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Coordinated care significantly lowers primary care practice spending

Arnold Milstein

Monitoring patients outside of primary care visits, ensuring patients complete referrals to specialists and scheduling timely follow-up appointments — collectively known as coordinated care — were deemed the most significant attributes in lowering primary care practice costs, according to findings recently published in Annals of Family Medicine.

“No prior research had explored this question even though we are on the brink of large variation in Medicare payments to physicians based on value,” Arnold Milstein, MD, MPH, of the Clinical Excellence Research Center at Stanford University, told Healio Family Medicine.

Researchers visited 16 sites that ranked “favorably” on both low total annual per capita health care spending and quality based on measures used by CMS or endorsed by national quality organizations. Practices operated by large multi-state health care organizations largely subject to population-based payments, those that did not self-identify as providing adult primary care, and those with fewer than 30 attributed patients or only one practitioner were not included in the study.

Milstein and colleagues interviewed staff members on the performance measures and obtained compensation information to compare it with Medical Group Management Association norms. They found the most statistically significant attributes were:

• coordinated care, where teams keep track of patients outside of primary care visits: , making sure patients complete referrals to specialists and schedule timely follow-up after unexpected hospitalizations, and occasionally tracking medication adherence by communicating with pharmacies or counting refills (P = .006);
• risk-stratified care management, where each patient receives support tailored to his or her needs, care managers advise and monitor high-risk patients and schedule longer office visits, office staff makes repeated phone checks, and clinicians occasionally perform home visits (P = .012);
• careful selection of specialists, where primary care physicians rely on a carefully selected group of specialists that they trust to follow evidence-based guidelines and stay in close contact as treatment plans move forward when a specialist’s services are needed (P = .013);
• standing orders and protocols, where the practice develops such standardized procedures for chronic disease management and uncomplicated acute illnesses that nonclinician team members can implement them without needing direct clinician intervention (P = .02);
• decision support for evidence-based medicine, where the care team ensures that patients receive all evidence-based treatment and care, by making frequent guideline-based reminders available to clinicians in the electronic medical record and in some instances, office managers regularly run reports to distinguish care gaps to alert the care team to take action and physicians consciously avoid ordering tests that would not change management (P = .02); and
• balanced compensation, where physician salary is linked to value instead of just volume, and compensation reflects performance on at least one of the following components: contribution to practice-wide improvement activities, resource use, patient experience, and quality of care (P = .027).

The 12 high-value practices studied saw a 34% decrease in their annual health care spending, according to Milstein, who said he was a bit surprised by the findings.

“We expected that the distinguishing attributes of high-value primary care would primarily relate to what happens during office visits. We found that they related more to degree of engagement by physician-led teams between office visits,” he said, adding that none of the “distinguishing” attributes identified would take a significant amount of time for a PCP to implement. – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.

Editor's Note: On Nov. 20, this story was changed to clarify Dr. Milstein's first quote.