Strategies for Implementing Best Practices in Independent Physician Associations

ABSTRACTObjectives: Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs.

Study Design: The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20 key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers.

Methods: Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices.

Results: Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms.

Conclusions: IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.

Am J Manag Care. 2020;26(6):262-266. https://doi.org/10.37765/ajmc.2020.43489

Takeaway Points

• Risk-stratification measures are a key component in efficiently allocating limited resources toward strategies that reduce inpatient utilization; using social determinants to enhance accuracy shows promise and warrants further exploration.
• This research points to the importance of the revenue model of the independent physician association (IPA) and its contractual obligations with health plans in assessing the likelihood of success in implementing best practice—based care management programs.
• Engaging physicians in best-practice programs may be linked with improved results; engagement of physicians in large networks may be more effective with high-volume or exclusive IPA physicians.

Despite decades of upward-spiraling health care costs in the United States, health care spending continues to outpace gross domestic product and will comprise an estimated 19.9% of gross domestic product by 2025.¹ To mitigate the increase in spending, scholars have highlighted the importance of preventing hospital admissions, readmissions, and emergency department (ED) visits for individuals with chronic conditions, a population that accounts for a large percentage of the nation’s health care spending. Approximately 171 million Americans are expected to have at least 1 chronic condition by 2030, a 37% increase from 2000.² Individuals with 5 or more chronic conditions spend 14 times more health care dollars than those without any chronic disease.³ As such, we need cost-effective strategies to manage this rapidly growing population.

Providing effective care management strategies and implementing best practices may help reduce ED visits, inpatient admissions, and readmissions, thereby reducing rising health care costs and increasing quality. We conducted an international systematic literature review of peer-reviewed research, which identified 6 best practices shown to significantly reduce hospital admissions, readmissions, or ED visits: (1) face-to-face interactions with patients and health care workers (primarily in the home),^4-13 (2) multidisciplinary care teams that include social workers and pharmacists,^4-9,11,13-15 (3) active engagement of physicians in care management practices,^{4,5,9,10,13,15} (4) disease-specific care programs (eg, congestive heart failure, chronic obstructive pulmonary disease),^{4,5,7,8,11-13,15} (5) transitional care models from inpatient to community settings,^7,8,12-15 and (6) risk stratification of populations into subgroups with defined clinical and social needs^4-13 (eAppendix A and eAppendix B [eAppendices available at ajmc.com]).

Because independent physician associations (IPAs) contract with multiple provider organizations and health insurance plans, IPAs implementing these 6 best practices in care management may experience unique structural and operational challenges. The challenges reported by IPAs include selecting, implementing, and sustaining the operations of evidence-based management strategies while maintaining contractual obligations to health plans; engaging physicians in large and diverse networks; and building high-touch care management programs in large geographic areas. Although IPAs comprise a significant portion of provider networks across the United States—it is estimated that 54% of managed care plans and 90% of point-of-service plans deliver care through IPAs—little research (only a few IPA-specific studies in the past 2 decades) has been conducted on how they implement evidence-based strategies, and very few of these studies focused on care management practices after the 1990s. Using key informant interviews, we explored the strategies that IPAs use to implement value-based best practices.

METHODS

Between May and August 2018, we conducted 20 semistructured interviews exploring barriers and facilitators to implementing the care management practices identified within the literature review (eAppendix C). Interviews discussed the ways in which stakeholders, internal pressures, and external (imposed) requirements contributed to the success or failure of implementation procedures for best practices among IPAs (for research questions, see eAppendix D). This study was approved by the University of North Carolina’s institutional review board, and informed consent of all study subjects was obtained.

The interviews were conducted with informants holding key roles within IPAs. Informants included (1) executives in leadership and decision-making roles (n = 5), (2) medical directors who implement and provide clinical oversight of the best practices (n = 6), and (3) case managers/nursing leaders who provide direct patient care (n = 9). Respondents represented 8 IPAs (7 located in California and 1 on the East Coast). IPAs were identified through their participation in a large national association. The average length of each interview was 60 minutes.

