The American Journal of Managed Care January 2007
Productivity Enhancement for Primary Care Providers Using Multicondition Care Management
Objective: To assess the impact of a multicondition care management system on primary care physician efficiency and productivity.
Study Design: Retrospective controlled repeated-measures design comparing physician productivity with the proportion of patients in the care management system.
Methods: The setting was primary care clinics in Intermountain Healthcare, a large integrated delivery network. The care management system consisted of a trained team with nurses as care managers and specialized information technology. We defined the use of the care management system as a proportion of referrals by the physician to the care manager. Clinic, physician, and patient panel demographics were used to adjust expected visit productivity and were included in a multivariate mixed model with repeated measures comprising work relative value units and system use.
Results: The productivity of 120 physicians in 7 intervention clinics and 14 control clinics was compared during 24 months. Clinic, physician, and patient panel characteristics exhibited similar characteristics, although patients in intervention clinics were less likely to be married. Adjusted work relative value units were 8% (range, 5%-12%) higher for intervention clinics vs control clinics. Additional annual revenue was estimated at $99 986 per clinic. These additional revenues outweighed the estimated cost of the program of $92 077.
Conclusions: Physician productivity increased when more than 2% of patients were seen by a care management team; the increased revenue in our market exceeded the cost of the program. Implications for the creation, structure, and reimbursement of such teams are discussed.
(Am J Manag Care. 2007;13:22-28)
Primary care physicians who engaged in Care Management Plus, a program using care managers and technology to help manage complex patients, had 8% to 12% increase in productivity. Such improvements occurred when physicians adopted and sustained the program, using it intensively. Decision makers should be aware that:
- The increased relative value units (RVUs) paid for the cost of the care manager, leading to increased adoption across the system.
- Increased RVUs were only partially from increased visits; increased documentation and selection of different physician activities also contributed.
- Environmental conditions (fee-for-service, unmet demand) likely created the opportunity to increase productivity and remuneration.
- Minimum clinic size to successfully pay for the program was 7 to 10 physicians; other clinic sizes would require different reimbursement structures.
- Other benefits included higher satisfaction and quality of care.
Almost half of the American population (125 million people) live with some type of chronic disease.1 Evidence suggests that more than half of patients with hypertension, diabetes mellitus, hyperlipidemia, congestive heart failure, chronic atrial fibrillation, asthma, and depression are managed inadequately.1,2 So great are the need and potential for improvement in chronic disease management that the Institute of Medicine specifically identified chronic disease care as a primary quality improvement area.3
Care management, which involves systematic restructuring of care to assure high quality, has been recommended as a potential solution to the challenges of chronic disease care.4 The broad definition of care management described herein includes disease management programs and some case management programs that directly address medical care. By assuring life-saving treatment and by keeping people healthier, care management could save more than $100 billion and thousands of lives annually.5 Many care management programs have taken the form of disease management (adopting guidelines into protocols to ensure higher adherence for specific diseases) or case management (focusing on the patient and his or her family, with patients often selected from among the small percentage that represent the highest cost and utilization). These programs have typically been initiated by the health plan or the employer with the intent to capture savings from the reduced costs of care. They are frequently delivered using telephone and information technology, and initial uncontrolled studies4,6 show some promise for effect.
An alternative to disease management programs is care management in the form of the chronic care model. The chronic care model is a multistep program that creates a clinical care team in ambulatory settings, which has shown significant improvements in process and intermediate outcomes in a number of chronic conditions.7 However, adoption of primary care-focused care management systems has been slow. In part, this is because of incentive structures within the reimbursement system.4 Whereas health plans or employers can reap the benefits of reducing costs for their sickest patients, physician groups that incur the costs of implementing and operating programs often do not receive the associated savings of such an investment. For example, a physician's office with a robust program may generate less revenue because healthier patients need less care.8
One possibility is to create a business case for these programs (especially for the most complex patients) in the outpatient clinic through increases in productivity. Because most patients with chronic illnesses receive care in primary care settings, efficiencies may be gained if these sites of care could provide high-quality secondary preventive care for multiple disease states.9,10 Care management programs can theoretically improve productivity. Because patients who present with multiple challenging problems often reduce productivity in a fee-for-service (or visit) system,11 educating patients to manage their own diseases (self-management) and providing a more seamless interface for their interaction (part of the chronic care model) could reduce these inefficiencies, while improving outcomes.12,13
Augmentation of these models could also provide the flexibility and prioritization needed for patients with coexisting illnesses, who account for most of the expenditures in Medicare.14,15 Furthermore, care management offers the promise of improved efficiency through minimization of patient barriers and reduction in the need to implement several different programs for each disease. However, empirical studies in this area are lacking.
The objective of this study is to address this need. We created a model for complex patients based in part on the chronic care model. In this model, called Care Management Plus (CMP), a team approach is used in an attempt to create efficient high-quality care. In the CMP model, nurse care managers are positioned in primary care clinics of moderate size (6-10 physicians) and are given extensive training in disease management protocols, motivational interviewing, and assessment of social, economic, and other patient barriers.
