At a time when issues around taking on risk-based contracts are becoming more complex and challenging for physician groups, some physician organizations are moving ahead to lay the foundations for success in risk-based contracting, all of which require strong health risk assessment processes around broad covered populations, and the creation of care management and population health management strategies for the long haul.
Among the physician organizations that has taken on these challenges and begun to lay strong foundations for risk-based contracting has been Community Medicine, Inc., which is the largest group of employed primary care physicians—330 in all—connected to the vast UPMC health system in Pittsburgh. The president of that group is Francis X. (Fran) Solano, M.D., an internal medicine physician, who is also vice president of the Physician Services Division at the umbrella UPMC system.
While taking on potential downside risk has been years in the making—Dr. Solano is currently working to develop a risk-based contract between Community Medicine, Inc. and the UPMC Health Plan—he has spent 15 years helping to lead a quiet, data-facilitated revolution around improvements in care quality and utilization management.
At the core of that effort has been the program Template for Change, which has laid a firm foundation for the taking on of financial risk in contracting, even as Template for Change has focused on initial shared-savings goals between and among the medical group constellation, the hospital system, and the health plan. The program, which has been applied to medical care delivery across all insurance lines (Medicare, commercial, Medicaid), has been implemented across the 330 primary care physicians in the Community Medicine constellation of groups, as well as 30 PCPs at Renaissance Family Practice based at St. Margaret’s Hospital, and 60 internal medicine physicians in a third group.
The focus, Solano says, has been on providing monthly performance metrics to every physician in the program, at the individual, practice, and specialty level, for the following core statistics: inpatient admissions per 1,000, inpatient days per 1,000, ED visits per 1,000, primary care visits per 1,000, specialty visits per 1,000, diagnostic imaging rates per 1,000, and medical expense ratio. The physicians in the program have also been receiving data on their “HEDIS gaps”—gaps in care conveyed by HEDIS (Health Effectiveness Data and Information Set) data. Solano himself and his team look at a monthly 400-page printout of data, but, he notes, he learned early on that sending out massive amounts of raw data to the physicians in practices only led to mass confusion and frustration. The key has been that providing the doctors with these data points has helped them find “the patients who are high utilizers but are not yet in care management.
Francis X. Solano, M.D.
What’s more, Solano says, the monthly sharing of clinical performance data, along with coaching sessions for physicians who are struggling, has made a huge difference. Still, “The biggest contribution” to physician behavioral change has been the average $20,000 in physician compensation that has been tied to individual physician performance on the various metrics being measured. Also very big has been the fact that the shared-savings program has involved sharing savings with the hospital system, an important factor, given that intended reductions in inpatient admissions and ED visits inevitably will affect the hospitals’ bottom lines.
Dr. Solano spoke this summer with Healthcare Informatics Editor-in-Chief Mark Hagland, as Hagland prepared the September cover story on physicians and risk. Below are some additional excerpts from their interview. This is part one of a two-part interview.
Tell me a bit about the background and context for what you’ve achieved so far at Community Medicine, Inc. This is quite pioneering work. What is the landscape of managed care like right now in western Pennsylvania?
Actually, there is very little true risk-based contracting going on in western Pennsylvania at this time. Most programs really only have upside potential, and not much in the way of downside potential. The Pioneer ACOs [accountable care organizations] can do either upside risk or two-tailed risk, involving some potential downside. We have a shared-savings program with our health plan, which is mainly based on hitting a medical expense ratio. We started our first year in 2013 with that program. Meanwhile, we over 30,000 Medicare members, 28,000 commercial members, and 30,000 Medicaid patients, or the largest [aggregation of such groups of patients by a medical group] in western Pennsylvania.
So Medicare has several models; it has the ACO model. And a lot of Medicare Advantage programs have developed their own ACOs, and that’s what this is. We’ve been extremely successful, getting this many physicians engaged to care about cost; and we’ve always cared about quality at UPMC. Our first year was interesting in that we were successful. Those programs take three years to become successful usually; but we’ve learned a lot about variability in practice patterns, and also how people approach access to primary care. One of the biggest challenges is to reduce the number of admissions, towards what I call appropriate admissions.
And in western Pennsylvania, where there are a lot of Medicare patients and a lot of Medicaid patients; and our emergency department utilization, urgent care utilization, and inpatient hospitalization, are all off the charts in western Pennsylvania.
Why have those utilization rates all been so high in your region?
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