Center for Studying Health System Change

reenville’s providers are only in the early stages of implementing financial incentives and formal systems to monitor and improve clinical care. Financial incentives are limited to primary care physician capitation and small-scale global risk arrangements among PHOs. According to some respondents, financial incentives for hospital-based or group practice physicians are more likely to be linked to productivity measures, such as patient volume, than to other measures of performance.

Several HMOs mentioned "incentive programs," in which primary care physicians are eligible for bonuses based on access (e.g., hours of operation), quality (e.g., chart reviews, patient satisfaction) and utilization measures (e.g., specialty referral rates, inpatient days per 1,000 population, compared with their peers). However, because HMO penetration is low, these incentives only apply to a small proportion of patients, limiting their impact on physician behavior.

Most major hospital systems, physician groups and health plans in Greenville are reviewing or have implemented practice guidelines. Guidelines are used primarily as an educational tool without strict monitoring to ensure compliance. For example, Greenville Hospital System reported using nine inpatient-focused practice guidelines and Carolina Multispecialty Associates reported using radiology guidelines to encourage appropriate use of CT scans and MRIs. The Companion HMO has established physician committees to develop and promote practice guidelines.

Providers and health plans are also interested in disease management, but few such programs have been implemented. Companion HMO’s asthma program uses telephone contacts and home health visits to monitor patient status and ensure appropriate medication. Greenville Hospital System is examining variations in pneumonia care, orthopedic treatment, cardiac catheterization and cardiac surgery by reviewing utilization data, average length of stay and readmission rates. Several organizations mentioned the use of Milliman & Robertson’s appropriateness guidelines to review selected cases.

Clinical decision making in Greenville is controlled by physicians, according to respondents. Hospitals, PHOs and managed care plans have relatively little influence over physician practice, although external measurement and management of clinical care may expand under global capitation arrangements. For example, St. Francis is contracting with North American Medical Management, a PhyCor subsidiary company, to implement financial and care management systems for capitated contracts in its PHO.

Carolina Multispecialty Associates is reported to have developed the most advanced clinical practice management capabilities. Its staff and contracted network include most major specialties, and the group reportedly is negotiating risk contracts with health plans. Carolina Multispecialty is also implementing practice guidelines in respiratory-related conditions, rehabilitation, outpatient surgery and other areas. In addition, it is developing clinical information systems to profile physicians and compare their performances against specific benchmarks.