While the motivation for employing CMP care managers is to improve the quality of care, CMP may also help physicians to be more productive by reducing the complexity of the office visit, increasing patient understanding, and allocating team tasks more effectively. The opportunity costs for other clinicians relative to these largely unbilled or underbilled tasks may be less as well. In this article, we evaluate the effect of CMP on a specific measure of the productivity of physicians in fee-forservice systems (as measured by work relative value units [wRVUs]). This measure, while limited, relates immediately to revenue generation for these clinics. Our hypothesis is that, as a larger proportion of their regular panel is seen by care managers, physicians will have more productive visits with patients, creating capacity for additional revenue generation, which can allow the clinics to afford some of the costs of the programs.
Intermountain Healthcare is an integrated delivery network consisting of 20 hospitals and more than 1200 employed and affiliated physicians in Utah and Idaho. The 450 physicians employed by the Intermountain Medical Group work in 1 of 92 clinics and provide more than 3 million outpatient visits each year. Clinics have multiple payers, including Intermountain Healthcare, private insurances, and Medicare and Medicaid. Within 7 of its ambulatory clinics that serve adult patients with a diverse spectrum of diagnoses and needs, Intermountain Healthcare augmented primary care services by hiring 1 onsite care manager per clinic. These care managers receive training to address new standards of care as they are adopted by Intermountain Healthcare, as well as ongoing reviews and updates on chronic disease management, care for senior patients, and assistance with barriers of care commonly faced by patients. They also use information technology to access patient information, ensure compliance with adopted standards of care, and improve communication with physicians and other care team members.
Selection of Participants
Physicians were the primary unit of analysis. We divided physicians into the following 4 groups: (1) physicians in the intervention group who did not use CMP or who used it at very low levels, (2) physicians in the intervention group who initially used low levels of CMP or no CMP and increased their use to high levels, (3) physicians in the intervention group who used CMP at high levels throughout the study period, and (4) physicians in the control group who had no access to CMP.
The use of CMP is voluntary, and physicians adopt it at various rates. However, the formal introduction to the program instructs physicians to refer the most complex subset of their patients (usually 3%-5% of the panel), focusing on patients with diabetes mellitus, depression (and other mental illness), cardiovascular disease, and significant social, agerelated, and financial barriers.
To account for referral bias in a voluntary program, our empirical approach was designed to isolate the effect of CMP on physician productivity by focusing on the group of physicians who increased their use of CMP (to act as a set of pre-post control subjects) and by comparing their increased productivity with any changes in the baseline productivity of the control group. In a second set of analyses, we expanded our sample to include physicians in the intervention group whose use did not change over time (ie, they used low levels of CMP or no CMP, or they used high levels of CMP). By increasing our sample, we improved the efficiency of our estimates, at the cost of introducing potential bias associated with greater self-selection.
We included providers who were primary care physicians who saw adults (internists and family practitioners). The providers had to practice at a clinic that had care managers or that was similar to the care manager clinics in terms of specialty, ancillary care, number of physicians, and access to information technology. Finally, the providers had to see patients at least 7 half days per week (80% of a full-time equivalent). Most were full-time providers (8-9 half days per week).
The intervention is described in detail elsewhere.9 Briefly, once patients are referred to the care management system, the care managers (all registered nurses [RNs]) assess patients and caregivers for readiness to change and for current needs, educate them in their diseases and self-management, and create a comprehensive care plan. Care managers also attend visits with other providers, advocate for their patients, and suggest changes in treatment plans as needed. Role-specific adaptations of the information systems allow easy access to various disease guidelines and to the patients' current adherence to them and summarize patient information, reminder lists, and previously formulated care plans.16,17 The care managers are generalists in that they prioritize and treat a large number of illnesses, attempting to create a comprehensive plan that addresses multiple needs. Care managers are encouraged to not simply follow protocols but to create flexible care plans that specifically meet patient needs and to help the patients and caregivers to overcome barriers.
The benefit of the intervention to the physician would occur following the referral to care management, on the patient's return to the physician's practice, with the patient educated, motivated, and ready to manage his or her illnesses. Therefore, the intervention is measured as a percentage of the physician's unique patient population (referred to as a panel) seen by a care manager within 6 months. This percentage increases as the referrals by the physician increase and as the care manager continues to actively follow up the patients.18 We estimated that 3% to 6% of the average clinic population in the study would be appropriate for care management based on age, comorbidities, and severity of chronic illness. Therefore, a cutoff of 2% was selected as the transition between low use and higher use of the care management system. This study was approved by the appropriate human subjects research ethics review committee.
We defined the independent variable of interest, the percentage of patients in a physician's panel seen by care managers, as an indicator variable, assigning values of 1 for referral rates of 2% or more and 0 for referral rates less than 2%. To adjust for other factors that might affect physician productivity, we included random effects for the region and clinic, as well as physician-level variables, including time since last training, sex, specialty (internal medicine or family practice), age, and time in the system.19