Physician Group Practice Demonstration Research Articles

Heart Failure Readmission Reduction.

Little is known regarding effectiveness of readmission reduction programs over time. The Heart Failure Management Program (HFMP) of St. John's Physician Group Practice (PGP) Demonstration provided an opportunity to assess outcomes over an extended period. Data from an electronic health record, an inpatient database, a disease registry, and the Social Security Death Master File were analyzed for patients admitted with heart failure (HF) for 5 years before (Period 1) and 5 years after (Period 2) inception of PGP. HF admissions decreased (Period 1, 58.3/month; Period 2, 52.4/month, P = .007). Thirty-day all-cause readmission rate dropped from Period 1 (annual average 18.8% [668/3545]) to year 1 of Period 2 (16.9% [136/804], P = .04) and remained stable thereafter (annual average 16.8% [589/3503]). Thirty-day mortality rate was flat throughout. HFMP was associated with decreased readmissions, primarily related to outpatient case management, while mortality remained stable.

Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures. The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures. Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems.

Abstract 18: Aco Payment Models And The Use Of Discretionary And Non-discretionary Cardiovascular Care

Background: Accountable care organizations (ACOs) seek to limit discretionary health care spending while ensuring high-quality care. We studied spending patterns in cardiovascular care, one of the largest cost centers for Medicare patients, in hospitals enrolled in an ACO pilot program, the Medicare Physician Group Practice Demonstration (PGPD). Methods: To estimate spending on discretionary and non-discretionary cardiovascular care in for beneficiaries in PGPD and non-PGPD care systems, we performed a quasi-experimental analyses comparing pre-intervention (2001-2004) and post-intervention (2005-2009) rates of use of diagnostic and therapeutic cardiovascular procedures. We studied ten physician groups across the United States. The intervention group was composed of fee-for-service Medicare patients (n=990,177) receiving care from the groups participating in the practices in the PGPD. Controls were Medicare patents (n=7,514,453) from the same regions who received care from non-PGPD physicians. Our main outcome measure was the difference in the rate of discretionary imaging and procedures in PGPD practices compared to control practices, before and after implementation of ACO payment models (difference-in-difference). We studied this for carotid and coronary imaging, in both discretionary and non-discretionary clinical settings. Results: As expected, before and after PGPD implementation, at both PGPD sites and their controls, the rates of carotid and coronary imaging and procedures were higher in non-discretionary situations when compared to discretionary clinical situations (55% versus 22%, p<0.001). For discretionary carotid and coronary imaging, the differences in the rate of change in imaging use before and after the ACO implementation period was minimal (carotid imaging difference between PGPD and controls, 0.25% (95% CI -0.44%-0.95%, discretionary coronary imaging difference between PGPD and controls, 0.06% (95% CI -0.45%-0.58%). Similarly, the differences in the rate of change in discretionary revascularization procedure use before and after ACO implementation was minimal between PGPD sites and controls (carotid revascularization 0.003% 95% CI -0.008%- 0.002%, coronary revascularization -0.13%, 95% CI -0.30% - 0.029%). Similar results were seen for non-discretionary cardiovascular imaging and procedures. Conclusion: Little evidence exists to suggest that ACO payment models will save money by limiting discretionary cardiovascular imaging or procedures.

The CMS Innovation Center: Delivering on the Promise of Payment and Delivery Reform

The CMS Innovation Center: Delivering on the Promise of Payment and Delivery Reform

The PGP Demonstrations: Were They Sufficient to Justify Accountable Care Organizations?

