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Engaging Primary Care
Physicians in Quality
Improvement:
Lessons from a Statewide
Payer-Provider Partnership
May 30, 2013, 12:00-1:00 PM EST
Christy Harris Lemak, PhD, FACHE
University of Michigan
School of Public Health
Department of Health Management & Policy
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The Griffith Leadership Center (GLC) cultivates
exceptional leaders who will transform health and
healthcare for a changing world. The Center works to
strengthen and catalyze connections among research,
teaching, and practice in health management and policy.
The GLC’s Mission is to promote and support excellence
in health management and policy leaders by strengthening
the connections among research, teaching and practice.
http://www.sph.umich.edu/glc/
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Today’s Learning Objectives
Describe how a P4P program improved care
processes in primary care practices.
Identify ways to successfully implement
physician practice improvement initiatives.
Understand that improvement for physicians
involves changes in philosophy as well as
practice.
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Agenda
• Background
• Evaluation Design
• Findings
• Drivers of Successful Provider Engagement
• Practice Changes
• Lessons Learned
• Bibliography
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Study Authors
Christy Harris Lemak, PhD FACHE is the lead investigator
of a Commonwealth Fund evaluation of the program
described. She is an Associate Professor of Health
Management & Policy at the University of Michigan and
Director of the Griffith Leadership Center. She teaches
management and leadership and serves as Chief Academic
Officer of the National Center for Healthcare Leadership.
Christy earned her MHA/MBA from the University of
Missouri-Columbia and her PhD from the University of
Michigan.
Genna R. Cohen is a PhD student and Natalie Erb is a 2013
MPH graduate of the University of Michigan.
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The Research Presented
Was previously presented at the American College of Healthcare
Executives (ACHE)’s 2013 Congress.
Has been accepted for publication and will appear this fall in
ACHE’s
Journal of Healthcare Management
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The Research Team
Evaluation of the Physician Group Incentive Program:
From Partisanship to Partnership
From the University of
Michigan:
From BCBSM:
• Christy Harris Lemak, PhD • David Share, MD/MPH
• Genna R. Cohen
• Darlene K. El Reda, DrPH
• Natalie Erb, MPH
• Mike Paustian, PhD
• Jeff Alexander, PhD
• Margaret Mason, MHSA
• Richard Hirth, PhD
• Andrew Billi
• Tammie Nahra, PhD
Funding Provided by the
Commonwealth Fund
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Background
• Aligning the goals and interests of payers,
providers, and patients
• Central for population health improvements and
efficiency (ACO approaches)
• Prior research:
•
•
•
•
•
Practice infrastructure
Organizational factors and clinician characteristics
Physician participation and buy-in
Clarity of program features
Demonstration of success in local efforts
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The Physician Group Incentive
Program (PGIP)
• Began in 2005, partnership of medical community and
Blue Cross and Blue Shield of Michigan (BCBSM)
• 40 physician organizations, 17,000 physicians, and 1.8
million members
• Incentive Payments for:
• Evidence-based care processes
• Population-based cost measures
• Participation in efforts to build infrastructure related
to Patient Centered Medical Home
• Others
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PGIP: Key Statistics
http://www.bcbsm.com/providers/valuepartnerships/value-partnerships-overview.html
Source: BCBSM
http://www.bcbsm.com/providers/valuepartnerships/value-partnerships-overview.html
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What is PGIP?
