2009 Projects

RESEARCH

These projects are designed to contribute to the body of literature and quantitative data analyzing the performance of accountable physician practices in the delivery of high quality and efficient care.

Dartmouth Group Practice Performance Study

In 2006, CAPP launched a study to analyze linked data from (1) CAPP multi-specialty group practices; (2) Medicare claims from Dartmouth’s Medicare fee-for-service claims database; and (3) National Survey of Physician Organizations (NSPO) NSPO1 and NSPO2 data on organizational attributes and care management processes at these organizations. The study provides insight into differences in performance across these organizations and the association between better performance and the presence of specific organizational attributes and specific care management processes. In addition, the study compares the performance of CAPP groups to other providers within their hospital markets. The research was led by Elliott Fisher, MD, of the Dartmouth Center for Evaluative Clinical Sciences; Larry Casalino, MD, of Weill Cornell Medical College and New York-Presbyterian Hospital; and Stephen Shortell, PhD, of University of California, Berkeley. In 2008, this study was completed. Results indicate that group practices generally outperform other providers in their regions on both quality and resource utilization measures. In 2009, a paper on this report was written and submitted to JAMA and the Annals of Internal Medicine.

STATUS: The paper has been published in Health Affairs.

Integration Quotient Study
In 2006, the CAPP Advisory Council recommended that CAPP collect best practices in (1) the use of IT and the EMR in the care of chronic conditions; (2) capabilities to provide feedback and guidance on the overall performance of a practice and its physicians; and (3) capabilities to provide patient-centered care. The study summarizes the current capabilities across the CAPP groups and examines the relationship between the degree of integration and use of care management processes. Findings indicate that the overall presence of care management processes was significantly and positively associated with measures of integration. Structural integration (i.e., having a hospital, home health, etc.) was related to use of care management processes, but not as strongly as clinical integration capabilities (e.g., IT interoperability, care arrangements across units). Even after adjustment for organizational characteristics that might account for some differences in care systems (e.g., organization size), associations of care systems and integration were still significant. Larger organizations, those with EMRs, and those providing coverage through their own health plan, show higher integration.

Participants in this project were HealthPartners Research Foundation; University of California, Berkeley; National Committee for Quality Assurance (NCQA); and Novartis. The principal investigator was Leif Solberg, MD, of HealthPartners Research Foundation; co-investigators were Stephen Shortell, PhD, and Robin Gillies, PhD, of U.C. Berkeley.

STATUS: Paper was published in August, 2009, by The American Journal of Managed Care under the title “Is Integration in Large Medical Groups Associated with Quality?”

LEADING CHANGE

These projects were designed to support policy positions or further the knowledge base about how multi-specialty medical groups provide care.

Payment and Delivery System Reform Roundtable
On June 5, 2009, CAPP, The Commonwealth Fund, and Kaiser Permanente Institute for Health Policy hosted a roundtable discussion on payment and delivery system reform in Washington, D.C. Attendees of the roundtable included many leaders of CAPP’s multispecialty medical groups and health systems; renowned academics and health care researchers; and private and government policy and health industry leaders. During the meeting, the group discussed a set of proposals for delivery system reform (including structural reform and payment reform), while examining a set of key design elements likely to determine the effectiveness and feasibility of those proposals. The objective was to formulate a set of recommendations for actions that Medicare can take to align payment incentives with desired improvements in health care delivery

STATUS: The Meeting Summary has been distributed to all attendees. A subsequent paper evolved from the meeting titled “How Can Medicare Lead Delivery System Reform?” authored by Dr. Jay Crosson, Nancy Taylor, and Rashell Young of The Council of Accountable Physician Practices, Stuart Guterman of The Commonwealth Fund, and Laura Tollen of the Kaiser Institute of Health Policy. The paper was published as a Commonwealth Fund Issue Brief on November 13, 2009.

“Partners in Health: How Physicians and Hospitals Can Be Accountable Together”
The concept of “accountable care organizations” has gained traction with the current health insurance reform debate, and there is increasing acceptance among industry leaders that care coordination that comes from system integration is necessary to achieve both the cost and quality goals of health reform. In light of these trends, a state-of-the-art book on physician-hospital integration (the centerpiece of delivery system reform) is not only timely but will be of great value as the debate progresses and pilot projects are developed. To this end, CAPP with the Kaiser Permanente Institute of Health Policy identified expert authors to write chapters for such a publication. A roundtable was held in July, 2009, to review ideas and chapter drafts, which include: a history of physician/hospital collaboration; a section on the obstacles and opportunities of such integration; a look at the barriers that stand in the way of improved collaboration and alignment; and a final set of policy recommendations that would foster change.

