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Quality improvement "can’t be done solely by a physician and office practice staff during a 15-minute office visit. Improvement requires work outside the usual office visit and must utilize data."
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Better Health and Lower Costs for People with Complex Chronic Conditions in Louisiana

By Ross Hamic | Monday, May 18, 2015

Louisiana has a high prevalence of chronic diseases such as hypertension, diabetes, chronic kidney disease, and cardiovascular disease. With a common vision to improve primary care delivery for patients with complex chronic conditions, Blue Cross Blue Shield of Louisiana and the Louisiana Department of Health and Hospitals Office of Public Health formed the Louisiana Alliance for Better Health (LABH). Primary care physician Ross Hamic, MD, is a core team member for LABH’s participation in IHI’s Better Health and Lower Costs for Patients with Complex Needs Collaborative. LABH joined the Collaborative in 2014 to support integrated learning about population health chronic disease management. In this interview with Catherine Mather, IHI Senior Project Manager, Dr. Hamic shares his experience to date in the Collaborative.

Dr. Ross Hamic

What efforts are underway in Louisiana to improve chronic disease care and what is your role in this work?

In 2013, Blue Cross Blue Shield of Louisiana (BCBSLA) launched a population health quality improvement initiative for patients with chronic diseases called Quality Blue Primary Care (QBPC). This program aims to address Louisiana’s high prevalence of hypertension, diabetes, chronic kidney disease, and cardiovascular disease by focusing on providing optimal medical therapy to these patients, which will result in lower future costs. Providers who enroll in the QBPC program receive monthly management fees in addition to traditional fee-for-service reimbursement and have access to a data analytics software tool that syncs with most electronic health records (EHRs).

Concurrent with the launch of QBPC, the state’s Department of Health and Hospitals Office of Public Health (OPH) conducted a scan of existing statewide chronic disease interventions. BCBSLA was quickly identified as a critical partner in the OPH mission to address Louisiana’s high prevalence of controlled hypertension and diabetes. The joint funded project, Louisiana Alliance for Better Health (LABH), comprises clinical, public health, and data analytics leaders from BCBSLA.

I’m a board-certified family physician working at The Family Doctors in Shreveport, Louisiana, which is one of the QBPC practices. I’m a core team member for LABH’s participation in the IHI Better Health and Lower Costs for Patients with Complex Needs Collaborative. In terms of my clinical interests, I’m especially interested in managing chronic diseases such as hypertension, diabetes, and vascular disease.

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Why did you join the IHI Collaborative, and what is the focus of the LABH team’s work in the Collaborative?

The Family Doctors was a pioneer clinic in the QBPC program and, through our involvement, I developed a good working relationship with Dr. Paul Murphree (CMO of BCBSLA) and Dr. William Bestermann (retired internist and BCBSLA consultant). They asked that I join the LABH team participating in IHI’s Collaborative.

Our work represents a really unique collaborative between clinicians, BCBSLA (Louisiana’s largest commercial insurer), and the state’s Office of Public Health. Using data analysis on cost and service utilization, we’re trying to test some changes in the way we deliver care to patients who have historically incurred a high cost of care. Our aim is to learn how successful practice changes and different patient engagement techniques can be utilized to increase the number of patients who receive optimal medical therapy and reach target measures for their respective chronic conditions. The hope is that these strategies can then serve as a template for other practices that provide care for BCBSLA members.

To start, BCBSLA ran an analysis on my 50 highest-cost patients over the preceding two-year period. Working together, we analyzed the data to see which patients incurred costs that were either unavoidable or one-time events versus patients who had a high cost of care due to recurrent and inefficient care-seeking behavior. We focused on the latter subsegment of patients.

What did you learn when you used the HARMS-8 tool to screen a subset of your patients with the highest costs? What did you learn from the data analysis or HARMS-8 implementation that was a surprise?

During every clinical encounter with patients I review medications in detail — what medications are you taking, what dose are you taking, are you taking it every day? The first patient I interviewed as part of the IHI Collaborative work was the patient with the highest cost of care (of my BCBSLA panel) over a two-year period. At the time I started treating him, he already had a history of uncontrolled diabetes, a previous CVA (cerebrovascular accident), and end-stage chronic kidney disease, to name just a few of his medical problems.