The Physician Group Practice (PGP) Demonstr-ation Project was designed to try to establish whether high-quality healthcare can be delivered to Medicare patients, while simultaneously lowering overall Medicare costs. In this project, participating healthcare organizations were provided a portion of any savings achieved, provided that certain quality goals were also achieved. The results of this project were used to provide evidence as to the feasibility of Accountable Care Organizations (ACOs), a healthcare delivery approach, which is rapidly becoming more prevalent. While the quality measures achieved by the vast majority of participants in the PGP Demonstration Project were widespread, the financial performance of these organizations was quite mixed. Many participating organizations received no shared savings whatsoever, while one received more “shared savings” payment that the others combined. Problems with the evidence supporting PGPs’ cost savings are discussed, and, based on these concerns, the future success of ACOs is questioned.

Financial and quality impacts of the Medicare physician group practice demonstration.

To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes. Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups. We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends. The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p<0.001) during the five-year demonstration period. Medicare paid performance bonuses to the participating PGPs that averaged $102 per person year. The net savings to the Medicare program were $69 (0.8%) per person year. Demonstration savings were achieved primarily from the inpatient setting. The demonstration improved quality of care as measured by six of seven claims-based process quality indicators. The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program.

A new era of patient- and family-centered innovation in healthcare

Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is known about how the model might affect high-risk, high cost groups such as cancer patients. The Physician Group Practice Demonstration, which ran from 2005 to 2010 in 10 physician groups, provides the best current evidence on the likely effectiveness of accountable care organizations for Medicare beneficiaries. Changes in cancer treatment and spending under this program may be indicative of cancer treatment under ACO payment reform.Using Medicare fee-for-service claims data, regression analysis was used to estimate changes in payments for cancer patients using a difference-in-difference design comparing pre- (2001–2004) and post-intervention (2005–2009) trends in spending on cancer patients in PGPD participants to local control groups.Regression models indicate the Physician Group Practice Demonstration was associated with average Medicare spending reductions per cancer patient of $721 annually across participating sites, an annual 3.9% reduction in payments per patient. Savings derived entirely from reductions in acute care payments for inpatient stays. The Demonstration was also associated with a reduction in mortality among cancer patients. There was no significant change in the proportion of deaths occurring in the hospital. There were significant reductions in hospice use, hospital discharges and ICU days, but no reductions in cancer-specific procedures or chemotherapy. Estimates of all measures varied considerably across participating sites.The Physician Group Practice Demonstration was associated with reductions in admissions for inpatient care among beneficiaries with prevalent cancer, with no adverse effect on mortality. Participants in the Physician Group Practice Demonstration did not change the trajectory of spending for cancer-specific treatments.Inpatient care for beneficiaries with cancer may represent a significant source of potential savings for ACOs, but evidence from the Physician Group Practice Demonstration indicates that no changes were made to cancer treatments such as chemotherapy or surgical procedures.

Cancer spending and accountable care organizations: Evidence from the Physician Group Practice Demonstration

BackgroundAlthough accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is known about how the model might affect high-risk, high cost groups such as cancer patients. The Physician Group Practice Demonstration, which ran from 2005 to 2010 in 10 physician groups, provides the best current evidence on the likely effectiveness of accountable care organizations for Medicare beneficiaries. Changes in cancer treatment and spending under this program may be indicative of cancer treatment under ACO payment reform. MethodsUsing Medicare fee-for-service claims data, regression analysis was used to estimate changes in payments for cancer patients using a difference-in-difference design comparing pre- (2001–2004) and post-intervention (2005–2009) trends in spending on cancer patients in PGPD participants to local control groups. ResultsRegression models indicate the Physician Group Practice Demonstration was associated with average Medicare spending reductions per cancer patient of $721 annually across participating sites, an annual 3.9% reduction in payments per patient. Savings derived entirely from reductions in acute care payments for inpatient stays. The Demonstration was also associated with a reduction in mortality among cancer patients. There was no significant change in the proportion of deaths occurring in the hospital. There were significant reductions in hospice use, hospital discharges and ICU days, but no reductions in cancer-specific procedures or chemotherapy. Estimates of all measures varied considerably across participating sites. ConclusionsThe Physician Group Practice Demonstration was associated with reductions in admissions for inpatient care among beneficiaries with prevalent cancer, with no adverse effect on mortality. Participants in the Physician Group Practice Demonstration did not change the trajectory of spending for cancer-specific treatments. ImplicationsInpatient care for beneficiaries with cancer may represent a significant source of potential savings for ACOs, but evidence from the Physician Group Practice Demonstration indicates that no changes were made to cancer treatments such as chemotherapy or surgical procedures.

