St. John’s Health System, part of Sisters of Mercy Health System (Mercy), continues to be among the nation’s leading health care institutions in decreasing costs of care for Medicare patients, while maintaining rigorous quality standards.
Centers for Medicare and Medicaid Services (CMS) announced that St. John’s, along with the nine other physician groups participating in the 5-year-long Medicare Physician Group Practice (PGP), achieved high quality marks on the delivery of preventive care and care for patients with chronic illness in year 4.
Performance year 4 was the second year that all 32 measures were in effect for the demonstration. The measures focus on diabetes, congestive heart failure, coronary artery disease, hypertension, and cancer screening. The measures are consistent with clinical practice and high quality care and have support from the physician community.
All 10 physician groups achieved benchmark performance on the 10 heart failure and 7 coronary artery measures. Over the first 4 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 13 percentage points on the seven heart failure measures, 6 percentage points on the seven coronary artery disease measures, 9 percentage points on two cancer screening measures, and 3 percentage points on three hypertension measures.
Under the PGP demonstration, physician groups earn incentive payments based on the quality of care they provide and the estimated savings they generate in Medicare expenditures for the patient population they serve. Five physician groups, including St. John’s Health System, will receive performance payments totaling $31.7 million as part of their share of $38.7 million of savings generated for the Medicare Trust Funds in performance year 4.
“These groups have been leaders in organizing care delivery to improve quality and reduce expenditure growth,” Dr. Donald M. Berwick Administrator, Centers for Medicare and Medicaid Services (CMS). “Now we want to raise the bar. We want to support these practices to demonstrate just how much American medicine can achieve if we put the right incentives in place.” CMS is currently working to transition the physician groups into the shared savings program established in the Affordable Care Act.
St. John’s focused on redesigning care to improve quality and reign in Medicare expenditure growth. Efforts have included better coordinating care for patients transitioning between care settings, proactively reaching out to patients with chronic illness and more aggressively monitoring them between physician visits, and incorporating health information technology to provide practitioners in the group with more complete clinical information about each patient prior to appointments. A medication access program assisting with free or low-cost medications also increased patient compliance and improved quality of life.
“We paid attention to each and every single patient – caring for that individual, making sure patient needs are met consistently,” explained Dr. James T. Rogers, St. John’s primary care department chair and medical director for the project. “Meeting these quality measures was possible because of St. Johns’ will to make it happen, and because of the dedication of the professionals and staff to make it happen – doing the extra work, making sure the care was delivered consistently and that the information was captured.”
When Mercy’s St. John's Health System joined the pay-for-performance for big medical groups in 2005, officials realized they were taking a financial risk. In addition to spending at least $60,000 to deploy an electronic patient registry, the Springfield, Mo.-based integrated health system added about 10 full-time employees to help oversee the comprehensive medical management services that are a key element of the project, invested tens of thousands of dollars of "in-kind" services and assigned several special committees to coordinate the five-year program.
"We got into this because it's the right thing to do, and we wanted to be at the table with CMS to help resolve issues around delivering cost-effective and high-quality care," said Janet Pursley, Vice President, and Mercy Health Ministry’s Care Management Services. "Of course, Mercy had to put a certain amount of funds at risk without any guarantee of return. But it was the Springfield Board's decision to participate because they hoped CMS gains a comfort level with the fact that the current financing system does not lead to coordinated care.”
"We were hoping this would put care management and disease management at the forefront of the reimbursement model,” Pursley explained.
The integrated approach is a departure from current Medicare model, in which physicians agree to a fee schedule and are reimbursed based on the number and complexity of specified services and procedures they provide.
"The current reimbursement methodology by Medicare does not provide incentives for physicians to coordinate care or track quality outcomes," said Rogers. “On the other hand, the physician group practice demonstration provides a unique reimbursement mechanism that rewards a group for coordinating and managing overall health status."
Integrated care is high-quality and cost effective care
One of the unique features of the demonstration is that physician groups have the flexibility to redesign care processes, invest in care management initiatives, and target patient populations that can benefit from more effective and efficient delivery of care. This helps Medicare beneficiaries maintain their health and avoid further illness and admissions to the hospital.
For the demonstration project, St. John's created a comprehensive health registry to track the needs of patients suffering from diabetes, congestive heart failure or coronary artery disease.
