With value-based payment reform on the horizon, quality improvement in the family doctor’s office is about more than checking boxes
By Jonathan Nelson
You can’t manage what you don’t measure. It’s an old business adage that has long been associated with the science of continuous quality improvement and the lean management principles made famous by manufacturing firms like Toyota and Ford, but in the era of “Big Data,” the concept has arrived at the doctor’s office. For employers, private insurers, and public purchasers of health care services, it’s an idea whose time has come.
In 2004, the Rand Corporation published “The First National Report Card on Quality of Health Care in America,” which contained the troubling fact that on average, patients in the United States received the appropriate and recommended care only about 55 percent of the time. The results varied little, regardless of age, ethnic identity, socioeconomic status, gender, geography, or health insurance status. To fix the problem, the study called for system-wide investments in health information technology, performance tracking, and incentives for quality improvement.
The Rand study was just one of many to point out what was becoming ever more obvious: everyone in America was at risk for receiving poor care. Business organizations like The Leapfrog Group began calling for higher quality, increased accountability, and better value in the health care employers purchased, adding to the building pressure to transform the health care delivery system from one based on the quantity of medical services provided to one based on the overall quality of care delivered.
Even in its failure, the most recent attempt by Congress to repeal Medicare’s flawed payment methodology—the sustainable growth rate—sent a powerful message to physicians and their professional organizations. The legislation would have started a clock on the implementation of value-based payment reform in Medicare over the next three to five years. The message for physicians? Payment reform is coming, and physicians will be expected to demonstrate quality or they’ll find it increasingly difficult to keep their practices viable in the current fee-for-service payment structure.
Does your practice foster a culture of continuous quality improvement?
Jen Brull, M.D., is a rising star in the AAFP membership, and as a solo family physician in rural Plainville, Kan., she presents an excellent example of how family doctors can work together to improve quality and prepare their practices to thrive in this changing health care environment. She practices with a community of like-minded family physicians who function like partners; they’re all plugged in to the same EHR and patient database, and they collaborate to conduct continuous quality improvement projects as a group. From outside, the five family physicians and five non-physician providers look like a group practice, but they’re not. They each own their own independent practice.
Jen Brull, M.D.
At a TEDMED presentation she gave to an audience hosted by The Breakaway Group last spring, Brull described a realization many physicians experience once they begin to systematically assess their performance.
“If you start to measure your data, you will have those ‘Aha!’ moments. You will awaken to the fact that you are not as good as you thought you were.”
She told the audience about an early effort in 2004, when a state organization asked Brull’s family of practices to work on a quality improvement project for diabetic patients. At the time, the physicians had no EHR, so they set up a patient registry using some database software. It was a bit clumsy and it required entering information twice, once in the paper charts and once in the registry, but the project gave the physicians two tools that allowed them to deliver better care.
“It let us do point of care management of the individual patient, and it let us do population management of our whole group of patients, so we could see who we were missing, who was falling through the cracks when it came to diabetic care,” Brull told the audience.
“Many physicians assume they’re doing a fantastic job taking care of their patients, and they usually are with the people who show up in their office in front of them on a patient-to-patient basis,” Brull said in a video interview published online as part of the TEDMED series. “But oftentimes what physicians don’t realize is that they’re not necessarily taking good care of patients who are on the fringes. They don’t show up all the time. They don’t necessarily come for their chronic care appointments. And my message is that if given the opportunity and given the data—you have to have data to show you how you’re doing—physicians will desire to make that change and will use electronic health records and meaningful use to get them to that point.”
Brull and her merry band of independent physicians flipped the switch on their first EHR in 2008, and she says they’ve been quite happy with it. They joined a patient-centered medical home initiative in 2011, achieving level three recognition through the National Committee for Quality Assurance in 2013. Over the years, the physicians have developed a culture of continuous quality improvement.
“I found that I have a real passion for quality improvement work. It is probably one of the most exciting parts of my job for me.”