Savings From the Medicare Physician Group Practice Demonstration—Reply

Savings From the Medicare Physician Group Practice Demonstration—Reply

Savings From the Medicare Physician Group Practice Demonstration

Savings From the Medicare Physician Group Practice Demonstration

Pay Experiment Worked Best in Dual-Eligibles

T he Medicare Physician Group Practice Demonstration, which was the inspiration for current accountable care organization pilots, achieved only “modest” overall savings, according to an analysis published in JAMA. On average, the Physician Group Practice Demonstration (PGPD) saved the Medicare program $114 annually per beneficiary. However, the biggest savings came from low-income beneficiaries who were dually eligible for both the Medicare and Medicaid programs. Physician groups enrolled in the pilot project were able to save the Medicare program $532 on average (or 5%) for dual-eligible beneficiaries. The average savings for beneficiaries who were eligible for only Medicare was $59 per year, which was not statistically significant ( JAMA 2012;308:1015-23). The findings could foreshadow the performance of ACOs, since the PGPD pilot also allowed physicians to share in savings if they could lower costs while improving quality and care coordination. ACO pilots were included in the Affordable Care Act in part because of promising results from the PGPD. In the program, 10 physician practices could earn up to 80% of any savings to the Medicare program, provided they generated at least 2% in savings. In addition, they had to show improvement on 32 quality measures that included chronic care management. Researchers at Dartmouth College analyzed 2001-2009 Medicare administrative data. The growth rate of spending for dual-eligible beneficiaries in the PGPD sites was 9.7%, compared with 15.3% for control practices during the study. The difference came mostly from fewer acute care hospitalizations, procedures, and home health care services for the dual-eligibles, the researchers wrote. Since the savings were similar across diagnosis groups, the researchers suggested that they were probably due to better overall care management, rather than disease-specific interventions. The results highlight the “potential benefits of the ACO model for patients with serious or complex illness, a group for whom improved quality and coordination is especially important,” the researchers wrote. The PGPD practices also had lower 30-day hospital readmission rates for medical reasons and lower readmissions for both medical and surgical admissions among dual-eligible beneficiaries. The researchers found significant variation in how PGPD sites performed, which also could hold clues for future ACO success. For instance, some sites were able to achieve large spending reductions, while others saw their costs increase compared to local control practices. Results of the latest analysis show an encouraging trend in lowering costs for beneficiaries who are dually eligible for Medicare and Medicaid programs, said Dr. Donald M. Berwick, former Centers for Medicare & Medicaid administrator and former president and CEO of the Institute for Healthcare Improvement. That group is critical because they account for more than $300 billion in annual costs and 40% of state Medicaid expenditures, Dr. Berwick noted in an editorial ( JAMA 2012;308:1038-9). While the ACO model holds a lot of promise, it is not the only option reforming the way care is delivered, he wrote. Whether federal officials are encouraged or discouraged by the PGPD experience, a lot more innovations than ACOs alone will be needed to emerge successfully from this fraught time, said Dr. Berwick. The research was funded by a grant from the National Institute on Aging, the Dartmouth Atlas Project, and the Commonwealth Fund. The funders had no role in the design and conduct of the study nor approval of the manuscript. The study authors reported having no financial conflict of interest. CfA

Spending Differences Associated With the Medicare Physician Group Practice Demonstration

