March 21, 2013
It’s a puzzle with a dizzying number of pieces, not to mention a price tag large enough to seem abstract to anyone in a typical consumer market. In Oregon’s Medicaid program alone, solving the health care reform puzzle could result in an estimated cost savings of $11 billion over the next decade. But this is no ordinary marketplace. This is health care. It’s a complex system of players, including providers, patients, payers, bureaucrats, advocates and politicians, operating under its own rules – or barely operating at all, depending on who you ask.
But David Dorr, M.D., M.S., is undaunted by the complexity of the health care reform puzzle. His background as a general medicine internist and an informatics researcher makes him well-equipped to study health care reform. And OHSU – as a statewide institution ensconced in Oregon’s headline-grabbing reform efforts with a growing capacity for what President Robertson calls “delivery system science”– is a unique laboratory for such work.
Utilizing quantitative elements of health system research, including analysis of electronic health record (EHR) system and billing data and health information technology user metrics, coupled with training to reorient clinicians and patients to a coordinated care delivery model, Dr. Dorr and colleagues are digging deep into the model of a patient-centered primary care medical home. “Changing incentives, changing practices, and using information technology to achieve success are really the core elements of my research,” said Dr. Dorr, associate professor of medical informatics and clinical epidemiology.
Train, test and transform
Dr. Dorr is heading up a pilot project called Transforming Outcomes for Patients through Medical home Evaluation & reDesign (TOPMED). TOPMED aims to provide measurable data on the effectiveness of the medical home concept in Oregon – and to disseminate the results nationally. A $1.6 million, three-year partnership with the Gordon and Betty Moore Foundation, TOPMED aims to analyze and identify – through a cluster randomized controlled trial – the most effective primary care delivery models, especially for older adults with multiple chronic conditions. Patients with chronic illnesses are estimated to account for approximately 75 percent of health care expenditures.
TOPMED is underway with eight clinics in diverse health care settings. OHSU Family Medicine Gabriel Park and the General Internal Medicine are both participating sites. Systems of varying sizes and ownership in Woodburn, Pacific City, Lincoln City, Lebanon, Springfield and Portland are also on board. The TOPMED study intersects with coordinated care organizations in four regions; CCOs are charged with transforming Medicaid delivery in Oregon.
“The gap in implementing patient-centered medical homes is widest in small- to moderate-size clinics, especially in non-urban settings, so TOPMED will focus on those settings,” said Dr. Dorr. “Academic medical centers are also crucial places for this model because of their complex populations and wide variety of learners, who are participants in making it a sustainable model.”
At the heart of the TOPMED trial is a focus on “high value” patient care: evidence-based care management based on need, deep patient and family engagement and population management tools to assess ongoing performance. Participating provider groups – often oriented around a nurse care manager – are provided with practice facilitation and monthly reports.
L.J. Fagnan, M.D., is co- investigator in the TOPMED study. “Rural practices and clinicians are passionate about implementing change to improve the health of rural communities,” said Dr. Fagnan, professor of family medicine and director of the Oregon Rural Practice-based Research Network (ORPRN). “TOPMED is a comprehensive toolkit that addresses time and capacity constraints in order for clinics to implement population-based health care interventions.” Practice facilitation is a key component of the TOPMED intervention. ORPRN Practice Enhancement and Research Coordinator (PERC) Beth Sommers is providing training and assistance for practice change.
TOPMED also engages patients and other stakeholders besides clinics. Payers, purchasers and patients were asked about their views of the high value elements and whether they were willing to align with the trial goals. The TOPMED team has focused on incentives to create alignment for practices and payers to help ensure the sustainability of the model.
Follow the evidence
An evidence-based care model called Care Management Plus (CM+) informs the TOPMED trial. Funded by The John A. Hartford Foundation, CM+ is an innovation team based at OHSU that creates and tests new models of health care for patients most at risk in primary care and other settings – often, older patients with chronic illnesses. CM+ uses advanced technology and informatics coupled with team reorganization around care management to change outcomes and develop effective solutions for teams of professionals providing primary care.
CM+ was initially tested at Intermountain Healthcare in Salt Lake City in a controlled clinical trial involving 4,000 patients and 13 primary care clinics. In that study, the model demonstrated a 24 percent to 40 percent reduction in hospitalizations, a reduction in mortality, and a two-to-one cost savings for patients with complex illness. The cost savings for Medicare were estimated to be approximately $17,384 per clinic per year. CM+ has also shown improvements in outcomes for patients with diabetes or depression, and has shown improved patient and care team satisfaction.
“The results of David’s care coordination research are so far promising,” said John McConnell, Ph.D., director of the Oregon Center for Health Systems Effectiveness and associate professor of emergency medicine. “We need evidence when it comes to reform, and it’s exciting to know OHSU is contributing to the conversation in such a critical way.”
Technology – the missing link
The availability of digital tools to achieve health care reform is a necessary piece of the puzzle in today’s age of EHRs and an increasingly tech-savvy population. The Integrated Care Coordination Information System (ICCIS) is a web-based software program for population management developed at OHSU.
ICCIS was used in a trial funded by the Agency for Healthcare Research and Quality (AHRQ) to explore whether the CM+ model could be adapted for a set of six diverse primary care clinics. Importantly, it addressed another critical question in health care reform: How do pay-for-performance incentives compare to care coordination incentives in achieving improved outcomes?
Clinics in the ICCIS trial were randomly assigned to either a care coordination arm or a quality arm, with different incentives for achieving both needs. The ICCIS system interfaced with four different EHRs and targeted crucial data to manage all clinic patients and stratify those with complex needs. TOPMED is using ICCIS for seven different EHR platforms.
“Research such as David’s provides critical data and analysis for future clinicians and informatics professionals,” said William Hersh, M.D., chair of medical informatics and clinical epidemiology. “Our workforce must not only be experienced in coordinated care settings, but also be highly knowledgeable in the science and best practice of informatics. He is a true national leader in this type of work.”
Despite small incentive size, the clinics in the AHRQ trial used the ICCIS system significantly differently, with the care coordination arm performing 1.8 times as many care coordination activities as the quality arm; the quality arm increased quality scores by 14.2 percent versus 8.9 percent in the care coordination arm. Dr. Dorr presented initial results from the ICCIS trial in 2012 at AcademyHealth Annual Research Meeting.
Finally, the philanthropic partnerships supporting Dr. Dorr’s work are significant. Mission-oriented organizations have a desire for such research on behalf of the communities they serve, and their support represents a promising source of non-federal research funding in academia. Overall, Dr. Dorr’s efforts have vast potential value for providers, health systems and administrators nationwide thirsty for evidence on reform efforts.
Pictured: (top) Dr. Dorr; (middle) Dr. Fagnan; (bottom) ORPRN Practice Enhancement and Research Coordinator Beth Sommers (second from right), MPH, regularly meets with the Division of Internal Medicine's quality committee.Attendees pictured include Katie Bensching, Paige Perry, Colleen Casey, Adam Woodward, Andrew Applegate, Mary Pickett, Melinda Leuthe, Cheryl Wyborney, Christine Mullowney and Beth Sommers