Focus:
Initiatives - Various initiatives to improve
process and outcomes of care
PCMH Designation Program - Annual
designation based on reporting on domains of
function
Support for Care Management –
T-Codes (non-physician providers can be
reimbursed)
Collaborative Projects – e.g., Lean Thinking
Clinic, Reengineering Collaborative Quality
Initiative, others
Payments To:
Physician
Organization
Physician
Practice Unit
Physician
Practice Unit
Collaborative
and/or Physician
Organization
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PGIP Initiatives
Clinical information technologyfocused initiatives
Accelerating the Adoption and Use of
Electronic Prescribing
Patient Portal*
Patient Registry*
Condition-focused initiatives
Cardiac Care — Phase I
Cardiac Care — Phase II
Cardiac Care — Phase III
Encouraging Evidence-Based
Utilization of Hysterectomy
Encouraging Evidence-Based
Utilization of Labor Induction
Environmental Cancer
Michigan Oncology Quality
Consortium
Michigan Oncology Clinical Treatment
Pathways
Michigan Urological Surgery
Improvement Collaborative
Core clinical process-focused
initiatives
Evidence Based Care Tracking
Initiative
Lean for Clinical Redesign
Michigan Transitions of Care
Collaborative
Coordination of Care*
Extended Access*
Individual Care Management*
Linkage to Community Services*
Patient Provider Partnership*
Performance Reporting*
Preventive Services*
Self-Management Support*
Specialist Referral Process*
Test Tracking and Follow-Up*
Service-focused initiatives
Advance Care Planning
Emergency Department Utilization
Increasing the Use of Generic Drugs
Michigan Anticoagulation Quality
Improvement Initiative
Radiology Management
Organized systems of care
initiatives
Integrated Patient Registry
Integrated Performance Measurement
Processes of Care
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BCBSM PCMH Efforts
• Patient Centered Medical Home (PCMH) program:
• ~5,600 primary care physicians and
~2,000 specialists
• 2011 BCBSM PCMH Designation:
• Over 2,500 primary care physicians and
specialists in more than 770 practice units
• Over $25M in annual E&M uplifts for
PCMH designated providers
Source: BCBSM
Early Internal Studies Show Positive
Program Results
• Generic Prescribing Rate - 38% (’04) to 74% (’11)
• Lower rates of hospitalization, radiology
utilization and ED visits
• Direct Radiology - $24M savings in 2010
• Cost trend fell to 1.9% with negative trend for
professional costs (lower than any other Blues
plan in the country)
Source: BCBSM Internal Studies
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Evaluation Questions & Methods
Research Question
What is PGIP? How was it developed and
what have been its progress,
accomplishments, and first-level impacts?
Methods
•
•
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To what extent have physician organizations
participating in PGIP changed their
organizational structures and systems of
care to align with PGIP initiatives and
•
objectives?
•
•
How have PGIP initiatives affected provider
attitudes and perceptions regarding practice
transformation, costs, and quality?
What has been the impact of PGIP on
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relationships among physicians and payers
•
in Michigan?
What has been the impact of PGIP on
utilization, costs, and quality?
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Stakeholder Interviews
Environmental Data Analyses
PGIP Data Analyses
PGIP Data Analyses
PO & Physician Data Analyses
Stakeholder Interviews
Stakeholder Interviews
Environmental Data Analyses
PGIP Data Analyses
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Key Informant Interviews (2011-12)
BCBSM
Other Payers
Total Sites Total Individuals
1
8
2
3
Employers/Purchasers
Other Stakeholders
Physician Organizations
3
5
11
5
9
25
Physician Practice Sites
35
58
46 sites
83 people
Total
Themes/Analysis Table/coding/Atlas.ti queries
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Overall Findings
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•
•
•
Physicians positive about the program
PGIP perceived as supporting primary care
Physicians valued the collaborative approach
Physicians energized to improve their practice,
become PCMHs and improve health of patients
How?
Why?
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Five Drivers of Successful Provider
Engagement in Quality Improvement
1. Vision of Improving Primary Care
2. Deliberately Fostering Practice-Practice
Partnerships
3. Utilizing Existing Infrastructure
4. Leveraging Resources & Market Share
5. Managing Program Tradeoffs
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(1) Vision for Improving Primary Care
• PGIP intentionally designed to support primary care
• Physicians believed the program was about this and
not simply about saving money
“The biggest catalyst for practice transformation is
creating a different culture. Registries are great, and
principles are great, but implementation of PCMH
through PGIP gave it a meaning. This helps people
understand not only individual parts, but also the whole
vision.”
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(2) Deliberately Fostering Collaboration
• BCBSM developed communities of practice
“They want to know what the physician community thinks.
They work with us, versus other companies who just tell us
what their program is and what to do.”
“There’s always someone who you can learn from.”
“Collaboration with other practices has been the most
helpful aspect of PGIP.”
“We’re all moving in the same direction and we’re helping
each other get there.”