The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs. To estimate cost savings associated with the PGPD overall and for beneficiaries dually eligible for Medicare and Medicaid. Quasi-experimental analyses comparing preintervention (2001-2004) and postintervention (2005-2009) trends in spending of PGPD participants to local control groups. We compared estimates using several alternative approaches to adjust for case mix. Ten physician groups from across the United States. The intervention group was composed of fee-for-service Medicare beneficiaries (n = 990,177) receiving care primarily from the physicians in the participating medical groups. Controls were Medicare beneficiaries (n = 7,514,453) from the same regions who received care largely from non-PGPD physicians. Overall, 15% of beneficiaries were dually eligible for Medicare and Medicaid. Annual spending per Medicare fee-for-service beneficiary. Annual savings per beneficiary were modest overall (adjusted mean $114, 95% CI, $12-$216). Annual savings were significant in dually eligible beneficiaries (adjusted mean $532, 95% CI, $277-$786), but were not significant among nondually eligible beneficiaries (adjusted mean $59, 95% CI, $166 in savings to $47 in additional spending). The adjusted mean spending reductions were concentrated in acute care (overall, $118, 95% CI, $65-$170; dually eligible: $381, 95% CI, $247-$515; nondually eligible: $85, 95% CI, $32-$138). There was significant variation in savings across practice groups, ranging from an overall mean per-capita annual saving of $866 (95% CI, $815-$918) to an increase in expenditures of $749 (95% CI, $698-$799). Thirty-day medical readmissions decreased overall (-0.67%, 95% CI, -1.11% to -0.23%) and in the dually eligible (-1.07%, 95% CI, -1.73% to -0.41%), while surgical readmissions decreased only for the dually eligible (-2.21%, 95% CI, -3.07% to -1.34%). Estimates were sensitive to the risk-adjustment method. Substantial PGPD savings achieved by some participating institutions were offset by a lack of saving at other participating institutions. Most of the savings were concentrated among dually eligible beneficiaries.

Abstract P216: Heart Failure Readmission Rates: Experience of St John's Physician Group Practice Demonstration

Objective: The appropriateness of using readmission rates alone as markers of the quality of Heart Failure (HF) care has been questioned. The HF program of St. John's Health System's Physician Group Practice (PGP) Demonstration provided an opportunity to assess a number of outcomes that help to put readmission rates in context. The HF program included disease and case management and a disease registry in the PCP office. Methods: Several data sets were analyzed including the EHR, an inpatient database, the disease registry, and the Social Security Death Master File. Traditional Medicare patients admitted to St. John's Hospital from 2000 to 2010 with a diagnosis of HF, were included resulting in data for 5 years before (Period 1) and 5 years after (Period 2) the 2005 inception of PGP. Results: Total admissions were 3559 in Period 1 and 3514 in Period 2. The prevalence of 3 co-morbid conditions in admitted patients increased during Period 2 [diabetes 35.3% (1256/3559) to 42.7% (1499/3514), p&lt;0.001; hypertension 54.8% (1952/3559) to 70.4% (2475/3514), p&lt;0.0001; and coronary artery disease 62.7% (2253/3559) to 66.4% (2332/3514), p=0.015] indicating that patients were getting more complex. HF admissions trended down significantly from Period 1 (709 annual average) to 2009 (637, p=0.007). The 30 day all cause readmission rate dropped in 2005 [16.9% (137/809)] from Period 1 [annual average 18.8% (671 / 3559), p=0.04] and remained stable thereafter [annual average 16.9% (595/3514)]. The 30 day mortality rate was flat from 2000 to 2009 [2.7(15/550)-5.0% (30/597), p=0.3] and increased in 2010 [8.6% (28/327), p&lt;0.0001]. The use of pacemakers and ICDs was unchanged during Period 2 but ACE inhibitor and beta blocker use increased in PGP practices during 2005 and was constant thereafter. Conclusions: The HF program implemented by this PGP project was associated with decreased HF admissions and with increased clinical complexity of admitted patients. Despite this increasing complexity, the 30 day all cause readmission rate dropped in the first year of the program and remained stable thereafter. Finally, 30 day mortality rates were not adversely affected until the last year of the program. The increased mortality in 2010 may be due to a change in case mix but remains unexplained.

