Pennsylvania Prepares to Revamp Approach to Chronic Care

Pennsylvania is preparing to launch a chronic care management program that will rely on family physicians and other primary care providers to coordinate and manage the care of residents of the state who have chronic conditions.

The state plans to begin implementing its new chronic care program in May, starting with several primary care practices in Philadelphia before rolling out the program statewide in September. Pennsylvania's program is based on a chronic care model developed during the 1990s by Edward Wagner, M.D., Ph.D., and his colleagues at the W.A. MacColl Institute for Healthcare Innovation at the Group Health Center for Health Studies, Group Health Cooperative of Puget Sound, in Seattle.

Under the Pennsylvania plan, primary care physicians will head multidisciplinary teams that work with patients to better manage current conditions, such as obesity and hypertension, and to help prevent the onset of other chronic ailments, such as diabetes and heart disease. In areas where primary care physicians aren't available, certified registered nurse practitioners may be tapped to serve as the head of the teams, but this point remains under discussion, said Pat Bricker, director of practice advocacy for the Pennsylvania AFP.

Each team may consist of a primary care physician, a nurse practitioner and a nutritionist, and will be connected to other resources in the community, such as exercise groups, said Amy Kelchner, director of communications for the Governor's Office of Health Care Reform. Each health care team will receive training in the chronic care model through intensive learning collaboratives established in various parts of the state.

The program will start with both private and public sector patients and will include private insurers and probably some Medicare and Medicaid managed care organizations. It will pay participating practices an extra fee to manage and coordinate patients' care and to help the practices pay for disease registries and other tools needed to better track patient care. Practices will receive enhanced payments to support the additional resources needed for the chronic care model, and, in addition, they will be eligible for pay-for-performance bonuses for improved patient outcomes, said Kelchner.

Practices also will receive coaching support to stay on track and implement the changes through the Improving Performance in Practice, or IPIP, program, which seeks to improve patient outcomes for chronic conditions, said Bricker. The American Board of Medical Specialties Research and Education Foundation convenes the IPIP program, which was developed in conjunction with the AAFP, the American Academy of Pediatrics, the American College of Physicians and other partners. The state chapters of these three national physician organizations are jointly leading the IPIP effort in Pennsylvania and are engaged in chronic care planning efforts in the state, said Bricker.

"The vast majority of payers have been at the table, which in Pennsylvania includes Blue Cross and Blue Shield, the dominant payers in our state," said Kelchner. "We are working with all the payers on guidelines to use in paying practices to get involved and stay involved.

"There is tremendous excitement about the program," she added. "This is the only thing we have done so far where we have gotten different stakeholder groups and everyone on the same page."

By implementing the chronic care model, the state's health care system will shift from an acute care to a preventive care paradigm, leading to better outcomes and potentially saving billions of dollars in the process, said Kelchner.

"Obviously, we want to improve the quality of life in Pennsylvania for chronic care," she added. "And secondly, all of the data show us that other states that have done this type of thing save money. We estimate in Pennsylvania in 2007, avoidable hospital admissions by chronic disease exceeded an estimated $44 billion in hospital charges, not counting emergency-room visits."

According to a report (65-page PDF; About PDFs) issued by the Governor's Commission on Chronic Care Management, Reimbursement and Cost Reduction, chronic care diseases are the leading cause of death and disability in Pennsylvania, accounting for 80 percent of all health care costs and hospitalizations and 76 percent of all physician visits.

"Pennsylvanians with heart disease are admitted unnecessarily to hospitals more than two-and-a-half times as much as the best performing states, approximately three times as often for asthma and more than four times as much for diabetes," the report said.

"Much of the hospital and emergency room costs for patients with chronic conditions would be unnecessary if patients simply received evidence-based care in a setting where multiple practitioners and health educators can easily communicate and collaborate," said the report.

It also criticized the current payment system for failing to "support or reward primary care practices for effective control of chronic conditions, care coordination and office systems that have demonstrated effective prevention of hospitalization and emergency room visits."

"The result of the current system is fragmented, suboptimal care that leaves patients inadequately supported, and primary care practitioners frustrated," the report said. "It is a system that too often waits for patients to become seriously ill; only then applies its full attention and resources to patient care."