1. Peer Networks of Primary Care Physicians and the Challenge of Care Coordination H.H. Pham, A.S. O’Malley, P.B. Bach, C. Saiontz-Martinez, D. Schrag Academy Health Annual Meeting, June 2008

2. National Institute on Aging American Medical Group Association

3. The challenge Coordinate across settings, conditions, providers Consistent with preferences and capabilities of patients and families Conscious interactions between providers –Timely transfer of information –Effective communication –Shared decision-making

4. The challenge in fee-for-service Medicare Highly fragmented care –Patients typically see 2 PCPs and 5 specialists in 4 different practices in a given year –Cadre of physicians seen varies between patients Medicare does not track referrals Patients have no designated “primary provider”

5. Defining peer networks Only physicians who treat my “core” patients Physicians who treat my “core” patients, plus the single “coordinator” for each of my other patients All physicians who treat any of my patients Smallest networkExtended network

6. Data sources 2004-2005 Community Tracking Study (CTS) Physician Survey –Nationally representative, clustered in 60 communities –Non-Federal physicians completed training and in clinical care >20 hours per week –53% response rate Medicare claims for FFS beneficiaries treated at least once in 2005 by these physicians Linked using Unique Physician Identifier Numbers (UPINs)

7. Identifying physicians, “practices,” and peer networks UPINs to identify individual physicians –Excluded outliers with >900 unique beneficiaries TAXID to identify “practices” Plurality of E&M visits to assign “core patients” to both CTS and non-CTS physicians –Exclude claims by RAP specialties and pediatricians Peer network = (All other providers treating “core patients”) + (Single “coordinator” for each of the physician’s other patients)

8. Study populations 2,284 CTS primary care physicians 576,875 Medicare beneficiaries they treated –65 years or older –Without ESRD or disability

9. Calculating the size of networks Consider all physician-related visits –Repeat considering only physician-related E&M visits Absolute and standardized to the size of the PCP’s Medicare panel Consider subsets of patients and visits –Networks only for patients with 4+ chronic conditions –Visits to: all physician peers peers not in emergency departments peers providing E&M services peers within the PCP’s state Peers of different specialties

10. Number of practices in the peer networks of primary care physicians % of PCP’s Medicare panel Peer Network Size Peer Network Size Standardized per 100 beneficiaries Related to care ofMedian IQRMedianIQR All Medicare patients 10010762-1655034-76 Only Plurality patients 448338-1333420-57 Only Plurality patients with 4+ conditions 277737-1253118-52 Only during one month NA178-2974-11

11. Number of physicians in the peer networks of primary care physicians Peer Network SizePeer Network Size Standardized per 100 beneficiaries MedianIQRMedianIQR Total number of other physicians 207118-3119468-126 Other PCPs5731-872618-36 Medical specialists6938-1073019-46 Surgeons6030-962617-39 EM physicians156-2463-10

12. Number of other practices in networks, by characteristics of the PCPs’ practices n (%) N = 2,284 Network sizeStandardized network size Practice type Solo/2-person885 (39.6)125 (73-179)61 (41-93) Large group (>50)96 (4.8)90 (48-148)39 (25-67) Medical school130 (4.5)65 (36-109)53 (40-67) % Revenue derived from Medicaid <6%972 (38.9)118 (70-183)59 (38-72) >15%694 (30.8)83 (47-134)44 (33-66)

13. Number of other practices in networks, by market characteristics n (%) N = 2,284 Network sizeStandardized network size Urban1,985 (80.6)108 (59-167)55 (38-84) Rural299 (19.4)107 (72-150)35 (26-45) Census division East South Central82 (5.8)132 (93-170)35 (26-62) Pacific324 (15.6)74 (31-110)52 (36-77) Mid-Atlantic319 (12.0)133 (72-200)75 (53-96) Specialists per capita Lowest quintile393 (20.2)107 (72-150)38 (28-55) Highest quintile575 (21.9)128 (79-191)59 (39-85)

14. Number of other practices in networks, by characteristics of PCPs’ Medicare panels n (%) N = 2,284 Network sizeStandardized network size Number of beneficiaries <101623 (24.4)33 (10-57)79 (54-108) >400473 (24.6)180 (147-247)31 (21-41) Mean number of chronic conditions Lowest quartile576 (24.4)79 (41-125)49 (33-74) Highest quartile611 (25.3)118 (68-195)57 (35-90)

15. These are conservative estimates of network size Only physician peers Used Plurality assignment that attributes only 40% of a typical PCP’s panel as his or her “core patients” Only peers caring for Medicare patients Focused on practices, optimistically assuming that physicians within an organization are better able to coordinate with each other

16. Conclusions Size of peer networks for primary care physicians is substantial in FFS Medicare Networks include many other PCPs Network size –Higher for PCPs treating sicker patients –Large even for subsets of important services –Varies substantially by practice type, geographic region

17. Limitations Did not assess –Longitudinal stability of networks –Quality of interactions between providers –Relation between network size and cost or quality of care Imperfect identification of physicians and practices using UPINs and TAXIDs –TAXIDs result in conservative estimates based on comparisons with physicians’ self-reported practice size

18. Implications (1) Even this single dimension of the challenge of care coordination is daunting –Consider complexity of addressing patients’ and families’ preferences in large peer networks Regional health information organizations might not wholly capture networks Truly coordinated care may remain an elusive goal in FFS Medicare without reducing network size

19. Implications (2) Payers might consider: –Tracking, feedback of information on sources of referrals –Extending incentives to other physicians in the network (outside of the medical home) to also coordinate care –Offering favorable payments to well-defined networks –Offering incentives for physicians to re-organize their practices Physicians might consider: –Seeking acknowledgement by payers of existing networks –Formalizing relationships with peers to increase integration Require compatible HIT and service agreements –Selecting peers based on cost and quality performance