FRESNO — A pilot project to improve the management of chronic disease and reduce health care spending has resulted in nearly a million dollars in savings over 12 months for a Central Valley school district.
The Fresno Unified Joint Health Management Board worked with the California Academy of Family Physicians in late 2010 to launch a patient-centered medical home initiative with a primary care medical group, Community Medical Providers.
The pilot project took 18 months of preparation and training, but the effort was worth it, said Catherine Direen, a media consultant for the California Academy of Family Physicians. It covered about 2,500 patients, 10% of the district’s beneficiaries. The cost of total claims decreased by 9% and the gross savings was $972,519. This was due in part to fewer emergency department and hospital visits and more patients adhering to their medications, she said.
“Implementing it is a huge deal, but the payoff was really quick,” Direen said. “It’s a well-proven model.”
The medical home model focuses on several critical factors such as data-driven improvement, population management, continuity of care and prompt access to care.
“It’s really a different way of taking care of the patient. It gets the whole office involved,” said Grant Nakamura, medical director for Community Medical Providers. “Part of it is making sure patients have access to the office and are seen in a timely fashion. The other part is developing registries so you know who all your diabetics are and you know which ones you need to control,” he said.
Key Practice Changes Led to Improvements
The physician group implemented broad-scale changes for the pilot project, Nakamura said. CMP hired a quality improvement coach to help providers focus on population management and identifying opportunities for betterment, such as improving blood pressure, blood sugar and LDL levels across an entire patient population. These efforts required data, generated through a registry and electronic health records.
Laurie Frye, the quality improvement coach, said a data-driven office doesn’t just rely on the personal experiences of the providers, but on actual numbers. For example, one physician told her all his patients with diabetes had A1C levels at seven or below. He was correct, she said, but what he didn’t realize was how many of his patients with diabetes hadn’t been seen recently and hadn’t had a current A1C test.
“That’s the challenge of manual charts and no registry,” said Frye. “That physician was practicing excellent medicine, but he needed more information to be able to deliver care where it was needed.”
A registry identifies the patients who need more care. It allows providers to reach out to patients and make sure they are taking their medications or checking their glucose levels as opposed to waiting for them to call for an appointment.
“For whatever reason, a lot of patients don’t take their meds,” said Nakamura. “When we see the patients now, part of what gets printed out now is their medicine adherence, how often they are filling prescriptions.”
CMP also uses registries to provide referral forms and lab slips when needed either in preparation of a patient’s office visit or to reach patients at home. For instance, CMP used the registry to run a list of patients who were due or overdue for a mammogram. Office staff members sent letters to these patients with referral slips enclosed.
Case Manager Reaches Out to High-Risk Patients
“If we’re going to try to get a hold on and manage chronic diseases, especially as we have more patients in a pre-diabetic state, we need to have additional support for our providers,” said Raquel Hernandez-Chavez, CMP’s complex case manager. “That continuity of care is key.” “If we’re going to try to get a hold on and manage chronic diseases, especially as we have more patients in a pre-diabetic state, we need to have additional support for our providers,” said Raquel Hernandez-Chavez, CMP’s complex case manager. “That continuity of care is key.”
Hernandez-Chavez reaches out to patients who are deemed at-risk by the registry. She is the person patients can turn to for answers without having to go through the hoops of another office appointment. She often gets the back story to a patient’s situation, the details he or she might not tell a physician. “When I sit down with them, they might say, ‘I can’t afford my meds’ or ‘I’ve got kids moving back in with me and I can’t afford to eat separate foods,'” she said.
Her goal is to help them make changes — even small ones. She asks patients open-ended questions such as what are your challenges, what can you do to improve the situation? She said this approach prompts patients to take more responsibility for their own health.
These broad changes led to a number of health improvements among the entire patient population, Nakamura said. For instance, the number of patients with diabetes whose blood sugar had been confirmed as under control increased by 50% and medication adherence among high-risk patients increased by 7%. Screenings for breast cancer also increased.
Fee-for-Service Pay Prevents Widespread Changes
With significant improvements in health and savings, why aren’t more providers embracing the patient-centered medical home model?
“The main reason why it hasn’t been more widespread really has to do with how providers are currently paid, which is fee-for-service,” said Nakamura. All of the extra outreach and follow-up work done by CMP is non-reimbursable because the doctor doesn’t physically see the patient.
He said his physician group had been looking at the PCMH model for years. “We had consultants come talk to us and they told us until a payer is willing to pay, don’t do it because it costs lots of money,” said Nakamura.
And then CMP found a payer. Fresno Unified agreed to pay a set amount each month to CMP to offset the cost of extra employees and the technology upgrades. That sum is in addition to the usual fee-for-service payments. On top of that, there are bonuses for achieving certain quality markers such as cost reductions and improved health of patients.
Fresno Unified was able to pay the extra money by terminating another disease management program it had tried that wasn’t very successful, said Devon Devine, practice leader at Claremont Partners, a consulting firm that assisted the school district’s Joint Health Management Board.
“Now that we’ve demonstrated the effectiveness of the model, we need to figure out a way to expand that,” said Devine.
Nakamura said CMP also would like to expand the model to all of its patients. “The 2,500 patients from Fresno Unified only make up 2% of our patients, and we’ve saved them close to a million dollars,” he said.
“The thing I like about this the most is now we know we’re taking the best care possible, getting the best outcomes we can and improving the quality of patients’ lives,” Nakamura said. “Professionally that’s very satisfying.”