The interviews were audiotaped and transcribed. Using Nvivo12 Plus (QSR International), 4 interviews (at least 1 from each key stakeholder group) were coded independently by 2 coders, achieving a final κ statistic of 0.66.¹⁶

RESULTS

Care Management Strategy

Many of the respondents explained that the organization’s revenue model and value-based contract arrangements heavily influenced which care management programs were ultimately adopted—this often occurred independent of evidence review (Table). All stakeholder groups reported choosing programs, in part, based on the type of performance measurement required or rewarded by the payer. This implies that some IPAs base their investment in care management strategies on what is measured and incentivized by payers. For example, health plans that receive financial rewards for increasing preventive screenings (eg, colonoscopies) may incentivize or contractually require the medical group to concentrate its limited resources on improving this metric, often to the exclusion of other needs. As a result, this may leave fewer resources for investing in chronic care strategies, such as home visits, which would focus on reducing acute inpatient utilization and streamlining care transitions.

One respondent explained that his IPA selects interventions and programs to implement based predominantly on what the health plan contracts dictate—which may not be based on evidence-based best practices or the needs of their specific populations. An executive respondent explained, “In all honesty, we do certain things because the contract directs us to do it that way.” Another executive commented on the importance of the IPA’s revenue and risk arrangements in selecting care management strategies: “[T]he financial model is determining whether or not certain interventions are cost-effective. So even though they’re shown to work statistically if implemented with fidelity, they are not necessarily cost-effective for everyone because of the risk environment.” Executive respondents and medical directors suggested that IPAs that are not capitated on a full-risk basis for a population often struggle in sustaining care management programs, which take a longer time to show results and returns. Thus, it appears that IPAs may focus on achieving the metrics for which they are being paid and that IPAs with revenue models that provide up-front funds to care for their members are more likely to succeed in the implementation and sustainability of best practice—based programs.

Physician Engagement

Physician engagement refers to the provider’s willingness to implement and sustain best practices among their patient population. Stakeholders reported that physician engagement was linked with improved results across the care management practices (Table). According to a majority of respondents, the contractual relationship with the IPA and the volume of patients that the physician has within a particular IPA influenced both their capacity and their willingness to engage in best practices being deployed by the IPA.

Physician contract type (exclusive, employed, open contract) and volume of patients per physician attributed to a single IPA were the 2 features most often cited as affecting physician engagement as it relates to the implementation of best practices within individual practices. Respondents noted an increased engagement and willingness to participate in IPA-dictated best practices when the physician was either exclusive with the group or had a high volume of that IPA’s patients. Respondents stated that high-volume IPA providers tended to be more engaged in care management programs than low-volume providers. One medical director said, “If they get 50[%] or 60[%] or 70% of their patients through 1 IPA, it makes cooperation and engagement easier.” Other respondents expressed that employed physicians were also more likely to refer to available best practice—based programs.

Risk Stratification for High-Touch Programs

Respondents noted that for high-touch programs (eg, face-to-face home visits) to be cost-effective, visits needed to focus on patients most likely to benefit. However, IPA strategies for selecting individuals for high-touch programs varied widely (Table). Some care manager respondents discussed targeting the elderly and frail for home visits, whereas others homed in on those with recent ED visits and/or hospitalization history. A few care managers said that the selection process was based on the individual patients’ needs, whereas others used a variety of automated risk-stratification algorithms that included a combination of the previously mentioned factors.

The most common risk stratification tool identified by participants was the LACE index scoring tool, which is a measure of future readmission risk after an inpatient stay. The LACE score was used to determine eligibility and placement into care management programs. Other methods of risk stratification commonly used by the IPAs in this study included proprietary algorithms that are based on factors such as utilization history, age, and information from disease registries.

All participants utilized some form of risk stratification, although only 2 respondents claimed to incorporate social determinants into their methodology. The 2 respondents using social factors believed that it was helpful in identifying patients most likely to benefit. One medical director explained, “Social determinants play a huge role; we have populations with a history of substance abuse who do not have safe homes, [and this information] helps us determine which programs [to use] and what the patient needs.” For the few that used social determinants as part of their stratification method, the IPA most commonly used the status of homelessness (yes or no) as the social determinant considered.

