Center for Studying Health System Change

fforts by health systems and health plans to influence the delivery of care or change care processes are in their early stages. With respect to outpatient care, these efforts are occurring primarily under the aegis of the health system-owned PHOs. PHOs that accept global risk face the responsibility of managing care within a fixed budget. The increasing number of primary care physicians who are salaried health system employees facilitates implementation of new care initiatives by PHOs. These initiatives include restrictions on physician referrals, as well as physician profiling, practice guidelines, disease management programs and targeted quality improvement initiatives.

Referrals within Indianapolis are increasingly influenced by physician affiliations with PHOs and health systems and by financial incentives in PHO contracts. Primary care physicians employed by health systems such as St. Vincent’s and Methodist Health Group, for example, are expected to refer to other physicians affiliated with these systems, and global capitation contracts between PHOs and health plans typically are structured so that physicians refer to a "preferred" group of specialists. For example, American Health Network, which accepts global capitation, negotiates sub-capitated arrangements with selected specialists in the community, limiting referrals to these groups. To date, there are no data documenting the actual impact of these policies with respect to patient referrals.

The practices of individual physicians are monitored and evaluated using physician profiling techniques. For example, Community Hospitals monitors physician practices using a new profiling and quality assurance data system. St. Vincent’s distributes physician practice profiles to its physicians through its computer system, a practice that reportedly has upset a few physicians, although most have responded with questions and suggestions for change. American Health Network and SpecialMed also have implemented physician profiling activities. SpecialMed uses its physician profiling capabilities for benchmarking and quality improvement initiatives.

Clinical practice guidelines are used less frequently by PHOs and other organizations to influence care delivery, but they appear to be growing in importance. Most health care systems and some health plans in Indianapolis report that they have developed or are developing guidelines. Maxicare has implemented practice guidelines for several high-volume services. The corporate office provides guidelines for Maxicare to use, but they are reviewed by local physicians. Methodist has developed guidelines for nurses and physicians to use in treating various chronic and acute conditions, but these guidelines are relatively new and their impact has yet to be measured.

Disease management programs also are increasing in popularity with health care organizations in Indianapolis. Amid reports that its asthma center has had a positive impact on costs and clinical outcomes, American Health Network is developing a program aimed at diabetes management. Community Hospitals operates an outpatient program for patients with congestive heart failure and an eight-year-old diabetes management program, and is launching a program for pediatric asthma. Other health care systems in Indianapolis offer or plan to offer similar disease management programs. However, few data are available concerning the impact of these programs on patient health outcomes or the number of patients they serve.

Virtually all of the health systems operate targeted clinical quality improvement programs, which typically are triggered by reviews of claims data, physician profiling information or quality assurance audits. For example, American Health Network and SpecialMed have care councils, groups of physicians who meet monthly to review utilization and quality assurance data. These councils provide a forum for discussion of clinical management issues. Community Hospitals has a clinical improvement team that reviews clinical processes and outcomes for major inpatient DRGs in all its affiliated hospitals, an approach that reportedly has produced quality improvements and cost savings.

The impact of these various attempts to influence clinical practice is still unclear. In many cases, implementation is in its early stages. More important, these efforts do not appear to be well coordinated within organizations, although some systems are taking steps to strengthen their coordinating mechanisms. In addition, attempts to influence clinical practice are not always coupled with supportive financial incentives or information systems. Considerable change may be expected in this area if PHOs increase the number of individuals they serve under global capitation contracts.