Quality: Shedding (Not Shifting) Costs

Janice Simmons, for HealthLeaders Magazine , October 8, 2009
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"What we are attempting to do with this project is to bolster it so it's much more seamless with the patient and the physician, as far as carrying the patient all the way through the process," Chan says.

Primary care providers will likely assume a pivotal role in this pilot process, says Rosaleen Derington, chief medical services officer with Hill Physicians. "I think we'll look for the primary care provider to be the ultimate gatekeeper of what is going on."

The Sacramento area was selected because it is a market with many CalPERS members. And it's where the three entities—Blue Shield, Catholic Healthcare West, and Hill Physicians—have substantial presence. And it is a place where changes implemented by each organization could make a difference in healthcare trends for CalPERS members (now numbering about 40,000 in that area).

The pilot will be reviewing various initiatives to keep costs down while promoting quality care such as hospital discharge planning. "Discharge is actually one of the major areas where we have breakdowns currently," Chan said.

Citing recent studies that show that nearly 20% of Medicare discharges result in readmissions within 30 days, he noted that discharges are "a prime example of breakdowns in communication and the lack of a mechanism to just carry the patient through one environment to the other."

For elements such as hospital discharge, "we're looking at a whole range of issues across the continuum," said John Wray, senior vice president for managed care with CHW. CHW will have four urban and suburban hospitals, varying in size from about 100 beds to 400 beds, participating in the Sacramento pilot.

"We're not just focusing on what happens in the hospital [at the time of discharge]," Wray said. Instead, they will go more in depth to look at issues such as what pharmaceuticals patients were taking or what access they have to primary care before or after hospitalization. "I think it's important here that we don't leave any stone unturned . . . and find ways to better deliver the care."

While the pilot will require coordination at the top of the healthcare organizations to make it work, it will not necessarily be driven just by those leaders. "What we're trying to do is have the people who are really closer to the delivery of care involved in designing this, too," Wray said.

This "pilot governance structure," as McCaffery calls it, will feature monthly meetings at the top level, but it will also encourage joint sessions with "working-level folks who represent the faces of the hospitals and the [Hill] physicians."

What they will be able to provide input on is how the pilot will be making progress through the year on numerous initiatives to improve quality and reduce costs. These include expanding patient participation in disease management and complex case management programs; promoting palliative care; increasing the use of generic drugs; and minimizing physician practice variation.

The underlying purpose to moving ahead with this pilot is to add value—to both patients and the community as a whole, Wray said. "All of us involved [with the pilot] have the responsibility to add value, and that value has multiple components—with quality, of course, being the most important."

Plus, the terms of "getting measurable outcomes—doing it in an efficient manner and doing it in a way where people can get access to care more affordably—is part of it," Wray said. "The value-added is something we're all going to be challenged to produce, and that's our responsibility to do that."

Janice Simmons is senior editor for quality for HealthLeaders Media. Se may be contacted at jsimmons@healthleadersmedia.com.

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