DISCUSSION

Revenue Model May Dictate Best-Practice Use

Contractual obligations and financial incentives between health plans and IPAs greatly influence which care management programs IPAs adopt, regardless of whether that particular strategy is considered a best practice or is most appropriate given the needs of a specific population. It is therefore paramount that financial rewards are appropriately aligned with evidence-based findings and attuned to the needs of local populations. Further, our findings support the concept that IPAs that do not assume full risk and/or that participate in revenue models with limited up-front revenue are less likely to adopt and sustain best practices that require substantial up-front investment costs. This in turn limits the type and scope of effective programs that can be implemented. Revenue models that support and sustain care management strategies should be proactively evaluated by stakeholders.

IPAs that do not assume full risk generally have less flexibility in spending their limited resources. This decreases the opportunity to invest in programs that either are more effective or require extended periods to demonstrate benefit. For the latter, IPAs could explore the duration of funding to ensure adequate time to accurately assess program effectiveness.

Understanding the structure of an IPA’s revenue model helps determine which types of care management strategies can successfully be implemented within its environment. Models associated with effective best practice use include full-risk capitation, global capitation, and other value-based models that reward based on health care outcomes while providing the revenue to care for the patient prior to spending on services. Alternatively, models without up-front investment were more likely to result in failed programs either during or shortly after implementation. This may be the case because it is more difficult to finance and sustain these care management best practices for longer periods of time. It is therefore recommended that prior to developing a care management strategy, IPAs evaluate their revenue model, contractual obligations, and the sustainability of funding necessary to support the program and see results.

Physician Engagement Used to Improve Care Management Program Outcomes

Because physician engagement and active involvement in care management programs have been linked with improved results, developing a physician engagement strategy is critical for IPAs. However, knowing which physicians to target in a diverse network spread over a large geographic area can be a formidable challenge.

Because it has been found that a robust network of exclusive, employed, or high-volume providers are better positioned to both administer best care management strategies and sustain them over time, it is recommended that IPAs target high-volume providers and exclusive providers first as a tiered approach when attempting to implement best-practice strategies across broad and diverse physician networks and patient populations.

Risk Stratification as a Tool to Increase Efficacy of Best Practices

Respondents discussed the high cost of implementing face-to-face care management programs, especially if patients are geographically dispersed, often leading to the failure of otherwise effective initiatives. To address this, the IPAs that were able to implement this best practice successfully targeted individuals who were most likely to benefit from the intervention using a risk-stratification system. Focusing in-person care management on those most likely to benefit helped IPAs demonstrate a positive return on investment. Therefore, it is recommended that IPAs take advantage of evidence-based risk stratification systems to identify patients who will benefit from resource-intensive interventions such as home visits. Those groups using social factors as a key piece within their risk stratification systems may have an advantage, as chronic disease is often associated with certain social determinants.¹⁷ It is recommended that future research might compare various risk-stratification methods, particularly those that integrate social determinants.

Limitations

There were several limitations to this study. First, all but 1 IPA was on the West Coast, which may limit generalizability of the results. Further research is needed to determine if the barriers and facilitators that we identified are similar to those in other parts of the country. Additionally, there was lack of standardization across IPAs when evaluating the efficacy of their internal best practices. This made comparing similar best practices across various IPAs challenging. Efforts that allow for more direct comparisons will help to further elucidate the barriers and facilitators of best practices nationally.

CONCLUSIONS

Recommendations from this study include assessing the organization’s revenue model and contractual obligations to health plans when developing care management strategies, concentrating best-practice dissemination among high-volume or exclusive providers, and using risk stratification including social factors to target members most likely to benefit from the interventions. Ultimately, it is critical to align appropriate funding models to achieve optimal outcomes by supporting the adoption of robust best practices by multiple stakeholders, including IPAs, health plans, and government payers. More research is needed to further explore facilitators and barriers to best-practice implementation among IPAs nationally.Author Affiliations: Regal Medical Group (JND), Laguna Niguel, CA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (MW, PS), Chapel Hill, NC.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JND, MW, PS); acquisition of data (JND); analysis and interpretation of data (JND, MW, PS); drafting of the manuscript (JND); critical revision of the manuscript for important intellectual content (JND, MW, PS); statistical analysis (JND); provision of patients or study materials (JND); and supervision (PS).