The Physician Group Practice Demonstration—A Valuable Model for ACOs?

Iglehart JK. Assessing an ACO prototype: Medicare's Physician Group Practice demonstration. N Engl J Med. 2011;364(3):198-200. Wilensky GR. Lessons from the Physician Group Practice Demonstration: a sobering reflection. N Engl J Med. 2011;365(18):1659-1661.

Lessons from the Physician Group Practice Demonstration — A Sobering Reflection

The mixed results of the Centers for Medicare and Medicaid Services' Physician Group Practice Demonstration project should dampen unreasonable expectations, particularly in terms of potential savings, for accountable care organizations.

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Gastroenterology in a New Era of Accountability: Part 3. Accountable Care Organizations

Wanted: Lots Of Ideas And A Sense Of What’s Possible

From the Editor-In-Chief Health AffairsVol. 30, No. 7: New Directions In System Innovations Wanted: Lots Of Ideas And A Sense Of What’s PossibleSusan DentzerPUBLISHED:July 2011Free Accesshttps://doi.org/10.1377/hlthaff.2011.0697AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSAccountable care organizationsMedicaidMedicare savings programsPopulationsShared Savings ProgramPaymentMedicareMarketsPublic healthNursing homes“The best way to have a good idea is to have a lot of ideas,” said the famed scientist Linus Pauling. Thus inspired, this month’s Health Affairs continues our exploration of system innovations—from the latest on accountable care organizations (ACOs) to Vermont’s moves toward a single-payer system. Interim stops take us to other states innovating with medical homes for Medicaid beneficiaries; to hospitals attempting reductions in preventable readmissions; and to other places in pursuit of the famed Triple Aim.Journalist Harris Meyer’s Entry Point provides an update on the early response to the Centers for Medicare and Medicaid Services’ (CMS’s) rollout of proposed ACO models, including the Medicare Shared Savings Program, the “Pioneer” program, and the “Transitions” extension of the earlier Medicare Physician Group Practice demonstration. Proposed regulations for the Shared Savings Program were widely panned, but the other models have garnered more favorable reviews.Lest we dwell too much on these prototypes’ imperfections, however, Jay Crosson reminds us that the ACO concept—delivering more coordinated care at less cost—is clearly too important to fail. And if it does, the alternative of more ratcheting down on fee-for- service payment could be grimmer still.Variations On A ThemeIn case we need any reminder that restructuring is needed, consider Todd Gilmer and Rick Kronick’s paper on regional and state-to-state variations in Medicaid spending, which exceed the well-documented Medicare variations in scope. Controlling for case-mix, the variations are mostly driven by the volume of services provided—with the highest volumes in the states of New York, Pennsylvania, and New Jersey. The analysis suggests that the care of Medicaid patients in some states could easily be held more “accountable” for appropriateness and value.Continuing on that theme, Jamie Robinson draws on data from value-based purchasing initiatives in eight states to flesh out our understanding of hospitals’ pricing behavior. A commonly recited story line holds that hospitals, “underpaid” by Medicare and Medicaid, “cost shift” by raising prices to private payers. In fact, Robinson’s analysis suggests that there are two different phenomena at work. Hospitals in concentrated markets may focus on raising prices to private insurers, while hospitals in competitive markets cut costs so that they can survive on lower payment. That’s a lesson to hold in mind amid the ongoing trend of hospital consolidation, sometimes under the guise of creating ACOs.Changing FocusHappily, there are plenty of hospitals moving beyond business as usual, as Amy Boutwell and colleagues note. They report on a four-state collaborative among hospitals and community organizations to reduce preventable rehospitalizations. In tandem with new requirements on institutions under the Affordable Care Act, such efforts translate into an altered set of responsibilities for hospital boards of trustees, as Elisabeth Belmont and colleagues write. Legally accountable for the quality of their institutions’ care, boards must shift focus from ensuring the accountability of individual providers to improving entire systems of care.Road Less TraveledWilliam Hsiao of the Harvard School of Public Health has spent much of his career advising countries such as China and Taiwan in reforms of their health care and financing systems. Recently, though, he and coauthors turned their attentions to Vermont, having been asked by the state’s governor, Peter Shumlin, to evaluate reform options. Their recommendation—now incorporated into state law—is to move toward a payroll tax–based public health insurance fund to pay for health care. The tough road lies ahead, as Vermont determines the level of payroll tax necessary to finance the system.Finally, two papers in the section “The Care Span” examine issues of race and ethnicity in the provision of long-term supports and services. Zhanlian Feng and colleagues report that the nation’s nursing home population is increasingly black and Hispanic—partly because of demographics, but also because those populations may be less likely than whites to access home and community-based services. Meanwhile, Holly Felix and colleagues recount the success of an Arkansas experiment to identify minorities in need and equip them with services that can obviate nursing home stays.We thank The SCAN Foundation for its ongoing support of The Care Span—and we hope that innovations described in this issue continue to inspire a sense of the possible. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 July 2011 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF download

