Effective Management of Chronic Disease

Study Shows Physicians Underutilize Care Management Tools

January 26, 2010 05:25 pm Sheri Porter

A recent study released by The Center for Studying Health System Change, or HSC, found that there's wide variation among U.S. physicians when it comes to using care management tools, such as patient registries and group visits, to treat patients with chronic diseases.

"The study suggests that providers in small practices are further behind their peers in larger practices and integrated delivery systems (such as Kaiser) in adopting care management tools," said HSC Senior Researcher Emily Carrier, M.D., M.S.C.I., in an interview with AAFP News Now. "Policymakers hoping to encourage wider adoption of those tools may want to focus their attention on small practices and the barriers they face," said Carrier.

Carrier and HSC Senior Researcher James Reschovsky co-authored the HSC issue brief "Expectations Outpace Reality: Physicians' Use of Care Management Tools for Patients With Chronic Conditions(www.hschange.org)." HSC is a Washington-based research organization that studies the financing and delivery of health care in the United States.

Study results were based on HSC's 2008 Health Tracking Physician Survey(www.hschange.com), which reported responses from more than 4,700 physicians, including a subsample of 1,304 family physicians and internists who take care of adult patients with four common chronic conditions: asthma, diabetes, congestive heart failure and depression.

The study notes that about 75 percent of U.S. health care dollars -- nearly $1.5 trillion -- are spent on patients with chronic conditions each year. Furthermore, previous research has shown that care management tools improve care processes and patient outcomes.

Physicians were asked about their use of seven care management tools in relation to chronic disease. Those tools and the percentages of primary care physicians across all practice settings using them are

  • written patient education materials (75 percent),
  • reports for physicians on the quality of care delivered to patients with chronic conditions (68 percent),
  • reports for physicians on the quality of preventive care delivered to patients (63 percent),
  • nonphysician educators (50 percent),
  • patient registries (42 percent),
  • nurse managers to coordinate care (31 percent), and
  • group visits (20 percent).

In the study, the authors suggest that physicians' preference for handing out patient education materials "may reflect expediency rather than effectiveness." They note that written materials are "inexpensive and require little upfront investment compared with the other interventions described, but they are also associated with the least benefit."

According to the study, of the seven care management tools highlighted, the average number of tools used by all physicians, regardless of practice setting, was 2.9. Notably, solo and small primary care practices with three to five physicians used a total of 2.6 tools. Large HMO practice groups used double that number, or 5.2 tools.

Carrier said that physicians face an uphill battle in terms of receiving compensation for implementing care management tools that could help them provide higher quality care. And, she added, solo and small primary care practices face even more challenges.

"Larger practices can spread the cost of care management over a much larger patient panel," said Carrier. "In many cases, the cost to a practice of building and using care management tools is relatively high, but once that practice has committed to it, then the cost of extending care management to additional patients is relatively low."

According to Carrier, the costs of incorporating new tools into a practice's chronic care procedures begin with upfront development costs but must include ongoing maintenance costs. For example, it takes staff time to establish a patient registry and enter initial patient data, she said. But a staff person also has to regularly update patient information and dedicate time to using the registry to accomplish designated tasks, such as processing patient reminder cards.

"In some cases, it may not make financial sense for a small practice to 'go it alone,'" said Carrier. Indeed, the report suggests that one approach is to provide incentives for practices to "join affiliated networks large enough to sustain a variety of practice innovations on their own."

The study points to an initiative called Community Care of North Carolina, or CCNC, an offshoot of North Carolina's Medicaid program, that has successfully created community-level resources and funded case managers that are shared among several small practices.

"In fact, changing compensation may not be the only answer," said Carrier. "Policymakers can also look at the experience of payers like CCNC that have taken creative approaches to providing small practices with access to community-based resources."

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