Physician Engagement is Critical to the Success of …

1 | Vol. 16, No. 3 | Journal of Managed Care medicine 67introductionaDvantaGe health solutions, inC. (ahs), a local health plan that insures many em-ployer groups in indiana, wanted to test the hy-pothesis that provider Engagement with aligned incentives could improve outcomes on a specific population with a benefit structure typically not amenable to usual health plan interventions. one of the large employer groups insured by ahs with about 5,000 employees and dependents has a benefit plan that does not discourage over utilization of cer-tain low-value but high-cost medical services and is not amenable to the usual utilization management strategies.

2 For example in 2011, the copayment for pCp office visits was $25; copayment for emergen-cy room visits was $0; copayment for advanced im-aging services such as computed tomography (Ct), magnetic resonance imaging (mri) and positron emission tomography (pet) scans was $0; and the cost differential between generic and brand name drugs was just $ was overutilization of emergency room services for nonemergent problems that was nei-ther cost effective nor safe for the members. most of these nonemergent conditions like upper respiratory illnesses (uri), urinary tract infections (uti) and summaryPhysician Engagement is Critical to the Success of any program where physicians are accountable for the quality, cost and overall care of an assigned population of patients like an accountable care organization (aCO).

3 It is well known that physi-cians control the majority of health care cost. however, as overall health care cost is a factor of unit cost and utilization rate of services, physicians could impact utiliza-tion of services but still not be able to control overall health care cost due to lack of control of cost of hospital-based services and outpatient procedures. The aCO could mitigate this problem through price transparency where providers are given ready access to the unit price of certain high-cost services by the provider and facil-ity so they can direct their patients to lower cost settings/providers assuming the quality of care is comparable.

4 The aCO could also provide the referring physicians a list of preferred specialists or hospitals with not just lower pricing but also better outcomes. Key p oints The level of Physician Engagement could directly affect the level of achievement of the triple aim better care for individuals, better health for populations and lower growth in expenditures. Physicians make decisions that control 87 percent of health care a lignment of incentives will increase Physician Engagement . Overall cost is determined by both utilization of services and unit cost of services. Physicians, especially primary care physicians (PCPs), have very little control over the cost of hospital- based services and most outpatient procedures.

5 To improve overall cost, providers should partner with hospitals to reduce both utilization and unit cost of services. although aCOs sponsored by Physician groups have seen more growth recently, the majority of aCOs are still sponsored by hospitals5. To remain competitive in the post health care reform environment, these hospital-sponsored aCOs have to reduce overutilization of services and lower their pricing. The lost revenue from reducing unit cost and decreasing over utilization of services could be recouped from the shared savings agreements with Engagement is Critical to the Success of any Accountable Care Organizationanthony N.

6 Akosa, Md, MB a68 Journal of Managed Care medicine | Vol. 16, No. 3 | removals could have been easily handled by the members primary care physicians. Creating a medical home for every member would give them access to personalized, coordinated and comprehensive primary care when it is convenient for them. this would improve both the quality of care provided to the members and member satis-faction. ahs also felt that Physician Engagement would be the key to decreasing the overutilization of some of these low-value but high-cost services as physicians serve as key advisors to patients and make decisions that control 87 percent of personal health goals and objectivesthe goals of the program are similar to achieving the institute for healthcare improvement (ihi) triple aim: improve the health of the population, enhance the patient experience of care (including quality, access, and reliability).

7 And reduce, or at least control, the per capita cost of program objectives are: avoidance of unnec-essary utilization, especially emergency room and advanced imaging (Ct, mri and pet scans); uti-lization of services at the right place and right time; for example, encouraging the members to utilize urgent care centers after hours for nonurgent prob-lems like uri instead of going to the er; part-nering with providers to promote outreach, health prevention and patient Engagement ; improving ge-neric utilization rate when appropriate by providing generic alternatives at point of care (provider prac-tices); and improving member satisfaction of overall care provided.

