors in big healthcare systems like Cleveland Clinic, MetroHealth, and the VA. The doctors wanted to improve the care of their patients even though they were competitors.

Those who take care of the least among us in the safety nets and community health centers, the public hospital system, were interested in participating, especially if we were able to capture social determinants of health such as race, income, language preference, and insurance type.

We are able to stratify our results and make it an even playing field for everybody, whether they are caring for the most affluent in our region or more similar to those in the community health centers.

HLM: Who gets the $40 million you saved?

Cebul: We didn’t specifically look at that in this study, but in the past I would say that it's likely to be public payment patients. Medicare would be most of the heart failure patients. Those wouldn’t be people who are exceptionally poor, except to the extent that they have Medicaid or Medicare.

HLM: Did the collaborative get any of the savings?

Cebul: That is a very good question. Maybe we will go cap-in-hand and ask for some of that savings.

It's actually a loss to the hospitals. They’re not filling beds with otherwise mostly insured. We are reporting on more than 400,000 patients and less than 6% of them are uninsured.

HLM: Does that make the collaborative a tough sell for hospitals?

Cebul: Hospitals need to be committed to lower costs, population health, the Triple Aim of better care, better outcomes and lower costs. It's just one more of those stressors that the healthcare community is facing. No hospitals that we asked to join us were unable to get the commitment from their visionary leaders.

HLM: What support mechanisms do these collaboratives require?

Cebul: These hospitals and the clinics that are mostly owned by these large medical centers really need to be using electronic health records and be willing to share their data. That creates variable problems.

We obtained data from eight different electronic health records systems. That’s a challenge on our end but it means that they need to commit to provide the data that we request, at the consensus of the primary care providers, in a timely and accurate way twice a year.

HLM: Why was that problematic?

Cebul: Before mid-2010 a number of our smaller organizations were using paper records and did not have mastery of their EHR. When the High Tech Act was passed and we were able to demonstrate the benefits of EHR they all lined up. We only use electronic health records now.

HLM: Is seed money available to begin a collaborative?

Cebul: We're a lean operation. We got some funding from the Robert Wood Johnson Foundation back in 2007 as part of their aligning forces for quality initiative. That initiative sunsetted in 2015, but along the way we have gotten funds from regional community foundations and they’re probably about one-third of our operations. We have membership dues that people pay and we also have both federal and state grants, from the CDC, state Medicaid, and those sort of things. 

HLM: Can your success be replicated elsewhere? What needs to be in place?

Cebul: You have to have people who care. We believe that all healthcare is local. So, being committed to a community is key. There has to be cooperation and leadership within the physician community and a willingness to share data and we’ve done that.