Chronic care improvement in primary care: Evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes

There is little debate that realizing improvements in the quality of health care, especially for chronic conditions, will require changes in our physician payment practices. There remains substantial controversy, however, in how to structure a payment system to align resource allocation with quality of care (IOM Committee on Quality of Health Care in America 2001). Much attention has been devoted to pay-for-performance (P4P) programs that link some portion of physician or practice compensation to the attainment of specific quality of care objectives (Rosenthal et al. 2004, 2005; Rosenthal and Frank 2006). P4P programs continue to expand in number and scope even though research on the effects of P4P on quality has produced mixed results (Rosenthal et al. 2005; Rosenthal and Frank 2006; Rosenthal 2007; Rosof, Sirio, and Kmetik 2008; Greene and Nash 2009;). Health services leaders recommend P4P programs as part of the effort to address long-term health care spending growth (Antos et al. 2009). In addition to restructuring financial incentives, improvement in the care of chronic conditions frequently involves disease management of affected patients (Fireman, Bartlett, and Selby 2004; Wagner 2004; Wagner and Reid 2007;). Conventionally, disease management is provided by call center nurses who maintain telephonic contact with enrollees in order to assist them with the implementation of their chronic care regimens. While effort is made to have consistency between call center nurse and her patient panels, her contact with primary care providers is highly variable, and often not part of the disease management service mix. This lack of integration results in gaps in communication and coordination of care, both of which may have deleterious effects on the quality of care and patient outcomes. In recent years, a “second generation” of disease management has sought to integrate the remote, telephonic services, such as those typically provided by nurse care managers, within the primary care medical home (Villagra 2004; Casalino 2005; American Academy of Family Physicians 2008;). Co-locating the care management professional with the primary care clinicians may be a superior approach for improving care coordination, especially for patients with multimorbidity, which is the norm among elders (Boult et al. 2001; Boyd et al. 2005;). This article presents an evaluation of a chronic care improvement initiative that consisted of P4P practice-based care coordination augmented by third-party disease management with call center nurses dedicated to patients in intervention practices. The initiative (the “Intervention”) had three components: (1) a practice-based care coordination program using an on-site care coordinator (registered nurses [RNs], licensed practical nurses [LPNs], and medical assistants—a new position in the practices), (2) a P4P program in which practices were given a bonus payment for meeting specific quality indicator goals, and (3) a disease management program with call center nurses dedicated to patients in the intervention practices. The aims of this paper were to examine the effects of the intervention on quality of care measures and resource use for patients with diabetes mellitus, the most common chronic condition that is care managed by third-party firms and for which there is an evidence base supporting its responsiveness to care management (Villagra and Ahmed 2004; Von Korff et al. 2005; Mangione et al. 2006; Weber and Neeser 2006;). Moreover, diabetes is a condition that has behavioral change and care management potential in that it is relatively controllable by adherence to a medical regimen and lifestyle patterns that include healthy nutrition and activity (Hill-Briggs 2003). This evaluation was guided by the following, general research question: “What is the intervention effect on incentivized quality measures, and what is the broader effect of the intervention on the overall quality of care for patients with diabetes?” Specifically, we examined the effects of the intervention on (1) quality of care for the incentivized care indicators for diabetes, (2) quality of care for nonincentivized care indicators for diabetes, and (3) utilization and medical costs incurred by the patients with diabetes in the intervention practices. We hypothesized higher quality of medical care for enrollees with diabetes exposed to the intervention compared with others receiving usual primary care and conventional third-party disease management only. In examining the various nonincentivized measures, we sought to explore any positive halo effect of the intervention or any unintended consequences of the intervention such as decline in the nonincentivized quality of care measures (Casalino 1999; Forrest, Villagra, and Pope 2006;).