By Christopher Guadagnino, Ph.D.

Published April 2008

AT: The initial goal of the Commission was to develop a strategic plan to:

· Implement widespread use of a new primary care reimbursement model that permits primary care practices to provide additional resources to proactively care for patients with chronic conditions and to assist those patients in taking a greater role in self-managing their health conditions.

· Broadly disseminate the Chronic Care Model to primary care practices across Pennsylvania.

· Achieve tangible and measurable improvement in the quality of care for chronically ill patients.

· Reduce the cost of providing chronic care and implement mechanisms to ensure that savings are realized by those paying for health care.

The commission includes many of the "who’s who" of health care: the state’s major health insurance companies, academic medical centers, union representatives, pharmacists, physicians, nurses and consumers. A number of them had participated in a HRSA grant with our office to come up with a plan to provide affordable health care coverage for all Pennsylvanians, improve the quality of care and reduce health care costs. Very early on, advisory members were telling us that, if we did not change how chronic care was being provided at the community level in Pa., we would continue to have serious quality and cost issues. The commission has completed the first part of its charge, which was to come up with a strategic plan to transform how Pa. provides care to people with chronic diseases, and it presented a strategic plan to the governor and to leadership of the General Assembly on Feb. 13. We are now moving into the implementation stage and the commission is continuing to give us advice on the rollout of that plan. The Strategic Plan can be found at: http://www.rxforpa.com/assets/pdfs/ChronicCareCommissionReport.pdf

AT: Pennsylvania’s hospitals report hospital charges and related data to the Pennsylvania Health Care Cost Containment Council. PHC4 determined that for the first six months of 2007, hospitals reported over $2 billion in charges for persons with chronic conditions for avoidable hospitalizations as defined by AHRQ. Patients in Pennsylvania are being hospitalized for conditions, which, if they had received the appropriate community-based care, would not have been necessary, and hospital charges are estimated to exceed $4 billion in 2007 for that care. That’s dramatic evidence that the lives of people who have chronic conditions are being put at risk because of their failure to get appropriate chronic care. Studies have shown that people with chronic disease get only about 56 percent of the recommended evidence-based care that they should be getting for their chronic condition. Pennsylvanians with heart disease are admitted unnecessarily to hospitals more than two-and-a-half times as much as the best performing states, approximately three times as often for asthma and more than four times as much for diabetes.

AT: There are a variety of obstacles. One is that we’re often not training patients in self-management of their conditions. Too often, patients go to see their primary care practitioners and expect them to work miracles, and believe that their only role and responsibility is to show up for the appointment. A person with a chronic condition such as diabetes really needs to play a more active role between doctor visits. The Chronic Care model helps involve patients, for instance, in setting realistic goals for weight loss, nutrition, exercise, and behavioral and lifestyle issues that can impact a chronic condition. Secondly, the way primary care physicians are reimbursed has helped contribute to this problem. There is great financial pressure to see as many patients as possible in order to cover overhead costs. Physicians often can’t take the time to spend with a patient who may have a number of chronic conditions. The Chronic Care model addresses that in two ways: by looking at how we change reimbursement for primary care, and by having multidisciplinary teams available so that all the weight is not on the shoulders of the primary care practitioners, so other trained staff members can spend time meeting non-physician clinical needs of the patient.

So, it’s practice redesign, reimbursement, and involving patients in self-management of their condition. Practice redesign changes involve use of patient registries that look, for example, at all of a practice’s diabetics to determine who needs what; and more proactively engaging patients to come in to get recommended care. Right now, physicians tell patients to come back once a month and, if the patient doesn’t come, the next thing you may find is that they’ve been in the hospital with an acute condition. The patient may have been on one set of medications with their primary care physician and may have been put on another set of medications at the hospital. It may take another month or two to get another appointment with the physician to figure out which of the medications should be taken or discontinued. It’s just not a good system of coordinating care and meeting the needs of the patient.

We have more than enough money in the system to make the appropriate changes. We know that 78 percent of all health care costs are for about 20 percent of patients, and those are patients with chronic conditions. Too much of that cost is going to avoidable emergency room visits and hospitalizations. What we’re looking to do is restructure payment so that more is going to physicians to provide much more comprehensive health care to people with chronic conditions. That’s long overdue, as we see fewer and fewer residents going into primary care because of the financial disincentives.

AT: There are six key components of the Wagner Chronic Care Model, which was developed by Edward Wagner, M.D., MPH, of the MacColl Institute for Healthcare Innovation, in Washington state. Dr. Wagner has been a frequent consultant to the commission. The first component is self-management support, providing patients with assistance in managing their disease and helping them set realistic health improvement goals. Second is delivery system design, transforming the practice from a reactive physician model to a proactive model that looks at what care patients across populations are getting, and uses multidisciplinary care teams to make sure they get that care. Third is decision support, which makes sure that care is based on the best evidence-based care guidelines. Fourth, are clinical information systems, which provide tools for physicians to better track and monitor their chronic care patients. Fifth, is partnership with community resources that can encourage healthy living, be they exercise groups, lay counseling or nutrition programs. Sixth, are health system incentives for quality improvement among caregivers, to make sure practices have the resources necessary to use patient registries and a multidisciplinary team approach to provide better chronic care. The model’s use by the Veteran’s Administration has been shown to dramatically increase the number of patients receiving the processes they should, and improve outcomes, while significantly reducing cost. It has also been effectively used in Federally Qualified Health Centers.

