By Christopher Guadagnino, Ph.D.

Published March 2008

FDB: We are a nonprofit company that creates and implements programs designed to recognize and reward physicians for delivering good quality care, and we have five programs, each designed to have three different levels of performance associated with them, with rewards commensurate with the levels achieved. Our Physician Office Link Program is designed to assess the types of care management and patient education protocols, information systems and care coordination activities that exist within the practice. It is designed to assess the extent to which the practice has developed a sufficient information base that can be pulled on to better understand the different types of patients, and to target follow-up activity such as care management and coordination for patients who are most at risk of complications due to their specific condition. Three other programs are focused on specific disease categories: Diabetes Care Link, Cardiac Care Link, and Spine Care Link; and our most recent is the Medical Home recognition program. A few more programs are in the development process, including hypertension, preventive cardiology, asthma and depression.

FDB: We’ve been working with employers and plans in New Jersey now for a couple of years, and in January we announced the formal launch of Bridges to Excellence in the state. The Diabetes Care Link will be the initial program to be implemented in New Jersey, with the flexibility for plans and employer groups to implement any combination of BTE programs that they think will be effective in their community for their employees. The way we are creating the designation of a physician practice as a medical home is automatic, as a consequence of that practice achieving a certain level of recognition on at least three BTE programs – the Physician Office Link, plus two disease-specific programs. The necessary milestone for the other designation programs to expand to New Jersey is a formal commitment from employers and health plans. We’re working with quite a few of them in an ongoing dialogue to figure out how we can deploy the medical home program, which is natural extension of our other programs. BTE is currently functioning in 18 states, and our medical home program exists in three states so far. It’s only been in the past couple of months that operationalizing the medical home concept and assessing physician practices to become medical homes has really hit the street. I expect that, throughout the course of 2008, we’re going to find a fair amount of momentum across the country to support this type of implementation.

FDB: The primary way to apply is through the National Committee for Quality Assurance’s Diabetes Physician Recognition Program. We’re also working on a pilot basis with a couple of organizations that would pull data directly from registries, or from electronic medical record vendors. We’re looking to make the performance assessment fairly flexible so that physicians and practices that have invested in systems can leverage the use of those systems for performance assessment purposes.

FDB: Sure: Aetna, Horizon, United, Cigna. Physician practices can earn up to $100 per diabetic patient by demonstrating good control of diabetic patients’ blood pressure, lipids and HbA1cs; as well as meeting other standard process measures which are part of NCQA’s Physician Recognition practice survey tool.

FDB: Bridges, like many other organizations, is participating in the Patient-Centered Primary Care Collaborative. One of our commitments is to find ways to support the concept of the medical home throughout the country. The features of a medical home include a number of things – systems and processes, evidence of care management and care coordination, constant monitoring of the quality of the care that’s being delivered to patients in the community, and a focus on delivering good results to patients. That’s essentially what Bridges has been focusing on for five years, so for us, it was interesting to see the national dialogue bubble up into this concept called the medical home. Moving from concept to implementation came roughly at the same time as we got a lot of results from our ongoing evaluation. We found that practices that combine adoption and use of good systems, and deliver good results in the management of patients, deliver not only good quality care but also efficient care and at a lower cost. The episodic cost of care for the patient is lower in that practice than those in matched practices that don’t meet the same criteria, with a lot of savings coming from reduced hospitalizations, greater compliance by patients with treatment regimens, better control of their chronic conditions. We have pretty good evidence that for a practice that has undergone a fundamental reengineering of the delivery of care – from reactive to very proactive in managing the patient – incredibly good things happen.

The extent to which a physician’s practice meets these criteria – that they can show they have adopted systems in their practice, re-thought the way they’re delivering care, and demonstrated that they’re effectively applying these processes and systems to the management of patients and producing good results, then that warrants a fairly significant reward which is commensurate with the amount of effort that it takes to get to that point. Our actuarial evidence is very solid that the rewards are matched by commensurate savings for the payors. This is one of those rare occasions where everyone ends up being ahead of the game – the patient, clearly; the physician, through the reward system; and the payor, because the quality of care is increasing and the cost of care is going down.

