hanges in care delivery have evolved over a long history of care management by physician organizations. Increased managed care penetration has served as a strong impetus for physicians to refine their practice efficiency. Financial incentives have prompted primary care providers to retain as much of the scope of care as possible. Referral patterns to specialists are strongly influenced by the manner in which these services are reimbursed. Organizational changes may produce greater uniformity in clinical service delivery patterns as the physician organizations that are growing in size attempt to disseminate best practices across their organizations.
Respondents said that physicians are in the driver’s seat in controlling care delivery. Physician groups and IPAs have developed techniques to deliver and manage care under capitation. HMOs, where possible, have delegated substantial care management responsibilities to these physician groups or IPAs with whom they contract. Some health plans have retained responsibility for collecting physician-level information to share with contracted providers.
Physician management companies, such as MedPartners, do not tightly control or monitor clinical management decisions; they leave considerable latitude to their subsidiary groups. IPAs report difficulty in integrating or directing care across multiple, distinct practices. Within a medical group, individual physician autonomy is subsumed, in part, by the group’s policies for referrals and utilization management. In groups that receive a large share of their revenue through capitation, physicians have implemented stringent gatekeeping norms and rules to preserve the group’s financial viability. Independent physicians, particularly specialists, who contract with groups or IPAs refer to them as "managed care organizations" because they construct sub-networks for contracting with specialists and then act as the referral agent and the utilization reviewers.
Direction of business to non-primary care providers reportedly is tightly controlled by the primary care physician gatekeepers within a beneficiary’s selected plan. The Friendly Hills Medical Group, Bristol Park Medical Group and Monarch IPA, for example, have different referral patterns for inpatient care. The details of each physician-hospital risk pool agreement provide physician organizations with different incentives for choosing specific hospitals to concentrate their business. As discussed, physician-hospital alignment historically has been quite loose. In particular, the St. Joseph’s Health System is attempting to increase the level of physician-hospital business integration through contracting arrangements it has structured through its medical foundation.
Physicians have developed and relied on a variety of measures to aid them in delivering and managing care. Many physician organizations, hospitals and health plans report that they have developed and implemented practice guidelines within the past four years. Plans and hospitals typically provide guidelines on a voluntary basis; some physician organizations are more likely to require their use. Clinical protocols are used to manage costs of complicated, high-cost and high-risk procedures, such as bypass surgery, or clinical conditions, such as congestive heart failure. Some hospitals and physician organizations reported having more than 60 guidelines, with still more in development.
Respondents described a trend among some medical groups and IPAs to maintain hospital-based admitting teams that specialize in managing the care of inpatients and can control utilization.
Having picked off the "low-hanging fruit" by shortening hospital stays and moving services to outpatient settings and reducing ancillary use, disease management programs are viewed as the next frontier to managing utilization. Providers and health plans are designing disease management programs; some are already applying disease management to asthma and diabetes and are looking to expand this approach to other diseases. Specific disease management tools include developing mechanisms to identify disease management candidates, providing intensive case management and patient education, compiling literature and clinical information on specific disease categories and developing monitoring approaches, including telemonitoring. The focus is on targeting patients at risk for high service use and costs and developing mechanisms to reduce costs while improving outcomes.
Financial incentives tied to utilization or practice style are common, and reportedly play a strong role in influencing physician behavior. The scope of primary care depends in part on whether specialists are paid on a sub-capitated, salaried or fee-for-service basis. Physician and physician-hospital risk pools that stipulate payouts based on specific utilization targets (e.g., length-of-stay targets, hospital admission targets) are prevalent. Some plans report that physicians are seeking more responsibility (through expanded scope of services and capitation) for ancillary services such as pharmacy, vision and mental health services.
Some physician respondents expressed concern regarding the impact of widely used financial incentives on the ultimate quality of care. A few respondents are worried that financial incentives are already resulting in late referrals by primary care providers trying to manage their financial liabilities. Continued financial pressure may exacerbate these trends.
Physician organizations, plans and hospitals conduct physician profiling to provide feedback to physicians, monitor performance and perform credentialing. In particular, physician organizations, especially the longest-standing groups, collect a large amount of data at the physician level. Previously, physicians used this information mainly to compare their practice patterns and cost with those of their peers. Some provider groups are incorporating quality-associated measures into their physician bonuses. Such measures include consumer satisfaction, appointment waiting times, specific chart review results, peer surveys or reviews, productivity, cost, utilization and outside referrals.
While community-wide information is available on health insurance premiums and health plan HEDIS measures, community-wide, provider-specific information reportedly is lacking. Individual organizations, including physician groups and health plans, collect and control use of this information.
Although ownership of providers and health plans is consolidating, clinical services are not integrated across practice sites or organizations. Within hospital systems, each facility manages its own clinical programs. There was no evidence of joint clinical programs, standardization of guidelines or sharing of information across hospitals within provider systems. Within physician corporations, each physician group or IPA remains responsible for its own clinical protocols, utilization review and quality assurance, although some information may be shared within the organization. Much information is collected by physician organizations, but not all of it is computerized. Information collection efforts are duplicated across different organizations.
The Kaiser system is an exception to this general rule. Kaiser has planned a systemwide electronic medical record that will enable physicians to share information across the organization. Kaiser has initiated systemwide health promotion and disease management programs that follow members across sites of care. The St. Joseph’s Health System is also planning a major investment in a joint physician-hospital information system.