Insurer, physicians team up for patient care

Goal of ACO pilot to increase quality, cut costs

When CIGNA members being treated by Piedmont Physicians Group in Atlanta are high-risk or noncompliant, Jennifer Farlow, RN, BSN, clinical care coordinator, contacts them and helps them get back on track for regular visits and recommended tests and procedures.

The health plan and the physician group split the cost of Farlow's salary as part of the two organization's accountable care organization pilot project.

The program, which began July 1, 2010, focuses on 10,000 individuals covered by CIGNA who receive care from one of more than 100 primary care physicians who are members of the Piedmont Physicians Group.

"Our goals are to increase quality and decrease the cost of care at the same time. We believe that we can achieve better clinical outcomes by collaborating to ensure that patients are receiving recommended care in a timely manner," says David Epstein, MD, CIGNA senior medical director for Georgia.

Epstein and other CIGNA officials meet every other week with the physician practice operational group and every other week with the clinical team to discuss how the project is going and to brainstorm on any changes that need to be made.

CIGNA is providing data from its own case management and disease management program to the Piedmont organization.

"We are sitting at the table with providers, and for the first time in my career, I feel that instead of duplicating resources, we are sharing information and optimizing resources," Epstein says.

Farlow enhances patient care by coordinating CIGNA data and clinical programs of the Piedmont Physicians Group, Epstein says.

Each month, the health plan sends two reports to Farlow. A gap report shows patients who are missing recommended care, such as a diabetic who hasn't had a hemoglobin A1c test recently or a patient with heart failure who hasn't filled his prescription for a beta-blocker.

The other report, called the previse risk report, shows who is at highest risk in the patient population, such as patients who use the emergency department for certain diagnosis codes.

When CIGNA's claims information indicates that a patient has a gap in care, Farlow reviews the chart in the electronic medical record to make sure that the patient hasn't already seen the doctor.

"Sometimes there is a lag in the claims data, and when I look at our records, I find that the patient saw the doctor last week," she says.

When she identifies patients who have gaps in care, Farlow makes an outreach call and works to get them back in to see the doctor.

"When a doctor tells a patient to follow up in six months, he or she has to trust the patient to follow up. This program gives us a chance to make sure that they do follow through," she says.

Farlow contacts all patients who show up on the gap report, regardless of their disease state or medical conditions.

"Many patients have multiple comorbidities. When I call the patients, I find out how educated they are about their conditions and identify their goals. I reinforce the education they have gotten and work with them to follow their treatment plan," she says. For instance, she says she finds that many diabetics check their blood sugar only once a week.

"I try to establish a rapport with every person I contact. If I know they have a lot going on or are having trouble being compliant, I make follow-up phone calls and support their adherence with the treatment plan," she says.

After she talks to the patients, Farlow sends a follow-up letter to them and sends the information to the physician by entering it into the computerized charting system.

She helps patients who have issues getting their prescriptions refilled or have a question about medication.

The program also targets patients who are making multiple visits to the emergency department for simple things that should be treated in another venue. When Farlow talks with them, she identifies the barriers to care.

For instance, some patients have told Farlow that they use the emergency department frequently because they can't afford the copay for a primary care visit.

In those cases, she works with the physician practice manager to set up a payment plan, so the patient can get treatment at the appropriate level of care.

"Access to care is a big issue. Some patients try to see the doctor, and they can't get an appointment, so they end up going to the emergency department for treatment. One of our major focuses in improving access to care is making sure there are same-day appointments available for patients who need to be seen," she says.

The physician group is working on ways to increase the number of same-day appointments available by expanding office hours, providing weekend care, and, in some cases, triaging after-hours callers rather than having a recording that tells them to hang up and go to the emergency department, Epstein says.

The primary goal of the care coordinator is to get patients with gaps in care or who are using the emergency department inappropriately back into the physician office, Epstein says.

"In a way, she's playing family therapist trying to get the two parties back together. That is the epicenter of how this process works. The patient needs to see his or her physician on a regular basis and receive recommended care. At the same time, the physicians need to make sure patients have access to care. If someone has a sore throat, they can't wait three weeks for an appointment," he says.

The outreach calls are particularly effective, because they are coming from the patient's doctor and not from CIGNA, Epstein points out.

"It's not the message as much as it is the messenger. The subject of the call and the information passed on could be exactly the same, but because it's coming from within the physician practice, and not from the insurer, the patient is more likely to pay attention. The physician practice has a lot more credibility than the insurer," he says.

The initiative also is addressing hospital readmissions in real-time, Epstein points out.

"When patients leave the hospital, there's often not enough good communication with the primary care physician. This program bridges that gap and makes sure patients receive a follow-up visit, that they get their medication, and understand their treatment plan," Epstein says.

Farlow collaborated with the case managers at Piedmont Hospital and is able to access their documentation system for information on the patients she is following.

"I can see who is in the hospital, who is in the emergency department, when they are discharged, and follow up to make sure they receive appropriate outpatient care. Our hope is to get them back to see their primary care physician or a relevant specialist and avoid any rehospitalization," she says.

She typically coordinates care for patients over the telephone. The physician group has 40 offices throughout the metropolitan Atlanta area, which makes it impossible for her to see everyone in person.

Farlow has a weekly conference call with the lead CIGNA case manager assigned to the Piedmont account, the health plan's health service specialists, and Epstein.

The health service specialist is the individual who understands the benefit plan eligibility and what each employee has purchased.

That way if the care coordinator is working with a patient with diabetes who doesn't know his or her benefits, the health service specialist can let that coordinator know what the health plan can offer the patient.

"We cover the administrative bases as well as the clinical bases," Epstein says.

The project is a collaboration between CIGNA and Atlanta-based Piedmont Physicians Group and is the first accountable care organization in Georgia. The project is one of several accountable care organizations the Philadelphia-based health service company is developing nationwide.

"We have a relationship with the Piedmont system on two levels. They are a key provider system in our network, and we administer their health benefits plan," Epstein says.

CIGNA is paying the primary care physicians as usual for the medical services they provide in addition to a fee for care coordination and other medical home services. The physicians also will be rewarded through a pay-for-performance structure if they meet targets for improving quality and lowering medical costs.

"We are going to analyze data from the project using evidence-based measures and compare it to baseline quality performance. We're also looking at the effects on costs year over year and trends in cost reduction. We believe this project will result in better clinical outcomes and save money at the same time," Epstein says.