Minnesota medical groups share best practices

ICSI links groups in best practice program

In the early 1990s, as managed care took off, a group of large companies in Minnesota got together and put out a request for proposals for medical groups interested in providing health care for the group. One of the key requirements was that the winning vendor would provide care with an energetic use of guidelines, measurements, and continuous quality improvement.

In response to that, three large medical groups — the Mayo Clinic in Rochester, and Health- Partners and the Park Nicollet Clinic, both of Minneapolis/St. Paul — got together to bid on the work. They didn’t want to merge, but they did want to share data and work together to develop best practices.

"The goal was to jointly develop evidenced statements of best practice and steadily work toward making actual care match best practice statements," says Gordon Mosser, MD, executive director at the Institute for Clinical Systems Improvement (ICSI) in Bloomington, MN. The formation of ICSI was the result of those initial group efforts and it now includes 18 group practices in the Minneapolis/St. Paul area.

Would competition be a problem?

But how could 18 groups work together and still compete? Mosser says because it was — and remains — a physician-led endeavor, there was a great deal of willingness to share information that would improve the quality of care.

"We are focused on science, on constructing best practices based on nursing and medical literature. We are much more open to sharing information than a lot of purely management people would be," he says.

Certainly most of the guidelines developed are clinical, ranging from preventive services and obstetrical care to respiratory diseases and mental and behavioral health. But there are some related to access to care. Mosser says that helps administrators accept the sharing of data. And the reports are blinded, with each medical group being assigned a letter. Mosser admits, however, at meetings, most of the groups know who is assigned what letter of the alphabet.

"I think that if we concentrated on nonclinical aspects of our business, like providing prompt and courteous telephone service, there might be more resistance to sharing information," says Mosser. "That is seen as being closer to success in the competitive arena, and it might raise more questions than talking about best practices for preventive services."

Although the focus is clinical, there are sound business reasons for the members to participate. Being part of ICSI initially helped them gain market share. Members had access to the 100,000 employees of the employer group that put out the initial request for proposals. In 1995, that model changed and the employer group allowed its enrollees to choose from a wider group of practices. But because quality of care has become a key part of competing in the Minneapolis/St. Paul market, the members still have a leg up on other medical groups in the area.

How ICSI operates

The institute is a freestanding corporation with 13 board members. Nine of those are physicians from the participating medical groups. Three of the physicians are from the founding group members and have permanent seats, explains Mosser. The other six are elected. HealthPartners’ HMO has a seat, as does the original employers’ coalition. Two other purchasing groups also have seats on the board.

There are two operating committees: one to create and maintain guidelines and one to help groups with implementation. There are also two sets of work groups: one to draft and maintain the guidelines and one to work on technology assessment reports. All the participating medical practices are required to provide physicians for those work groups.

A group that includes a lead physician, a facilitator, health care providers, and occasionally a purchaser representative develops the guidelines. Among the newer work groups, patient representation also has been included. The work group drafts a guideline based on current medical literature. Member practices then review the draft, and the work group evaluates their input before a pilot guideline is created and implemented at select sites. The work group then convenes about once a year to reevaluate the guidelines, including new scientific information and feedback from the member practices in its discussions. The guideline is revamped as needed.

Technology assessment reports review new medical technology. The technology work group chooses a topic, and one of the 19 permanent staff at ICSI researches it and prepares a draft report for the work group. That group reviews and revises the draft until it reaches a consensus. The final report is distributed to all ICSI members. The work group reviews each report every two years to determine if it should draft an update. More than 45 of these reports have been created to date. (For a complete list, see box, p. 33.)

Sharing? No problem!

Mosser says there has been little resistance to sharing information. The printed documents are all blinded, and there is wide agreement that the care improvement guidelines provide makes giving up some of that proprietary information worthwhile.

"Most of what we share are process changes that are undertaken, like new rules for nurses on hypertension follow-up and how they relate to blood pressure control," says Mosser. For instance, one group had a new procedure for dealing with patients who had high blood pressure. "It’s common for patients to have their blood pressure measured and have it be high. You might want to keep an eye on it, but there is no plan. This group implemented a new procedure in which a patient who has high blood pressure is invited back to have his or her pressure checked at two additional times. After those visits, a decision is made on what to do about the pressure if it remains high. To ensure that the patient is invited back, nurses put a blank, brightly-colored Post-it note on the chart. That prompts the physician to extend the invitation."

The group measured 25 patients over 18 months and showed the number of patients whose blood pressure was controlled increased. The group presented the information to the work group, a guideline was created, and many of the groups have implemented that same protocol.

Mosser says this kind of sharing may bleed into administrative issues, but because it is based on scientific and clinical matters, "it doesn’t raise the prickles about competitiveness. And it plays to the culture of physicians who are used to reviewing evidence together on what is best practice."

Managers are kept in the background, and physicians take the lead, something that Mosser says helps keep worries at bay. ICSI has also succeeded because it has a secure source of funding. HealthPartners has stepped up to the plate because it sees the institute as a means to improve care for its members. "A lot of HMOs try to do this themselves, but the physicians are wary of it," he says.

"They see it as a control issue, or a way for the HMO to cut their income. Our arrangement amounts to the HMO telling us, Here is $2 million dollars. You pony up your time and work on improvement.’ There is a common interest. If they don’t think we are using the money well, they’ll cut it off. They have given the authority to the docs to hire the staff."

HealthPartners also thinks it can gain some goodwill and cooperation from member medical groups, Mosser says. Certainly the 800 physicians who are on a work group or action group, and the total 3,500 physicians who are members of ICSI represent a large portion of the state’s physicians. HealthPartners may win just by playing the numbers. And the HMO gets prestige. "These guidelines have become default guidelines for the state," Mosser adds. "Blue Cross/Blue Shield uses our guidelines."

[For more information, contact:

• Gordon Mosser, MD, Executive Director, Institute for Clinical Systems Improvement, 8009 34th Ave. S., Suite 1200, Bloomington, MN 55425. Telephone: (612) 883-7999. E-mail: gordon.mosser@ icsi.healthpartners.org.]