American College of Physicians: Internal Medicine — Doctors for Adults ®

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College promotes new model to manage chronic care

From the December ACP Observer, copyright © 2004 by the American College of Physicians.

In a poll taken earlier this fall, Americans ranked the key issues that would drive their decisions in the November elections. According to an article in the Sept. 23, 2004, New England Journal of Medicine, their top four concerns were terrorism, the war in Iraq, the state of the national economy and health care.

While the first three pose major challenges, health care is no less daunting, particularly as health care services continue to eat up an ever-growing portion of federal and state budgets.

The new Medicare drug benefit taking effect in 2006 will cost taxpayers hundreds of billions of dollars. Physicians still need equity and fairness in Medicare reimbursement, which will only add to the cost of health care services. And money will have to be found to meet the needs of aging baby boomers, not to mention the more than 44 million Americans who have no insurance and can only sporadically access health care services.

As both the public and policymakers grow increasingly alarmed about containing health care costs, chronic care is receiving new scrutiny. One out of five Medicare beneficiaries has five or more chronic diseases—a patient population that consumes more than two-thirds of all Medicare dollars.

At the same time, studies show that patients with chronic illness receive less than 60% of the recommended clinical care they need. It is increasingly obvious that coming up with a new model for chronic care is not only the key to improving the quality of American health care, but the only way to stretch Americans' beleaguered health care dollar.

A new Medicare paradigm

We need true innovations to solve the problems with chronic care, and, fortunately, Congress and the Centers for Medicare and Medicaid Services (CMS) are willing to answer that call. As part of the Medicare reform package approved in late 2003, Congress established a chronic care improvement program pilot project that will be launched next year.

The program acknowledges the fact that Medicare's current fee-for-service program does not adequately recognize—or compensate—vigorous chronic care management. The first phase of the pilot will be rolled out in 10 areas across the country with high concentrations of Medicare beneficiaries. Initially, the pilot will focus on implementing and evaluating programs for patients with congestive heart failure and/or diabetes.

In those 10 areas, designated chronic care improvement organizations will, for the first time, have access to Medicare claims data. They will also have to meet performance improvement goals for patients, as well as cost-saving targets set at least 5% below current fee-for-service spending. Those organizations that set (and meet) even higher targets will be able to pass on some savings as financial bonuses to physician case managers.

The pilot phase of the program will be in effect for three years. The CMS will then implement nationwide those elements of chronic care management found to be the most effective.

ACP's chronic care efforts

While the College applauds Congress and the CMS for testing this bold new design, ACP is also devoting many of its own efforts to studying chronic care innovations. A new College policy paper approved in October by the Board of Regents lays out several recommendations for crafting a new paradigm of patient-centered, physician-guided chronic care.

Many of those recommendations are based on a model developed by Edward H. Wagner, FACP, MPH, director of Seattle's MacColl Institute for Healthcare Innovation. Dr. Wagner has identified the following elements as essential to high-quality chronic disease care:

  • community, with strong links to such resources as senior centers;

  • the health system, which should emphasize care coordination and patient safety;

  • self-management support, to give patients guidance and education;

  • delivery system design, including cultural competency and case management;

  • decision support to make evidence-based practice guidelines available at the point of care; and
  • clinical information systems. These systems can track guideline compliance and give feedback to physicians about their ability to meet specific performance measures, such as measuring lipids in diabetic patients.

The model also depends on another key component: practice teams with clearly defined duties and responsibilities. (More information on Dr. Wagner's model is online.)

ACP's policy paper makes it clear that internists are particularly well-suited to lead those teams. The paper also states that case management fees and performance incentives need to be linked to both improvements in care and cost savings. And, the paper continues, physicians will need incentives to use information technology and decision-support tools before any new model of chronic care can become a reality.

The information age

Fortunately, the CMS is also rolling out another three-year demonstration project to test how information technology can boost quality and save money.

The Doctor's Office Quality Information Technology (DOQ-IT) demonstration project is designed to foster information technology integration in small- to medium-sized physician offices. The program, which is being launched in California, Utah, Arkansas and Massachusetts, will track how well physicians meet clinical care standards for patients with chronic coronary artery disease, diabetes mellitus and heart failure, and for prevention. (The CMS and the AMA Physician Consortium for Patient Improvement have developed the quality performance measures that will be used.)

The program will help participating physicians adopt information technology and point-of-care decision support tools, and pay them to do so. Having rapid electronic access to vital patient information—with decision support software such as PIER, the ACP Physicians' Information and Education Resource—will allow physician case managers to optimize available incentives.

It is gratifying to see that the College and the CMS are both moving in the same direction to redesign chronic care and harness the potential of information technology. That willingness to embrace new care models and support experimentation may be our best hope to give our patients the services they need—and keep our increasingly strained health care system afloat.

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