AT: The Medical Home and Advanced Medical Home models are rooted in the Chronic Care Model, and share much in common with the latter, including a population-based approach to care management, use of information technology to support care management, and proactive care management. The Medical Home concept is an approach to providing comprehensive primary care to all patients, whereas the Chronic Care Model focuses on those with chronic conditions. Also, the Chronic Care model has more emphasis on community resources needed to support healthy lifestyles and can be used by physician practices and advanced practice nurse primary care practices. We will be using both models in our first rollout in southeastern Pa.

AT: We’re going to start with diabetes for adults and asthma for children. The state Health Department has been working with more than 200 stakeholders over the last several years to come up with a work plan to improve diabetes care in Pa. People with diabetes often also have other related comorbidities, so it’s an opportunity to deal with other related chronic conditions, such as high blood pressure and heart issues. To implement the Chronic Care Model, we’re going to use learning collaboratives. We’re starting in the southeastern section of Pa. because the payors there had already been meeting to change the reimbursement system to support the advanced Medical Home. We also have interest by payors in southcentral Pa., and we’re looking in September to launch it in that region. We also have interest in southwestern Pa. We want to have the program operational in all regions of the state within the next year.

Our first learning collaborative for the southeastern region will be held in May and will involve 30 to 60 physician practices, which will use a secure Internet-based patient registry. All of the practices agree to attend four sessions throughout the year. We’re accepting applications now from primary care practices, and we’re looking for those practices that are committed to transforming how they provide chronic care. Practice coaches will go out to the practices and help them use the patient registry, get them ready to come to the first learning collaborative, and be in touch with them periodically to help solve problems and implement practice redesign.

AT: The primary up-front financial costs are the patient registry – there’s a licensing fee, the time to get it populated with patient information, and the lost time from practice for attending the learning collaboratives. We are talking with payors about reimbursing practices for much of those initial one-time costs – a flat fee that would attempt to eliminate some of this financial barrier. Process and outcome measures of the practice guidelines are metrics that typically would go into the patient chart, and practices will use the registry to report monthly on how many of their patients have met the parameters of the guidelines. The registry produces reports for physicians to track their improvement and compare it to other practices in the collaborative, as well as to the aggregate. Practice performance is not shared outside the collaborative.

The collaborative is very much a shared learning process of performance improvement. So for instance, if one practice comes in and they’re doing 100 percent foot exams of diabetics, and another practice is doing 60 percent, the first practice may share that the way they significantly improved this rate was that their nurse gets the patients’ shoes and socks off before the physician comes into the examination room and that, when the physician sees those bare toes, it triggers a reminder to do the foot exam. Patients aren’t necessarily going to see more of the physician. Additional time in the office will be with other staff members who will work with patients on diabetes and asthma patient education, improving self-management, setting goals for healthier living and helping patients to take a much more active role in maintaining their health.

AT: It can, depending on how many people the practice has available. That’s one reason that we ask the practice to bring a team to the learning collaboratives. Typically a practice might come to the collaborative with the physician, a nurse and the front desk person, and together they talk about how to restructure duties to meet the needs of patients. In some cases practices will need to add additional staff.

AT: Practices have found that group visits are often very beneficial, as patients learn from each other. Lay coaching can also be very effective. For example, if you have a diabetic who successfully lost weight and improved her health, you could consider using her to talk with patients who need to do that. Open scheduling – leaving appointment time available each day – increases the ease of access to the practice’s services. The practice coaches will try to scout out all the potential community resources in a practice’s area and share that with the practice so that they can make good referrals for needs that are better met from community resources as opposed to practice resources.

AT: The payors may have their own evaluation process. The state will also be evaluating it, starting with benchmark data on process, outcomes and cost. We’re going to start with baseline data and look at trends over time. The payers have made a commitment to have reimbursement increases for three years. By the end of three years, we want to see some significant improvement in health outcomes and decrease in avoidable hospitalizations and ER use. The state will be seeking foundation support for an independent evaluation, down the line.

AT: We have very strong interest from several payors, and we’ll be looking for commitment in the very near future. We’re currently talking to HealthChoices Medicaid HMOs, the benefit plan for state employees and retirees, two of the Blues, Aetna, and UnitedHealth. We’re looking at three buckets of payment for physicians. The first is a one-time payment for expenses involved in participating in a learning collaborative. The second is an ongoing payment enhancement for practice change to the Chronic Care Model/Advanced Medical Home. The insurers don’t want to go into every practice and figure out whether it has fully adopted a chronic care model, so they’re looking for some kind of certification process by an independent entity to serve that purpose. We’re looking at certification through the NCQA. Enhanced payments would be scaled based on the degree of transformation of the practice. Practices that join the collaborative have to commit to apply for certification within the first year and, upon receiving certification, they then would be eligible for enhanced reimbursement. The third payment is through existing pay-for-performance programs. Initially, plans are staying with their own programs, but we would look to have all payors eventually move to the same measures. To the extent that improvement occurs through the chronic care collaborative program, we would anticipate that practices would benefit from enhanced pay-for-performance reimbursement. We’re also talking to health plans about financial incentives for consumers, but that is proving to be challenging because plans are not used to having consumer incentive programs for subsets of their membership. Of course, the major consumer incentive is better health and quality of life.