Address Correspondence to: Jennifer N. Dunphy, DrPH, MBA, MPH, Regal Medical Group, 8510 Balboa Blvd, Ste 150, Northridge, CA 91325. Email: Jennifern.Dunphy@gmail.com.REFERENCES

1. 2016-2025 projections of national health expenditures data released. CMS. Accessed March 8, 2017. https://www.cms.gov/newsroom/press-releases/2016-2025-projections-national-health-expenditures-data-released

2. Mattke S, Mengistu T, Klautzer L, Sloss EM, Brook RH. Improving care for chronic conditions: current practices and future trends in health plan programs. Rand Health Q. 2015;5(2):3.

3. Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. RAND Corporation; 2017. Accessed March 8, 2017. https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221/RAND_TL221.pdf

4. Hickam DH, Weiss JW, Guise JM, et al. Outpatient case management for adults with medical illness and complex care needs. Agency for Healthcare Research and Quality. January 2013. Accessed March 8, 2017. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/case-management_research.pdf

5. Nelson L. Lessons from Medicare’s demonstration projects on disease management, care coordination, and value-based payment. Congressional Budget Office. January 2012. Accessed May 19, 2017. https://www.cbo.gov/sites/default/files/112th-congress-2011-2012/reports/01-18-12-MedicareDemoBrief.pdf

6. Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of case management for ‘at risk’ patients in primary care: a systematic review and meta-analysis. PLoS One. 2015;10(7):e0132340. doi:10.1371/journal.pone.0132340

7. Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? The Commonwealth Fund. August 7, 2014. Accessed March 8, 2017. https://www.commonwealthfund.org/publications/issue-briefs/2014/aug/caring-high-need-high-cost-patients-what-makes-successful-care

8. Joo JY, Liu MF. Case management effectiveness in reducing hospital use: a systematic review. Int Nurs Rev. 2017;64(2):296-308. doi:10.1111/inr.12335

9. Peterson K, Helfand M, Humphrey L, Christensen V, Carson S. Evidence brief: effectiveness of intensive primary care programs. US Department of Veterans Affairs. February 2013. Accessed March 8, 2017. https://www.hsrd.research.va.gov/publications/esp/primary-care.cfm

10. Ruiz S, Snyder LP, Rotondo C, Cross-Barnet C, Colligan EM, Giuriceo K. Innovative home visit models associated with reductions in costs, hospitalizations, and emergency department use. Health Aff (Millwood). 2017;36(3):425-432. doi:10.1377/hlthaff.2016.1305

11. Takeda A, Taylor SJ, Taylor RS, Khan F, Krum H, Underwood M. Clinical service organisation for heart failure. Cochrane Database Syst Rev. 2012;(9):CD002752. doi:10.1002/14651858.CD002752.pub3

12. Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774-784. doi:10.7326/M14-0083

13. Van Spall HGC, Rahman T, Mytton O, et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis. Eur J Heart Fail. 2017;19(11):1427-1443. doi:10.1002/ejhf.765

14. McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: an evidence synthesis. The Commonwealth Fund. October 29, 2015. Accessed March 8, 2017. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/models-care-high-need-high-cost-patients-evidence-synthesis

15. Göhler A, Januzzi JL, Worrell SS, et al. A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. J Card Fail. 2006;12(7):554-567. doi:10.1016/j.cardfail.2006.03.003

16. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-282.

17. Cockerham WC, Hamby BW, Oates GR. The social determinants of chronic disease. Am J Prev Med. 2017;52(1S1):S5-S12. doi:10.1016/j.amepre.2016.09.010

Download PDF: Strategies for Implementing Best Practices in Independent Physician Associations