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
Internal
Capabilities
External
Incentives
Care Management
Processes
Improved
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
Internal
Capabilities
External
Incentives
Care Management
Processes
Improved
Outcomes
Care Management
for Asthma and Diabetes
Electronic registry
Guideline based reminders at point of care
Performance feedback to physicians
Send reminders to patients
Specially trained patient educators
Provide nurse case managers
Mean number of CMPs (out of 6)
Diabetes
Asthma
51.0 %
50.8 %
65.6 %
51.6 %
73.6 %
54.6 %
38.1 %
36.0 %
56.5 %
35.6 %
53.1 %
42.6 %
3.66
2.86
Care Management
for CHF and Depression
Electronic registry
Guideline based reminders at point of care
Performance feedback to physicians
Send reminders to patients
Specially trained patient educators
Provide nurse case managers
Mean number of CMPs (out of 6)
CHF
Depression
38.4 %
32.8 %
51.1 %
35.4 %
53.4 %
47.6 %
23.6 %
22.8 %
33.2 %
20.0 %
35.4 %
25.3 %
2.79
1.78
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
Internal
Capabilities
External
Incentives
Care Management
Processes
Improved
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 IT use
Receive extra income -- for pt satisfaction
-- for quality
-- for IT use
Receive better contracts for quality/pt sat
Receive extra income for efficiency
80.6
82.8
53.4
46.5
55.4
32.8
28.7
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