St. John’s Clinic has been selected to participate in the first pay-for-performance initiative for physicians under the national Medicare program.

The project gives physician groups an opportunity to demonstrate that improving care in a proactive and coordinated manner also reduces costs.

St. John's Clinic physician David Barbe, M.D. of St. John's Clinic - Mountain Grove.

“At St. John’s we have been providing care this way for years, often despite economic losses,” explains J.T. Rogers, M.D., St. John’s Clinic internal medicine physician. “We are thrilled Centers for Medicare and Medicaid Services (CMS) is considering alternative reimbursement policies to better support what’s needed to take care of today’s patients.”

St. John’s Health System has seen financial and quality outcome success with a patient-centered medical management model that better coordinates care in between doctor and hospital visits. This model is currently being used in partnership with large employer groups directly contracting with St. John’s for health insurance coverage.

“Health care has always been focused on events of care, whether it’s a hospitalization where someone comes in for pneumonia, or whether it’s going to a doctor’s office for advice on how to care for themselves or to get a prescription,” said Walter Gaska, M.D., St. John’s Clinic president. “And by and large, payment systems have been designed around this focus. We have demonstrated that by focusing on chronic conditions, we can keep people healthier and avoid more expensive treatments down the road.”

Currently Medicare reimburses physicians based on the number and complexity of the services provided to patients. Evidence is growing that by anticipating patient needs, especially in those patients with chronic diseases, health care teams that partner with patients can intervene before expensive procedures and hospitalizations are required.

“At St. John’s, we’ve literally designed a health system: hospitals, physician clinic and health plans to link the events of care,” said Kim Day, St. John’s Health System president/CEO. “By linking the events of care and enabling patients to care for themselves better between the events, we facilitate the relationship between the physician and the patient to help them improve health care outcomes.”

And it’s working.

Janet Pursley, RN, is St. John’s vice president of medical management services. Her team uses strategies such as case, disease, utilization and data management to identify and coordinate care at a very customized level.

“What we’ve been able to do is take clinic, hospital, and health plan resources and combine them in studying the most prevalent chronic diseases affecting our patients and, in many instances, improve clinical outcomes. The best resources, evidence-based medicine and education are used to positively affect these patients.”

For example, St. John’s put into place a disease management process to look at the number of asthmatics coming into the emergency room. Through education and helping patients follow the instructions from their physicians, as well as understanding the factors that drive asthmatic attacks, they were able to show a 50 percent eduction in the need to come to the emergency room for asthmatics.

“That related to better quality of care for those patients and less cost,” Pursley explained.

As part of the CMS Demonstration Project, St. John’s will expand this already successful medical management approach to the Medicare fee-for-service population and be rewarded for it when certain performance targets are met.

St. John’s will provide Medicare patients with management and coordination of both inpatient and outpatient services including full continuum case management, 24/7 telephonic nurse triage, social worker facilitated care transition, outpatient preventive and disease management programs, and palliative care. Specific disease management programs to be expanded to the Medicare fee-for-service population include diabetes, CHF, asthma, COPD, and depression. An arthritis disease management program currently under development will also be implemented under the demonstration.

“Chronic conditions account for nearly 70 percent of US deaths and represent more than half of all health care spending,” said Pursley. The most common are asthma, diabetes and congestive heart failure.”

“How well do we keep them informed, how well do we share decisions with them, how well do they see the team of physicians and nurses working together? Those are the things that I think are really important to the patients,” said Ronnie Brownsworth, M.D., executive vice president of St. John’s Health Plans. “To the payers it’s a little bit different matter. They certainly want to see outcomes like “return to work” and “cost of health care. We feel we have an answer to both of these questions.”