As new members have joined the team along the way, the commitment to QI has only strengthened. “Now we just have people that know that every staff meeting, we’re going to be looking at a different quality improvement project. We’re going to be seeing where we came from last time and where we’re going this time and what our goals are, and what are we trying to improve, and how might we get there. Everybody knows if they have a good idea, they’re going to be listened to.”
Many physicians are skeptical of assessing their performance on clinical quality measures because such efforts inevitably involve increasing the amount of required documentation. In other words, they don’t want to spend time and energy checking boxes. But Brull says the benefits begin to outweigh the costs once physicians see they are delivering better care for their patients.
“Many physicians assume they’re doing a fantastic job taking care of their patients, and they usually are with the people who show up in their office in front of them on a patient-to-patient basis. But oftentimes what physicians don’t realize is that they’re not necessarily taking good care of patients who are on the fringes. They don’t show up all the time. They don’t necessarily come for their chronic care appointments. And my message is that if given the opportunity and given the data—you have to have data to show you how you’re doing—physicians will desire to make that change and will use electronic health records and meaningful use to get them to that point.” – Jen Brull, M.D.
“You will not realize what you aren’t doing until you begin to measure it, and you can’t measure it if you don’t check the boxes.”
For example, Brull had one of those “Aha!” moments when demonstrating meaningful use of her EHR to the Centers on Medicare and Medicaid Services a couple of years ago. She had to report whether she asked patients if they smoked, and if they said yes, she had to report what action she took.
“The first year I did it—I wouldn’t have believed it until I ran the data—but I was not doing a good job at all about asking my patients if they smoked. Obviously if I wasn’t doing a good job of asking if they smoked, I sure wasn’t doing a good job of telling them not to, or offering support for them to stop.”
She developed a workflow that allowed her to document quickly and easily, and as she completed the documentation, she found she was much more likely to discuss the dangers of smoking and the importance of cessation, regardless of the patient’s reason for the visit.
“I had some great wins clinically from people who said, ‘Wow, you’ve talked to me about this three times this year. It must really be important. I guess I’ll quit,’” Brull says.
“That experience of ‘I’ve got to click the box’ turned into ‘I’ve got to talk to my patients’ and in that way, it drove a change that was really good in my practice. Had I not had to click the box, I don’t think that change would have happened.”
Will checking boxes lead to checks in your box?
Kurt Frederick, M.D., of Austin realized several years ago that value-based payment models for health care services were on the way, and the ability to collect, analyze, and report clinical data would be crucial to the success of his practice. His prediction is coming true, and the actions he and his partners have taken have positioned their practice to succeed in this new payment environment.
“I think measurement is inevitable,” Frederick says. “I think every other industry measures quality; they measure performance, and so we’ve been sort of insulated from that for years. But I think the cat’s out of the bag now. We’re going to have to measure what we do and be able to report on it.”
After years of having diminishing influence in the health plan contracts they signed, Frederick says he and his partners became convinced they had to transform their practice.
“We were a group of seven family practice doctors who had a pretty good business model and a good practice, and yet still we saw every year increasing pressures on our bottom line and decreased payment for certain services, and more forms to fill out and more hurdles to jump just to get the money that we thought we had contracted for.”
They needed more control in those contracts, and the only way to get it was to play the value game, he says. “Measure and report, improve quality and improve access for patients.”
They began meeting with local private physicians, seeking those interested in aligning with them, and once they had identified several, they hired a CEO to provide the business expertise they needed. Now they were a group of 20 family doctors with five locations under the new name Premier Family Physicians. They bought some land in the southwest part of town, and broke ground on a state-of-the-art 80,000 square foot multi-specialty facility.
In January 2014, they began seeing patients in the new Southwest Medical Village. Premier Family Medicine serves as the anchor practice of the facility, its partners having vetted and invited each of the specialty practices that are now on board. All must agree with the core tenants of increased quality and access to care.
“We also noticed that a number of other physicians were interested but they didn’t really want to take our tax ID and our exact business model, so we took the next step, which was to form a broader organization.” They formed a 250-physician accountable care organization, Southwest Provider Partners, LLC, and enrolled in the Medicare Shared Savings Program.
