Physician groups slow to adopt optimal care management processes

January 21, 2003

Tens of millions of patients with chronic diseases in this country are not receiving the type of care management that has been proven to be effective, according to a nationwide survey of physician organizations published by researchers at the University of Chicago and the University of California, Berkeley, in the Jan. 22, 2003, issue of the Journal of the American Medical Association.

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, MD, PhD, assistant professor of health studies at the University of Chicago and lead author of the paper. "Our research indicates that physician organizations are beginning to create effective processes to increase quality, but most still have a long way to go."

"The results suggest that Americans are not receiving care that is as good as it could and should be," said Stephen Shortell, PhD, professor and dean of UC Berkeley’s School of Public Health and principal investigator of the study. “In many ways, physicians are still organized to practice medicine the way they did 100 years ago.”

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 ten 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.

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 with health plans.

The researchers found that the key to getting physicians to use care management processes is for health plans and large purchasers of health care--corporate employers and federal and state governments--to provide external incentives. However, one in three physician groups reported having no such incentive to improve quality.

"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 incentives. They have the opportunity and the responsibility to do so. Most Americans probably don’t realize that those who purchase health insurance on their behalf are not paying for quality 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," said Shortell.

The study, funded by the Robert Wood Johnson Foundation, follows two recent Institute of Medicine (IOM) reports that found the nation’s health care delivery system falling far short in its ability to apply new technology and biomedical knowledge safely and appropriately. The IOM reports blame a lack of organized processes rather than shortcomings in individual physicians for the quality gap.

The reports call for the federal government to lead efforts to improve treatment safety and quality. They say health plans, large employers and government programs such as Medicare and Medicaid should reward physicians for improving quality.

Casalino pointed out that some Fortune 500 companies have set up successful programs to do just that, and that Medicare and Medicaid have recently created 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 in this country,” said Casalino.

"There are now 125 million Americans suffering from chronic illness, and that number is only going to grow," said Shortell. "We have an opportunity to provide much better care for ourselves than we do now."

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