Business Intelligence

Dean C. Coddington

With Medicare readmissions running about 20 percent within 30 days, what would you think of a medical group that got its readmission rate down to 1 percent?

New West Physicians (NWP) is a primary care group (80 providers in 16 locations) serving the western suburbs of the Denver area. NWP serves more than 10,000 participants in United Healthcare's Medicare Advantage program. It receives risk-adjusted capitated payment for professional services (primary and specialty care) for this population.

NWP's success is in large part attributable to effective use of business intelligence-in this case, through the active application and coordination of information required to ensure patients receive the highest quality of care possible. The full story revolves around the following six key steps, which are emblematic of NWP's approach to managing its patients' care.

Use of an electronic health record (EHR) to facilitate the coordination of care. NWP performs periodic clinical studies on its patients with one or more chronic diseases (e.g., diabetes, asthma, congestive heart failure). Having access to an EHR greatly facilitates these types of studies by providing analysts with access to medical information in the physician's office. The goal is to improve the management of care for this population, as these are the patients most likely to be hospitalized and, if not managed properly, are the prime candidates for readmission following an acute care episode. The EHR search engine allows the physicians to identify patients with specific medical conditions who may benefit from a research program.

Careful screening and utilization of specialists. NWP has 450 specialists in its panel but uses only 150 on a regular basis. NWP represents as much as half of the business for some of these 150 specialists, all of whom are committed to the same quality goals as NWP's primary care physicians. NWP routinely monitors data on the physicians' costs and utilization. If a specialist exhibits recurring problems relative to either of these factors, the specialist's performance is carefully reviewed and then referred to the NWP medical management committee and the chief medical officer. It is not uncommon for a specialist to be replaced on the NWP panel.

Analysis of claims data to identify clinical variation among physicians. NWP uses an analytical program to monitor claims data, on a real-time basis, and identify clinical variation of physicians who are caring for its United Healthcare Medicare Advantage population. Ruth Benton, CEO of NWP, says: "This software enables us to pull the information from the United Healthcare claims data base, and we have developed our own matrices and other analytical tools to assess the performance of individual physicians. Where someone-either one of our primary care physicians or a specialist in our panel-appears to be out of line with clinical guidelines in their treatment of one of our patients, the physician is notified of the corrective action that is necessary or to understand the reasons why."

Use of employed hospitalists. NWP employs its own hospitalists (a group of eight), who are called immediately when a NWP patient is admitted. On such an admission, the hospitalists are routinely given access to the patient's EHR. If an NWP patient in the United Healthcare program is admitted to a hospital not used by NWP, the patient is transferred as quickly as possible (when safely stable) to one of the preferred facilities that NWP uses.

When an NWP patient is admitted to an NWP facility, an NWP hospitalist immediately alerts the primary care physician of the admission. Having received the assurance that NWP's hospitalists have access to the patient's full clinical information, the primary care physician yields responsibility for the admission to the hospitalists, who perform as the primary care physicians in the hospital, caring for and closely monitoring the patient during the hospital stay. Then, when the patient is discharged, the hospitalists ensure that he or she is put in the hands of NWP's discharge planners and the patient's primary care physician to provide the discharge note in the EHR.

Follow up by a NWP midlevel provider to ensure prescriptions are filled. The NWP midlevel provider who coordinates discharges makes sure all prescriptions are filled, even to the point of going to the pharmacy, picking up, and delivering the prescriptions. Most important, this nurse confirms with the patient and family members what prescriptions are to be taken, and when. The nurse also educates the patient on what is required to recover from the hospital visit. A follow-up visit with the patient's primary care physician or applicable specialist is scheduled within a week of discharge.

Preselection, screening, and monitoring of postacute care facilities. NWP's preselection, screening, and monitoring of postacute care facilities, used for transitional care from a hospitalization, also contribute to the organization's success in reducing readmissions. NWP selects these facilities on the basis of their track record in delivering excellent care to NWP patients who require rehabilitation or other subacute care following hospitalization, and their communications with NWP's primary care physicians. NWP's case management nurses see the patients in these facilities to monitor the progress and appropriateness of the care. The average length of stay is three to six days.

Apart from these six steps, one additional factor is extremely important: Financial incentives with NWP are aligned up and down the line. Because NWP's patients are all on a Medicare Advantage program, the organization is paid on a risk-adjusted capitated basis; its financial incentives are to provide high-quality care at the lowest cost.

An important part of delivering high-quality care is the avoidance of hospital-acquired infections. Benton says a very small percentage of NWP's readmissions are due to such conditions, reaffirming that NWP is able to manage most of the factors affecting readmissions by applying the six care management steps described here.

It also should be noted that NWP does not receive the hospital part of the capitated payment received by United Healthcare under its Medicare Advantage program. So what is its incentive to work so hard on avoiding readmissions?

Says Benton: "First, our physicians want what is best for their patients, and a readmission is usually not in a patient's best interests. Second, we reduce our payments to specialists by cutting down on readmissions, and we benefit financially from that. Third, we receive a significant bonus from United Healthcare for achieving a low readmission rate and achieving other quality targets."

With such clear incentives, all that remains is having the information and wherewithal to get the best results. NWP 's philosophy is, "Do the right thing for the patient the first time."

Dean C. Coddington is a senior consultant, McManis Consulting, Denver, and a member of HFMA's Colorado Chapter (


Publication Date: Wednesday, February 01, 2012

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