Kevin Spencer, M.D., one of the original partners of Premier Family Medicine, says the group now has a number of value-based contracts in place, with several more in the works. He says these contracts are mostly examples of a blended payment model.
“What that looks like is a per member per month fee up front to deliver clinical care coordination with the idea being that we would invest that as an organization into the staff and administration that it requires to manage patients in this way. Then there is a fee-for-service piece in the middle based on the volume of the care you deliver, and then a back-end piece, which is based on quality metrics or some sort of gain sharing based on your ability to deliver the care more cost-effectively.”
Kevin Spencer, M.D.
These value-based contracts are becoming available to Premier Family Medicine and other practices that have undergone similar transformations in large part because they have learned to leverage their data—not just the ability to collect, access, and report it properly, but the sophistication to recognize trends and understand what they mean. The lessons these practices learn in blended payment and shared savings models will prepare them for what might come next, when payers begin expecting physician groups to share risk across patient populations in global payment and capitated payment models. But for Spencer, the real benefit accrues to his patients who he says are receiving better care.
“What it allows me to do is focus added quality on the patients who really need it,” he says. “I’m able to identify my chronically ill patients, my 100 sickest and most expensive patients who have gaps in their care, or who could be getting their care in a more valuable way that’s easier on them.”
Whether it’s the ability to generate a list of diabetic patients who need a microalbumin screening and then send them a message, or the ability to quickly identify all patients taking a newly recalled drug, then notify them and issue new orders to their pharmacies, Spencer says the data allows his team to manage his patients’ health, not just treat their illnesses.
“So much of medicine has become care coordination and really shepherding the patient through the health care system and not just waiting for them to choose when they think they’re sick enough, or they read an article, or their family member bothered them enough that they should come in for a physical.”
Any patient of Premier Family Medicine who hasn’t had a physical exam in over 15 months gets an e-mail from the clinic complete with educational material on what a health maintenance exam is and why it’s valuable.
“It’s changing what we do fundamentally, both in the exam room and in the way we touch the patients and engage them in every way as we look at strategies on our patient portal, as we look at strategies when they call and talk to our phone operators, as we look at strategies when the nurses put them in the room.”
This kind of population management requires a huge investment in practice infrastructure, and today, payers are only beginning to pitch in. Spencer admits he and his partners have taken quite a risk, but they are confident their investment will pay off. “We believe it was right for our patients; we believe it was right for our office.”
He advises practices looking to begin this type of transformation that the first step is to understand your current health information technology and figure out what processes you can measure. “Can you run a report on an appointment type? Can you run a report on who hasn’t had a physical in the last year?”
Start small, he says, and because you probably won’t be paid for it in the beginning, focus on those clinical measures that help serve the patient while generating income. Physical exams and disease control measures for diabetic patients are good options to try. “Those are both good for patients; they improve measurements, and create income in a fee-for-service environment. So you start with those then you press the organization to be able to measure something.”
“What it allows me to do is focus added quality on the patients who really need it. I’m able to identify my chronically ill patients, my 100 sickest and most expensive patients who have gaps in their care, or who could be getting their care in a more valuable way that’s easier on them.” – Kevin Spencer, M.D.
Throughout the twentieth century, quality improvement philosophies and process management techniques revolutionized industries around the world, making businesses and products stronger, safer, and more efficient. In an industry as complex as health care delivery, the transition has been slow and halting. When it takes place, it happens in the exam room, practice by practice, group by group, and while a few high-performing health systems report significant success, the vast majority of the nation’s delivery system is just beginning to adapt.
Spencer believes the time is right for physicians in practices small and large to step forward and lead the change. “I think sometimes we get caught up on, ‘well, they’re measuring the wrong thing,’ and that can be true.” We are measuring too many things, he says, and some of them will surely turn out to be useless. “That’s why you need physician involvement and physician leadership.”
Physician leaders in practice transformation, in academia, and in physician organizations can work to identify those clinical quality measures that lead to better care outcomes for patients, improved quality in the delivery system, and lower health care costs—the triple aim. But divining which are the right quality measures to track and which should be discarded is battleground number two, Spencer says.
“Battleground number one is can we measure anything.”