Physicians groups not implementing care management processes proven to increase quality of patient care

Lawrence Casalino was the lead author of a paper that described how patients suffering from chronic disease are not receiving the benefits of many care management processes.

A recent nationwide survey of physician organizations–conducted by researchers at the University and at the University of California, Berkeley–shows that millions of patients with chronic diseases do not receive quality care because, in large part, effective care management processes are not being practiced.

The researchers found that physician groups on average use only 32 percent of 16 recommended care management processes.

One physician group in six uses none. These processes include using nurse case managers to maintain contact with patients; teaching patients how to understand and care for their illness at home; keeping a list of patients with each disease; developing timely reminder systems for patients and caregivers; and providing feedback to physicians on the quality of their care.

“The processes we studied are known to improve the quality of patient care,” said Lawrence Casalino, Assistant Professor in Health Studies at Chicago and lead author of the paper on the survey, which appears in the Jan. 22 issue of the Journal of the American Medical Association. “Our research indicates that physician organizations are beginning to create effective processes to increase quality, but most still have a long way to go.”

Stephen Shortell, professor and dean of the University of California-Berkeley’s School of Public Health and principal investigator of the study, noted that a lack of resources often hinders improvements in care. “Unfortunately, most physician practices don’t have a lot of extra resources or capital to invest in electronic medical records and to hire new types of personnel required to implement team-based care,” he said.

In their study, the researchers focused on care for asthma, congestive heart failure, depression and diabetes, which together account for 140,000 deaths and $173 billion in costs each year in the United States. They surveyed 1,040 medical groups and independent practice associations with at least 20 physician members.

The presidents, chief executive officers or medical directors of the groups took part in one-hour telephone surveys from September 2000 to September 2001.

Seven out of 10 physician groups surveyed do not keep a list of patients who have serious chronic diseases like diabetes. Half of the groups reported having no electronic data systems to track patients’ illnesses, medications and laboratory results.

Casalino emphasized that the study’s key finding was that physician groups are more likely to use organized processes to improve care when they have clinical information technology in place and when they are given external incentives to provide high quality care, such as financial rewards, public recognition or better contracts from health plans. However, one in three groups reported having no such incentives, and the average group had only 1.7 of 7 incentives surveyed.

Funded by the Robert Wood Johnson Foundation, the survey supports the arguments of two recent Institute of Medicine reports that suggest that the nation’s health care delivery system is falling far short in its ability to apply new technology and biomedical knowledge safely and appropriately. The institute reports blame a lack of organized processes rather than shortcomings in individual physicians for the quality gap, and they call for the federal government to lead efforts to improve treatment safety and quality.

The survey researchers concluded that corporate employers–who are large consumers of health care, government programs, such as Medicare and Medicaid, and health plans–should reward physicians for improving quality. They also found that, with external incentives, physician groups often make improvements. However, one in three physician groups reported having no such incentives offered.

“We know incentives work, but for the most part they are not being used,” said Casalino. “The federal government and large employers have the most leverage to establish them.”

Casalino pointed out that Medicare and Medicaid have recently created a few demonstration projects that reward quality. In addition, six California health plans have recently started a new Pay for Performance initiative designed to reward physician groups for achievements in documented performance measures.

But such programs remain the exception, and the use of organized processes to improve quality is still uncommon. “Given that most physicians practice in smaller organizations with fewer resources to implement care management processes, our study probably underestimates the extent of the problem,” said Casalino. “However, we believe that there has been improvement, and there are resources to help physician groups that want to improve quality.”