National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II AcademyHealth 2007 Annual Research Meeting Diane R. Rittenhouse, MD, MPH University of California, San Francisco

Collaborators Stephen Shortell, PhD (Principal Investigator) Lawrence Casalino, MD, PhD James Robinson, PhD Robin Gillies, PhD Sara Fernandes-Taylor, Doctoral Student Rodney McCurdy, Doctoral Student

National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II Funded by: Robert Wood Johnson Foundation The Commonwealth Fund California HealthCare Foundation

Care Management for Chronic Illness  Quality Chasm  Particularly concerning for chronic illness care  Substantial disease burden and cost:  Diabetes, Asthma, CHF, Depression

Care Management for Chronic Illness  New models of care delivery are needed  Physician organizations (large medical groups and IPAs) well positioned to improve care

Physician Organizations’ Role in Improving Chronic Illness Care InternalCapabilitiesExternalIncentives Care ManagementImproved Processes Outcomes

National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II  Comprehensive list of all U.S. physician groups (medical groups and IPAs) with 20 or more physicians n=1063  35 minute phone survey with Medical Director or CEO  1/1/06 - 3/31/07  52% response rate; n=551 physician groups

Physician Organizations – Improving Chronic Illness Care InternalCapabilitiesExternalIncentives Care ManagementImproved Processes Outcomes

Care Management for Asthma and Diabetes DiabetesAsthma Electronic registry 51.0 % 38.1 % Guideline based reminders at point of care 50.8 % 36.0 % Performance feedback to physicians 65.6 % 56.5 % Send reminders to patients 51.6 % 35.6 % Specially trained patient educators 73.6 % 53.1 % Provide nurse case managers 54.6 % 42.6 % Mean number of CMPs (out of 6)

Care Management for CHF and Depression CHFDepression Electronic registry 38.4 % 23.6 % Guideline based reminders at point of care 32.8 % 22.8 % Performance feedback to physicians 51.1 % 33.2 % Send reminders to patients 35.4 % 20.0 % Specially trained patient educators 53.4 % 35.4 % Provide nurse case managers 47.6 % 25.3 % Mean number of CMPs (out of 6)

Care Management for 4 Diseases  On average, physician organizations used 11.1 (out of 24) care management processes for all 4 chronic diseases.

“Practice Re-design”  Advanced Access scheduling: 59.7%  Group visits for chronic illness: 24.7%  Primary care teams: 30.3%

Physician Organizations’ Role in Improving Chronic Illness Care InternalCapabilitiesExternalIncentives Care ManagementImproved Processes Outcomes

Patient Centered Culture  Does good job of assessing patient needs  Staff promptly resolve patient complaints  Patient complaints are studied to identify patterns  Patient data are used to improve care  Patient satisfaction data are used in developing new services

Health Plan Activities  To what extent do physician organizations report that health plans are providing CMP services to their physicians/patients?  Are health plan and P.O. efforts complements or substitutes?

Participation in Quality Initiatives  Does your group participate in any quality improvement demonstration programs?  (Eg: Bridges to Excellence, IHI, Pursuing Perfection, Improving Chronic Illness Care)  Does your group use the rapid cycle quality improvement strategy (PDSA)?

External Incentives for Quality % yes Evaluated -- on patient satisfaction on quality -- on quality on IT use -- on IT use53.4 Receive extra income -- for pt satisfaction for quality -- for quality for IT use -- for IT use32.8 Receive better contracts for quality/pt sat 28.7 Receive extra income for efficiency 33.9

Emerging Story  Internal Capabilities  Culture plays an important role  Health plan care management activities are complementary to physician organization efforts  Participation in quality improvement programs  External incentives  Prevalent and associated with increased care management