8 There were three provider groups in one of the counties in indiana to whom all the members were assigned and they were named provider Group 1 (Group 1), provider Group 2 (Group 2) and pro-vider Group 3 (Group 3). ahs met with Group 1 and Group 2 to explain the program, the provider incentive and the provider Dashboard for each pro-vider. Group 3 was not engaged in the program and did not meet with ahs. although Group 3 was not engaged, ahs still sent information about the pro-gram to the members assigned to them. the program was called a shared savings incen-tive program and comprises: member Engagement activities e xhibit 1.

9 Advantage health solutions, Zero Copayment Prescription drug l isting for 2011acyclovir (ZOVira X)albuterol soln neb (aCC uNeB)allopurinolamitriptyline (ela Vil )amitriptyline hcl/perphenazine (eTraf ON e/fOrTe)amitriptyline hcl/perphenazine (Tria Vil )amitriptyline/chlordiazepixide (li MB iTrOl)amoxicillin & k clavulanate (aug MeNT iN)amoxicillin & k clavulanate susp (aug MeNT iN susP)amoxicillin (aMOX il )antipyrine/benzocaine (auraglaN)atenolol (TeNO rMiN)atropine sulfate (is OPTO aTrOP iNe)baclofen (li Oresal)belladonna alkaloids (aNT i-sPas )belladonna alkaloids (dONN aTal )benazepril (lOT eNsi N)benzonatate (TessalON P earls)benztropine (COge NT iN)betameth/propylene glycol (di PrOle Ne af )betameth/propylene glycol (di PrOle Ne)betamethasone dipropionate (di PrOsON e)betamethasone dipropionate (MaXiVaTe)betamethasone valerate (Valis ON e)bisoprolol (ZeBeTa)bumetanide (BuMeX)buspirone (Bus Par )captopril (CaPOT eN)captopril/hctz (CaPOZ ide )carbamazepine (Tegre TO l)carbamazepine sr (Tegre TO l X r)carvedilol (COreg )cephalexin (Kefle X)chlorhexidine (PerideX)cimetidine (Taga MeT)ciprofloxacin (Cil OX aN)citalopram (Cele Xa)clonidine (CaTaPres )

10 Clonidine hcl/chlorthalidone (COMBiPres )cyclobenzaprine (fle Xeril )dexamethasone (de Cadr ON)dexamethasone (he Xadr Ol)diclofenac ophth sol (VOlTare N OP hTh sOl)diclofenac potassium (CaTafla M)diclofenac sodium (VOlTare N/X r)dicyclomine (BeNT yl )digoxin (la NOX iN)diltiazem (Cardi ZeM/ sr /C d)diltiazem (dila CO r X r)diltiazem (TiZaC)doxazosin (Cardura)doxepin (si NeQua N)doxycycline hyclate (Peri OsTaT)doxycycline hyclate (ViBra MyCiN)doxycycline hyclate (ViBra -T aBs)enalapril (Vas OT eC)enalapril/hctz (VasereTiC)erythromycin base (eMgel )erythromycin base (e-M yCiN)erythromycin base (ery CeTT e)erythromycin base (eryderM)erythromycin base (erygel)erythromycin base (ery MaX)erythromycin base (T-sTaT)erythromycin base/benzoyl peroxide (B eNZ aMyCiN)erythromycin ethylsuccinate ( )erythromycin ethylsuccinate (ery -P ed )erythromycin stearateerythromycin/sulfisoxazole (Pedia ZO le )estradiol (es Tra Ce Tabs)estropipate (Oge N)estropipate (OrThO- es T)famotidine (PePC id )fluconazole (difluCaN)fluconazole susp (difluCaN susP)fluocinolone acetonide (sy Nalar )fluocinonide (lide X/ e)fluoxetine (PrOZ aC)fluphenazine hcl (Per MiTil )fluphenazine hcl (PrOli XiN)