Medicare demonstration shows accountability can save money

A federal project has shown that financial incentives can induce large physician group practices to increase the quality of care for Medicare beneficiaries and help the government spend less than it otherwise would on hospitalizations and office visits. Participants in the project, officially known as the Physician Group Practice Demonstration, have been called prototypes of accountable care organizations (ACOs). Results from the fourth year of the five-year project were announced on December 9, 2010. The Physician Group Practice Demonstration was mandated by a law that preceded creation of the Medicare prescription drug benefit, or Part D. Congress in 2000 authorized the demonstration to compare physician-based health care groups against other health care delivery systems on “efficiencies of providing health care.” Under the demonstration, a health care group could receive more than the usual fee-for-service payment. The financial incentives, in theory, would encourage coordination of the health care provided to persons under Medicare parts A and B, promote investment in administrative structures and processes to ensure efficient service delivery, and reward physicians for improving their patients’ health outcomes.

Assessing an ACO Prototype — Medicare's Physician Group Practice Demonstration

The Medicare Physician Group Practice (PGP) demonstration project was the model for health care reform's accountable care organizations. Results from the fourth year of the PGP project were recentl...

A Quality Improvement Initiative to Enhance the Care of Diabetic Patients in a General Medicine Clinic

D iabetes is a major health problem in the United States. The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 17.9 million in 2007. Diabetes is associated with increased risk of serious health conditions, including heart disease, renal failure, retinopathy, vascular compromise, peripheral neuropathy, and limb loss. The impact of these multiple comorbidities led to an estimated economic impact of $174 billion in 2007.1 Evidence-based management of diabetes can lower the risk of these comorbidities and other complications.2,3 In addition to evidence-based guidelines, measures have been developed to help assess the quality of care that patients receive. The 2008 National Healthcare Quality Report4 highlighted several measures across different conditions and concluded that “health care quality is suboptimal and continues to improve at a slow pace.” The report's sections on diabetes showed suboptimal care for recommended services: 71% of adults ≥ 40 years of age received foot exams, 60% had dilated eye exams, and 90% had an A1C test. Only 40% received all three of these components of diabetes care. These rates have not improved during the last 3 years.4 Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., provides health care for rural communities in New Hampshire and Vermont. General internal medicine (GIM) within DHMC provides primary care to 22,000 adults and averages > 50,000 visits annually. Patients diagnosed with either type 1 or type 2 diabetes make up ~ 8% of GIM patients. In 2005, DHMC was chosen as one of 10 participants in the Centers for Medicare and Medicaid Services (CMS) Physician Group Practice Demonstration Project.5 This project was designed to determine whether financial incentives would lead to improved quality and decrease the cost of care. Diabetes measures were the focus during the first performance year, and …