FDB: In order to motivate a physician practice to participate actively and engage in the difficult reengineering process to achieve a designation of medical home, you need to achieve a certain critical mass of dollars in rewards or incentives. Our suggestion is that health plans and self-insured employers reward physician practices $125 per patient per year, as part of the incentives they offer to physicians. It’s up to the payor how to operationalize that reward – whether they want to cut a piece of that as a capitation fee, bonus, or as a fee schedule increase. If you multiply that reward by a large enough number of patients in the practice, it could be tens of thousands of dollars. We’ve suggested an annual cap of $100,000. It’s almost an artificial cap, in the sense that we don’t expect Medicare to participate in anything like this anytime soon. We don’t expect Medicaid plans to participate in this either, or if they do, it would be on a highly limited basis. When you take out those patients and you’re left with a commercially-insured population, that acts as a natural cap in a lot of physician practices.

FDB: You have to do two things. First, demonstrate that the practice has achieved at least a Level 2 (out of three possible levels) of "systemness," gauged by using either a practice assessment tool from the NCQA – such as its Physician Practice Connections – Patient-Centered Medical Home; or the office system survey administered by the Quality Improvement Organization in the state, which includes a supplement that was created for the BTE programs. The core of achieving a Level 2 is having at least a functional registry to do panel-wide patient management, so you can pull from that registry reports about your patients, their most recent office visit, blood pressure levels, etc. You don’t necessarily have to have a whole bunch of clinical decision support tools, but you do need to have some care management protocols, including the ability to track patients who are at high risk for complications, given the current condition of their health. You have to have processes associated with giving information to patients to improve their rates of compliance with a treatment regimen. It’s pretty tough to get to Level 3 without a fully functional electronic medical record. While we think that’s a great tool to have in a practice, having a highly functional registry is quite good, as well.

Second, you have to achieve Level 2 in at least two of the condition-specific BTE programs, as measured by NCQA’s Physician Recognition practice survey tools. Level 2 in those programs is about demonstrating good control of patients. For patients with diabetes, their blood pressure is under control, their lipids are under control, and their HbA1cs are under control; in addition to standard process measures being met by the practice. Similar criteria apply to BTE’s cardiac and spine care programs. You have to do more than "check in a box," – ordering certain diagnostic tests or screening – because that is more managing to the test, than managing the patient. You have to demonstrate that you’re actually controlling their intermediate outcomes.

FDB: It depends on the practice’s current state of "systemness." For a classic physician practice with paper records in the walls and no real information system except for a billing system, the cost would be about $25,000 to $30,000 per physician for the first year or 18 months, and it tapers down to somewhere around $10,000 to $15,000 per year. That includes the cost of the system, as well as patient education, outreach and management, which requires deployment of human resources – a nurse case manager or physician assistant – to track patients, monitor them, call them, and get them back into the office. You cannot get physicians to make this type of investment unless there is a reward that is at least commensurate with that investment. Below a reward level around $30,000 per physician, you will get some physicians to step up and participate in an effort like this, partially because they will take this as a signal of something else coming. But you’re going to get stuck at a participation or "transformation" rate of about 10 to 15 percent of the physicians in the community. If you want to crack the 20 percent ceiling, you really need to have an incentive amount that is at least equal to the investment amount. If you have enough employers and enough plans, between their fully-insured and their self-insured business, that is what’s going to create the critical mass of dollars that ultimately gets you above that investment threshold, from the provider’s perspective, and flips people from sitting on the sidelines to actively participating in the transformation.

If a physician practice is starting from scratch and wants to hit the "trifecta" of the medical home designation’s three required BTE programs right away, the total number of patients for whom it is going to get a reward should be in the vicinity of 200 to 250. That will get them in the right zone, and that’s not an unreasonable number if the majority of commercial payors are actively participating.

FDB: It’s a two-for-one. The total savings are somewhere around $250 per patient, so half of the money goes to the doctor as an incentive, and the other half stays with the plan.