The registry is designed to track patient information, identify gaps in care, and ensure that appropriate and timely care is provided. A key element of the patient registry is the visit planner which is designed to complement physicians’ established clinical work-flow process. It provides a “to do” list for physicians prior to each patient visit, with reminders for needed tests or interventions.
The visit planner consists of a one page summary for each patient showing key demographic and clinical data, including test dates and results. An exception list highlights tests or interventions for which the patient is due and provides physicians with reports on areas where patient care can be improved. The provider/clinic manger uses the decentralized reporting feature to generate un-blinded outcome reports from the registry at both the individual provider and clinic levels.
“Designing and implementing a patient registry was the key to St. John’s first year of participation in this project,” Rogers.
“We found that many of our physicians utilize the patient registry to track and coordinate all of their patients’ care – not just the Medicare patients. The registry was designed to track the needs of patients with diabetes, congestive heart failure and coronary artery disease for the CMS project, but it’s proven to be a very useful tool for physicians to track all of their patients’ care,” he continues.
Springfield, Mo. internist Dr. Sean Tarsney agrees. “I use the patient registry for every patient, and have since it was available at St. John’s,” he said. “The advantages are that it gives me easy access to each patient’s information. It’s a time-saver and it allows me to spend more time with my patients,” Tarsier says.
Another advantage of the patient registry is its ability to track and issue reports on treatment goals met for certain patient populations, such as diabetics, congestive heart failure patients, asthmatics and those with other chronic diseases.
“For example, if a diabetic patient is overdue for their hemoglobin A1c test or hasn’t had their feet examined, the registry will flag that overdue date and it’ll be right there on top of the chart for me to remind the patient to schedule those tests,” Tarsney said.
As part of the project, St. John’s expanded an already-successful medical management approach to chronic diseases such as diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease, arthritis and depression, to the Medicare fee-for-service population.
A case manager was deployed in the emergency department to collaborate with the health system and community services to provide transition planning. A heart failure team was designated to drive the coordination of heart failure care, provider education, and increase outcome success. Special groups are being convened to focus on diabetic retinal eye exams, mammography and colorectal cancer screenings.
Why St. John’s?
St. John's selection by CMS to participate in the pay-for-performance demonstration was the result of a lengthy, complex, and competitive process. The groups were selected based on a variety of factors including technical review panel findings, organizational structure, operational feasibility, geographic location, and implementation strategy.
"The CMS initiative has really been an extension of what was already in place at St. John’s in 2005,” said Jon Swope, St. John’s Health System President /CEO. "St. John’s Health System – its hospitals, physician clinics and health plans - are designed to link the events of care. In this model, we have nurse case managers and social workers dedicated to the coordination of care. Disease management nurses provide education and coaching on self-monitoring and managing the symptoms of chronic illness. This demonstration allowed us to continue to develop our integrated approach to system resources and measure what makes a difference.”
St. John’s Health System’s integrated care model has been recognized twice as the nation’s number one integrated health system and this year ranks number 3, right behind another Mercy system – St. John’s Mercy in St. Louis. The ranking is by independent research firm Verispan reported annually in Modern Healthcare magazine.
Both systems are part of the larger Mercy ministry,the eighth largest Catholic health care system in the U.S. and serving more than 2.7 million people annually. Mercy includes 28 hospitals, more than 200 outpatient facilities, 36,000 co-workers and 1,300 integrated physicians in Arkansas, Kansas, Missouri and Oklahoma. Mercy also has outreach ministries in Louisiana, Mississippi and Texas.
Improving care for all
While St. John’s participation in the project is designed to improve and coordinate care for Medicare patients, it’s actually accomplishing that goal for all St. John’s Clinic patients, whose physicians are participating in the project.
In addition to the creation of the patient registry, in 2005, the broader Mercy began charting plans for a comprehensive electronic medical record (EMR) and invested $450 million in the project. Besides reducing the chance of medical errors, integrated EMR’s also provide:
“We are among 2.6 percent of hospitals nationwide who have an integrated electronic medical record (EMR) sophisticated enough to allow us to access and share medical records among multiple Mercy facilities in a four-state area,” said Will Showalter, Mercy’s chief information officer. “This level of technology connects all the dots and ultimately means greater safety in patient care.”
Besides a higher level of safety, patients now have access to “MyMercy” – a tool that gives Mercy patients the ability to view portions of their own medical record, make medical appointments and refill prescriptions all online.