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Collaborative uses data to bring uniformity
Variation can lead to improved outcomes
Increasing data show that variations in care have a negative impact on outcomes and costs some estimates are that almost a third of healthcare dollars are spent in a wasteful manner or go to overuse of the system. That is one reason why a group of Findlay, OH-based employers came together with a local health system and area physicians to look for ways in which care varied and try to bring more consistency to what they do. Their hope was to use evidence-based medicine and proven protocols to reduce costs. The bonus was that while they succeeded in saving dollars, they also improved the health of patients suffering from chronic illnesses such as high blood pressure and diabetes.
The Employer Data Project was founded in 2005 and included more than 300 doctors, as well as employers such as Marathon Oil, which is headquartered in Findlay, a Whirlpool plant, Cooper Tire and Rubber, Bridgestone, and Nissin, says Patricia Beham, director of managed care for Blanchard Valley Health System. The health system includes two hospitals and a level three trauma center. Although the town has just 50,000 people, Beham says the employer base is bigger than one would think, representing about 30,000 employees.
"We had a long history of informally working together," says Beham. That made creating a formal group easier. "We wanted to do something to help employers manage their healthcare costs, and do it in both a constructive way and a local way."
The group hired the Delta Group, a consulting firm, to look at claims and determine severity-adjusted episode-of-care measurements, such as inpatient and outpatient costs and pharmacy benefits. A six-month course in proper coding and chart audits was initiated. Physicians also learned about evidence-based practices for the various conditions, such as hypertension, diabetes, and knee-replacement surgery.
For hypertension alone, there was a reduction of more than a quarter in combined physician and hospital costs between 2004 and 2007, representing savings of more than half a million dollars by the employers. From an outcome perspective, the number of patients with controlled high blood pressure increased by more than 25% over a two-year period.
In looking at emergency department (ED) visits, the consultants discovered physicians were "practicing defensive medicine" according to a report by the Commonwealth Group on the program. (The entire report with data on inpatient and outpatient measures is available at http://www.commonwealthfund.org/Content/Newsletters/Quality-Matters/2011/February-March-2011/Case-Study.aspx.) According to the report, they were more likely to order expensive tests that were probably not necessary MRIs rather than simple X-rays, for example. Again, education was employed to effect change. The look at ED figures also uncovered the fact that some primary care physicians referred patients to the ED after hours rather than using nurse lines or some other triaging service, the report says. Often, these same patients were referred right back to their primary care physicians the next day, even if a prescribed treatment could not be assessed in that short of a time period. Those physicians were coached to tell patients to call their doctors, not visit, the day after an ED visit. The rate of visits to the ED for otitis media alone fell by a full percentage point to 10.8 in a single year, according to the report.
To help reinforce the changes, physicians are regularly provided with feedback that includes their data, as well as group data and national medians for key elements, Beham says. This helps them know where they stand and how they should adjust.
For diabetes, more problems were uncovered. Too few patients getting appropriate tests in the outpatient setting, for instance, and in the hospital, physicians did not always use the most up-to-date ways to control blood sugar, she says. Tight control can lower length of stay and promote faster recovery. For surgical patients, it can reduce infection rates. Nursing now work with dietary services to be sure that medications and meals are given at the appropriate time. The interventions led to more hospitalized patients with diabetes having basal insulin orders from 47% in January 2006 to 69% in April 2010, according to the report.
In another element of the program, elective surgical patients have to have an A1C level of below eight to be cleared. "Surgeons have been educated about that, and they can opt to do a fructosamine tests for a faster turnaround," says Beham.
Anesthesiologists are pulled into the program, too, working with surgeons for preoperative and intra-operative care for patients with diabetes or hyperglycemia. Beham says infection rates are down as a result of many efforts, but she believes it is at least partly because of the diabetes program for inpatients.
The protocol even has an impact on future patients, she adds, noting that some physicians report seeing patients who are suddenly "very motivated to get their blood sugar under control in order to have elective surgery."
The employer group didn't stop with those three areas. It has also focused on gastro-esophageal reflux disease (GERD) and related ED visits for the condition. In two years, the number of such visits declined by more than a third, to 22 in 2007, a savings Beham says is worth some $30,000. Heart failure and high cholesterol, as well as kidney disease are next in line for attention.
While the successes are enviable, and reducing variations in care, processes, and even coding can impact healthcare organizations in a positive way, the Findlay group thinks there may be some obstacles to others replicating what they have done. Geographic areas where hospitals are in direct competition with one another may see a lack in willingness to share data or collaborate; employers, likewise, may not be interested in committing resources to study the problems and effect necessary changes or to change benefits significantly. Insurers might not want to share data, either.
The financial costs alone may be daunting for any organization: Beham said the hospital has laid out in the "hundreds of thousands" of dollars over the years. Some of that is offset by subsidies from the companies involved, but the money is still considerable.
It helped that the health system CEO was interested in doing whatever was good for the community as a whole. "If it is good for the area, it is good for the hospital," Beham says. "Keeping jobs here, by keeping companies competitive because we have lower healthcare costs is good for everyone."
Physicians also have to be on board. A key group of physician leaders who have been involved from the start made the Findlay program work, she says. "This takes a process of having to reach out and get support from other doctors. Largely, we have been lucky that there has not been a whole lot of negative pushback. That might be because we are a smaller community where everyone knows each other."
The beauty of the project is in how its goals have morphed. Beham says it started out as a way to save money. They have quickly discovered, however, that by reducing variation, they also improve the quality of care and improve outcomes for patients. Everyone wins.
For more information, contact Patricia Beham, Director of Managed Care, Blanch Valley Health System, Findley OH. Telephone: (419) 297-8894.