Data analysis from BCBSLA not only provided total cost of care data for him, but also his emergency department (ED) utilization rates. I learned that, in the first two years under my care, this patient had been to the ED 26 times — and few of the visits were truly emergencies. His first point of contact for every acute medical problem, regardless of severity, was the nearest emergency room and not my office or urgent care. Prior to our clinic joining the QBPC program, I had no data on patient visits to an emergency department unless there was a follow-up visit shortly afterwards.

He was the first patient I interviewed using the HARMS-8 survey. One question in the survey asks whether the individual has trouble affording his or her medicine. Even though I had always asked this particular patient if he was taking his medicine and he always said “yes,” I had not yet asked him about medication affordability. When I did, he answered “yes” to having trouble with affording his medicine — it was then that I learned he often had to stretch out his insulin prescription before he could afford a refill. So, even though he was taking his medicine, he was routinely skipping doses.

As a result of learning this, my nurse contacted a nurse manager at BCBSLA, with whom we already had a working relationship through the QBPC program, to let her know this individual was having trouble affording his insulin. BCBSLA then waived his co-pays for this particular medication. Thankfully, this was an immediate intervention we were able to deploy. This can’t be done for everyone, but for an individual who already has complex medical needs and is at high risk for future adverse outcomes my hope is that discovering this fact prevented future unneeded ED visits or another diabetic complication.

This was just one individual. We’re now working to screen another 5 to 10 more patients on my “top 50” list of individuals with the highest utilization and costs to see what else we can learn.

Identifying a way to implement HARMS-8 on a broader scale is a priority for your team. What is the significance of these systems-level changes?

We’re trying to modify the HARMS-8 tool to create a questionnaire or survey that a BCBSLA case manager can use to reach out directly to targeted members. If this survey provides valuable information to either the case management team at BCBS or to a primary care provider, then the goal would be to roll out this survey to the entire BCBS population across the state. We plan to add questions related to self-rating of health status, whether patients feel in control of their health problems, and whether they find the information provided by their doctor to be useful. We also want to get more specific with questions related to prescription medications, such as the perceived importance of taking prescription medications, belief that prescription medications will do more good than harm, and whether a person’s prescription medications are creating a financial burden. We also plan to ask questions related to wait times for an appointment with a primary care provider, to see if there is any link between this and ED utilization.

A goal of this questionnaire is to really understand if patients are doing what physicians think they are doing and to identify any hiccups in the system. It’s not designed to be judgmental of patients or physicians. Our vision is to develop a tool that will help us “check the pulse” with a specific patient panel to see if there is more we can do as a joint effort — meaning a collaboration between a payer and physicians — to improve the health outcomes of patients and bend the projected cost curve. We want this questionnaire to be viewed by patients and physicians as positive and beneficial. Again, our hope is to learn and then formulate engagement strategies that are fully reproducible and can be used in every practice — large or small — at the statewide level.

What tips would you give to other physicians based on what you’ve learned?

Having access to and the ability to use comprehensive and accurate data analytic tools can help physicians improve care delivered to their respective patient population. Paired with this, physicians and support staff need to be ready to engage patients differently than they have in the past.

If questioned, most, if not all, physicians would say that they provide excellent care to their patients. However, if we were to analyze large population health data and pay particular attention to the percentage of patients who receive optimal medical therapy and meet well-defined clinical targets for high-cost conditions like hypertension, diabetes, and vascular disease, I think we would find there is room for improvement — starting with my practice. This improvement can’t be done solely by a physician and office practice staff during a 15- or 20-minute office visit. Improvement requires work outside the usual office visit and must utilize data that can only be provided by outside sources such as payers. 

A critical component to any population health improvement effort is patient buy-in and participation. Patients must understand their medical conditions, the cost and complications that can result from not meeting defined clinical targets, and the need to adhere to their recommended treatment plans. Our research in Louisiana focuses most of our attention on the patient component. We want to be able to identify what reversible barriers exist that negatively impact care delivery and outcomes at a substantial cost.

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