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

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Internists should pursue innovative practice models

From the March ACP Internist, copyright © 2013 by the American College of Physicians

By David L. Bronson, MD, FACP

We are entering a new era of medical care with organized delivery system models, such as accountable care organizations (ACOs) and the patient-centered medical home (PCMH), attempting to improve care and control costs. As ACP president, I am frequently asked questions about the changing environment of care. Does organizing medical care matter? Why should an internist pursue becoming a PCMH? Will a PCMH result in better health outcomes and lower costs? What support can the American College of Physicians offer members in transforming their practices?

I have practiced in a medical group setting throughout my career, first in a five-physician, university-based, general internal medicine group and the past 20 years in an academic multispecialty group. Our adult primary care practice has grown to include more than 250 primary care internists, family physicians and mid-levels at 18 practice sites caring for more than 350,000 people in northeastern Ohio.

In 2006, I was asked to consider having our practice participate in a Robert Wood Johnson Foundation grant initiative whose goal was to improve the management of chronic disease in primary care settings. Our group enthusiastically joined the effort. We were one of 14 initial communities receiving grants through the Aligning Forces for Quality initiative. Our multistakeholder effort was later named Better Health Greater Cleveland (BHGC).

There are now 55 practice sites in the BHGC collaborative, with more than 600 physicians and mid-levels, from eight organizations. All models of care are represented, including small practices, large academic medical centers, a health maintenance organization, a public hospital, and federally qualified community health centers. Our first report in 2008 encompassed the care of 26,000 patients, and we’ve grown so that we now report quality measures for 137,000 adult primary care patients who have diabetes, hypertension, and/or heart failure.

We’ve learned a great deal working together across practices. We’ve learned how to effectively use registries, provide meaningful and nonjudgmental feedback to physicians, successfully collaborate in developing practice standards and share best practices across our region.

The collaborative has fostered implementation of the PCMH in our region, with most of our practices now achieving NCQA (National Committee for Quality Assurance) level III recognition. All the practices participate in continuous quality improvement efforts and public reporting of quality measures by practice.

The results have been impressive, with sustained and continuing improvement for all categories of patients—those covered by Medicaid, Medicare, commercial insurance and the uninsured—in virtually all of the participating practices.

As one might expect, patients with insurance, higher income or higher education levels tend to achieve the highest levels of success, but all categories have improved from their baseline levels. One key finding from a study published in the Sept. 1, 2011, New England Journal of Medicine was that practices that are supported by electronic medical records and use quality management tools achieved higher levels of quality and improved more rapidly than paper-based practices. The ease of data collection with an electronic medical record system and more regular feedback were obvious reasons why these practices performed at a higher level.

Most recently, we have begun understanding the impact of the collaborative on hospital admissions that should be avoidable through quality ambulatory care. Over a three-year period in 2009 to 2011 in 10 participating hospitals and 69 practices, we saw a 10.7% decline in these types of admissions, translating to a savings of more than $20 million over three years. The results are reported in our 10th “Community Health Checkup.”

As health care continues to evolve, College members should take advantage of new models of care, such as the PCMH and the PCM Neighborhood, that can improve health outcomes for our patients. The College has extensive resources available online to help members understand new models of care, with tools to assist members in finding the right delivery model. The College’s Medical Home Builder is an excellent tool to get started. In fact, it’s so good that one insurer, WellPoint, has contracted to use it to support up to 20,000 clinicians as they transform their practices into PCMHs.

Many communities have similar initiatives to improve quality of care. I encourage you to engage with such activities, as they are one way of showing how new methods can improve care, and to learn how to use them in your own practices. You can also have significant input into the collaborative’s development, and your experience and participation are vital to its success.

New models of care that focus on quality can allow us to do a better job caring for our patients, and there is at least some early evidence that they may reduce the costs of care. The delivery system matters, and we need to be leaders in planning and implementing new models of care. We can react to the changing environment, or we can be part of creating it. Let’s lead and ensure that our patients get the best care possible.

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