STATUS: This book was published by Jossey-Bass (Wiley) in 2010.

Delivery System Reform Tracking
This is a joint project of CAPP, The Commonwealth Fund, Kaiser Permanente Institute for Health Policy, and Alain Enthoven, PhD, of Stanford to develop a mechanism to understand and measure the evolution of delivery system reform to be integrated across the nation. The goal for 2010 is to publish a white paper that makes the case for such a tracking effort and that proposes elements that should be included (structural, payment and enabling tools) and can be measured.

STATUS: A roundtable meeting has been scheduled for March, 2010, and a concept paper is in the early stages of development.

Reporting Level Project
The current practice of reporting at the individual physician level in “transparency” initiatives doesn’t capture the value of care coordination, and encounters problems due to small sample sizes and difficulties in determining accountability for care when multiple providers deliver services.  CAPP embarked on research to better understand the impact of reporting levels on sample size needs, the number of available measures, and attribution methods. Variance among physicians, hospitals, or health plans has been evaluated as an intraclass correlation (ICC) in a quality measure, and low ICCs have been interpreted to indicate low potential for quality improvement at that level. The objective of this research was to examine changes in variance components at the primary care physician and medical facility levels as performance improved for four quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. The research has been completed and the conclusion is that low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all four indicators.

STATUS – This research has been published as “Meaningful Variation in Performance: What Does Variation in Quality Tell Us About Improving Quality?” Selby JV, Schmittdiel JA, Lee J, Fung V, Thomas S, Smider N, Crosson FJ, Hsu J, Fireman B., Medical Care. 2010 Feb; 48(2):133-9


COMMUNICATE

These projects are designed to increase our understanding of how to communicate the benefits of the multi-specialty group and integrated delivery system to all stakeholders within the context of federal efforts towards health care reform.

Consumer Health Reform Market Research
In 2008, CAPP completed a series of consumer focus groups to test marketing language and strategies promoting coordinated care. In 2009, we sought to further understand consumer attitudes about the kind of care they can receive in a “coordinated care” multispecialty group or organized health care system. With the support of the Kaiser Permanente Institute of Health Policy, CAPP conducted another series of eight national focus groups to determine consumer understanding of the difference between fragmented care and coordinated care, assess consumer acceptance of coordinated care, and explore the willingness of consumers to make tradeoffs in a transition to coordinated care.

The major finding from this study is that the majority of consumers would give up their current doctor to join a system that provided accountable coordinated care; however, most are not aware that availability of such a system is a current or even potential reality for them. A clear vision of what quality, coordinated care looks like needs to be created for the consumer, and then broad-reaching education of all stakeholders will be required to convince consumers that this vision of care is one they should expect from the American health care delivery system.

STATUS: The final report was written and disseminated to the CAPP Communications workgroup at end of June, 2009.

Accountable Care Public Education Strategy
Using the results of the 2009 focus groups, the Communications workgroup developed a strategy designed to establish a vision of quality coordinated care, build on opportunities to define accountable care in reform debates, and position our organizations as best suited to provide it. The workgroup agreed on a social marketing Internet campaign built around “Coordinated-Care.org.” The campaign involves three micro sites—one targeted to consumers, one to media, and one to policymakers—with content tailored for each audience. The consumer site provides a vision of coordinated, accountable care, FAQs about the benefits of care coordination and ACOs, tools with which to assess quality care, and case studies and patient testimonials, as well as an action center through which consumers can weigh in on care coordination. The media micro site, while similar in its purpose and some content, provides more case studies, facts and statistics, clear definitions of care coordination, ACOs, etc., and the ability to find experts in their media markets to contact for commentary on delivery system reform. The policymaker site likewise strives to educate policymakers on delivery system attributes that foster care coordination and accountability, provides patient testimonials on the need and benefits, and features a research packet that legislative staffers can download for a quick tutorial on care coordination and ACOs.

STATUS:
This campaign was approved by the CAPP leadership, has been funded by our CAPP medical groups, the American Medical Group Association, California Association of Physician groups, and the Alliance of Community Health Plans, and is currently in active development.  It is scheduled to launch in early second quarter 2010.