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(3) Working with Existing Infrastructure
• BCBSM worked with existing physician
organizations to implement the program.
“PGIP works because of the physician organization
(PO) model. These doctors together have the
resources. The onesies and twosies who don’t play in
this will not make it.”
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(4) Leveraging Resources
• BCBSM market position helped secure
physicians’ attention and made the program
financially worthwhile.
“It is very hard to change physician behavior to “do
the right thing” …when there is money backing up the
guidelines, the money gives us a tool to help position
practices in the direction we want to go.”
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(5) Proactively Managing Trade-offs
• Flexibility and responsiveness meant a complex,
ever-changing program.
“Blue Cross asks us for ideas and is willing to
implement them….but sometimes it feels like the
program is always changing (as new initiatives are
implemented)”
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Impact on Physician Practices
• PGIP was associated with practical changes in:
• Staff and Workflow
• Adoption of health information
technology
• Use of LEAN Process Engineering
“…the whole practice is involved - even my billers
know when someone’s A1c level is too high…”
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Impact on Physician Practices
• PGIP inspired philosophical changes
• Population-focused model for clinical
improvements
• Improvement approach (rather than just
performance)
“I used to think I was the best primary care
physician anywhere. With the patient registry,
now I know I’m not and I am working to
improve.”
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Lessons Learned & Opportunities to
Improve
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•
•
•
Data
Program Design
Structural Shortcomings
Calls for Evaluation & Transparency
“They tell us it works, but it’s time to show us the
results”
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Summary: Successful Strategies
Strategy:
Specific Example(s):
Entire program focused on bolstering primary
care, with consistent messaging and
reinforcement.
Deliberately Fostering Support (financially and structurally)
Practice-Practice
communities of practice, connecting individuals
Partnerships
with common interests.
Utilizing Existing
Existing intermediary organizations support
Infrastructure
communication and physician integration.
Vision of Improving
Primary Care
Leveraging Resources Focus on areas with significant market share first.
and Market Share
Put money on the table early.
Managing Program
Tradeoffs
Develop flexible learning organizations with
robust communication as program elements
evolve.
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Questions?
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Bibliography
1. Alexander, J., G. Cohen, et al. (2012). "The Policy Context of Patient Centered Medical Homes:
Perspectives of Primary Care Providers." Journal of General Internal Medicine: 1-7.
2. Bitton, A., G. R. Schwartz, et al. (2012). "Off the Hamster Wheel? Qualitative Evaluation of a
Payment-Linked Patient-Centered Medical Home (PCMH) Pilot." Milbank Quarterly 90(3): 484515.
3. Cohen, G. R., N. Erb, et al. (2012). "Physician Practice Responses to Financial Incentive
Programs: Exploring the Concept of Implementation Mechanisms." Advances in Health Care
Management 13: 29-58.
4. Goldberg, D. G., S. S. Mick, et al. (2012). "Why Do Some Primary Care Practices Engage in
Practice Improvement Efforts Whereas Others Do Not?" Health Services Research: n/a-n/a.
5. Kreindler, S. A., B. K. Larson, et al. (2012). "Interpretations of Integration in Early Accountable
Care Organizations." Milbank Quarterly 90(3): 457-483.
6. Share, D. A., D. A. Campbell, et al. (2011). "How A Regional Collaborative Of Hospitals And
Physicians In Michigan Cut Costs And Improved The Quality Of Care." Health Affairs 30(4): 636645.
7. Share, D. A. and M. H. Mason (2012). "Michigan’s Physician Group Incentive Program Offers A
Regional Model For Incremental ‘Fee For Value’ Payment Reform." Health Affairs 31(9): 19932001.
8. Wise, C. G., J. A. Alexander, et al. (2012). "Physician Organization-Practice Team Integration for
the Advancement of Patient-Centered Care." Journal of Ambulatory Care Management 35(4):
312-323.
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Contact Information
Christy Harris Lemak, PhD FACHE
Director, Griffith Leadership Center
Associate Professor, Health Management and Policy
School of Public Health
Associate Professor, Surgery
University of Michigan
Chief Academic Officer, National Center for Healthcare Leadership
734-936-1311
chrislem@umich.edu