If necessity is the mother of invention, then Philip Gaziano is the midwife. Over the past six years this Springfield, MA-based internist and geriatrician has guided the birth and development of a homegrown IT infrastructure that has helped to rapidly propel his multi-specialty group toward the Triple Aim.
“Our quality has gone up, we are able to save money consistently year after year, and our patient satisfaction scores are 95 percent good or excellent,” says Gaziano.
Having achieved national best practice ratings in five key areas measured by a respected health care auditor, the group—Hampden County Physician Associates (HCPA)—has created a spin-off medical services organization that Gaziano heads.
As president and CEO of Accountable Care Associates (ACA), Gaziano now works with a network of more than 800 providers in the surrounding counties, helping them to achieve the same outstanding results as his own group.
IT and Payment Reform Go Hand-In-Hand
As the organization’s name implies, Accountable Care Associates and its leaders believe that success lies in the marriage of a user-friendly, flexible IT infrastructure and a payment system that supports it. Gaziano favors global capitation. “If managed right it has low risk and can be done by even small groups of four or five doctors.”
His own group, HCPA, has been doing risk contracting with Medicare Advantage plans since 1997, which is why the group began investing heavily in IT infrastructure. “We were one of seven IPA physician networks in our county to do Medicare Advantage, but we were the only one that put in the IT infrastructure to support it. Over the next six years the other six all failed and came under our wing.”
Once the other groups joined his network, Gaziano says “it only took three months for their financial data and their outcomes to equal ours, which were best in the state, and equal to national best practice standards.”
Infrastructure and payment structure have to support each other, says Gaziano. The trick, he adds, is to “right-size” your infrastructure. “Don’t overspend on stuff you don’t need and data you can’t use,” he says.
Handcrafted and Homemade
The IT infrastructure that Gaziano and his colleagues built is simple but powerful. It includes tools for care management, disease management for high-cost cases, information sharing, chart review, quality oversight, and a data warehouse for help with quality measures and pay-for-performance.
“It’s a web-based overlay that works either inside an electronic medical record, inside a hospital electronic record, or along with a paper chart,” explains Gaziano.
“It not only connects the PCPs with each other, it connects them with what the specialists are doing, with the hospital records, and with the care managers.”
Gaziano says the system has been so effective because “it was developed by providers for providers.”
Achieving Best Practice With A $300 PC
ACA manages nearly 150 primary care physicians in three counties, and has plans to expand that number to about 400 in early 2012. “Our region looks a lot like the rest of the country,” he says. “We have a big teaching hospital, a medium sized medical center and some smaller hospitals. About a third of the physicians in our county are employed by the teaching hospital, and the others are independent, working in multi-specialty or single-specialty groups.”
“About a third of all those physicians are in solo practice or in practices of three or less. They’re not integrated. The six or so large multi-specialty groups are on different electronic medical record systems, that don’t talk to each other. The hospitals are on different EMRs that don’t talk to each other, and about half of the physicians are still on paper charts.”
The region has both rural pockets and small towns, as well as inner city populations in Springfield and Holyoke where the teen pregnancy and high school drop-out rates are the highest in the state.
“We’ve been able to link all those practices together despite the lack of IT infrastructure and communication interconnectivity in the lay of the land,” says Gaziano. “The only thing the practice needs is a PC or tablet with a browser. In some of the small practices that are still on paper charts, we bought them a $300 PC, and it works. Their outcomes became equal to the national best practice.”
Quality Up, Costs Down
Gaziano thinks the information-sharing component is the key to the whole system. “It allows our disease management nurses to have more information and lowers the cost of our nurse case management program. It allows regular case management to be cheaper and more integrated with the PCP practice. It allows our hospitalists to be integrated with the PCP office and with the case manager. It gives the PCP a list of things to do at each visit, and it’s a whole lot cheaper than an electronic medical record or an electronic health record in the hospital.”
And certainly no one can argue with the results that HCPA has achieved.
HCPA’s Medicare admissions are about 25 percent below those for fee-for-service Medicare, and 20 percent below the state’s, according to Gaziano. He estimates the group’s risk savings are $6 million per year.
Three years ago the group became the first in the state to enter into a global payment contract with Massachusetts Blue Cross Blue Shield. “We started with 5,000 members, now we have 11,000 and next year we’ll have 22,000. We’ve been able to save significantly in the commercial model as well, bringing our cost inflation down from eight percent to three 8percent. And again, every single quality measure improved, and we estimate that we save about six lives a year.”
“Last year Deloitte evaluated the largest physician groups in our state to see how ready they are for new kinds of accountable care payment models,” says Graziano. “They looked at seven groups in the Boston area and ours, and they evaluated the groups in five areas: contract structures, physician leadership, case management, disease management, and information-sharing tools. Our network is sort of loosey-goosey compared to the Boston groups, but Deloitte reported that none of the Boston groups achieved national best practice in any of the five categories, while we achieved it in all five.”
Not coincidentally, says Gaziano, “Our Web-tool links all five areas.”