Center for Studying Health System Change

ith a few notable exceptions, respondents did not identify significant changes taking place in clinical practice or delivery of care. Clinical practice can be characterized by the following observations:

• Physician referral patterns in Little Rock are largely informal and relatively undefined.

• Physicians -- not health insurance companies or their agents -- drive clinical decision making, with specialists still controlling a large number of those decisions.

• The balance of power between specialists and primary care physicians may be shifting slowly to the latter.

• Profiling information and other sources of data are increasingly being used to make clinical decisions.

• Hospitals are using case management and other techniques to reduce the cost of inpatient care.

• Formal and informal group practices are developing.

The emerging shift in power from specialists to primary care physicians may be attributed to two different forces, respondents said: declining professional fees that discourage primary care doctors from referring to specialists as readily as they once did, and the growing number of people in health plans that use gatekeepers to control specialty care use. No quality issues were raised with regard to this shift in power. Declining fees have also reportedly led an increasing number of specialists and primary care doctors to increase their patient volume by traveling to outlying towns to maintain their income.

Another emerging change in clinical practice is the use of physician profiling data to disseminate information to clinicians and the use of this data by health plans to alter physician behavior through payment incentives. Health Advantage appears to be going to great lengths to get physician support for the profiling initiative, with limited success. For instance, plan officials conduct one-on-one consultations with providers to explain their own profile results and are reportedly recruiting local doctors to lead efforts to modify performance benchmarks and other aspects of the practice, guidelines based on input from other clinicians in the area. Other plans and some area hospitals are using similar profiling tools solely to provide providers with educational feedback in hopes of encouraging practice changes.

Despite these activities, Little Rock’s profiling systems still appear to be at a fairly modest stage of development and tend to focus on resource use and medical transactions (for example, total spending per member, average length of stay, number of procedures per patient, etc.) rather than clinical outcomes or other measures that focus directly on quality of care. Moreover, there is no evidence that these profiling systems are looking at episodes of care, a unit of analysis that extends across treatment settings and over the course of an illness or disease. Respondents said that these limitations restrict the power of existing profiling tools.

A small number of hospitals in Little Rock also report using clinical pathways and other techniques to control the cost of hospital care and improve patient outcomes. Clinical pathways -- detailed guidelines for inpatient care -- are becoming important care management techniques at both Baptist and University Hospital, although to date such pathways have only been implemented for a handful of conditions. Baptist Health has also launched case management programs in each of its hospitals. Under these programs, a nurse or social worker is assigned to selected patients with conditions or procedures that tend to result in long lengths of stay. These "care coordinators" use patient care conferences and standardized care protocols, among other tools, to reduce patients’ average length of stay. Respondents say this program is largely responsible for both a drop in the hospital’s average length of stay of two days over the last two years and a moderate decline in average resource use per admission.