Backed by a nearly $50 million grant from the U.S. Department of Health and Human Services, the New Jersey Innovation Institute (NJII) will spend the next four years working with thousands of medical practices in the state to improve the quality and efficiency of the care they provide, while also lowering its cost.
Through its Transforming Clinical Practice Initiative (TCPI), the federal government seeks to move practices from a fee-for-service model that reimburses caregivers for dispensing treatment at episodic visits to what is known as a "value-based" care system that compensates them for keeping their patients well through ongoing, evidence-based disease management. The program is aimed in particular at the sickest patients with complex conditions such as diabetes and cardiovascular disease who often cycle in and out of emergency rooms, as well as have longer hospital stays.
Reducing the rate of hospital readmissions is a top priority in New Jersey, which last year had the highest proportion among the 50 states of hospitals penalized by government insurance programs for readmitting patients within 30 days of their discharge, said Tomas Gregorio, NJII's senior executive director of healthcare delivery systems, in citing a recent report based on government data.
"One of the programs we will implement is transition-of-care management, making sure patients are referred electronically to caregivers in the community while leaving the hospital," said Gregorio. "Upon discharge, a nurse will submit a clinical profile of the patient to the appropriate provider, who will see the patient in the office within 7 to 14 days from the discharge date. The doctor will, in turn, be reimbursed for that service, creating an incentive to care for these patients."
A centralized nursing service will call patients after they've been discharged to make sure they have seen a doctor within 14 to 24 days. NJII, an NJIT corporation, will also train both its own coaches as well as staff based at hospitals to go to doctors' offices to ensure providers are meeting the quality metrics identified in the grant.
The NJII team is in the process of developing a list of clinical targets for the state, identifying gaps in the health care delivery system besides hospital readmissions, said Ronald Manke, North Jersey regional director for the grant. Chief among them is managing patients with chronic diseases more effectively to keep them healthier - and out of emergency rooms in the first place - while also reducing the volume of expensive, unnecessary tests.
"We will monitor up to 16 care metrics. We'll begin by evaluating practices, establishing a baseline to see who their patients are and what care they've been providing. We'll then figure out where the gaps are and provide training on evidence-based care and effective monitoring practices to modify those practices so they are meeting more of their health outcome targets," Manke said. "The training will include on-site visits by coaches, webinars, and innovative programs such as our Transitional Care Management Clearinghouse, a turnkey service that will help physicians properly care for patients after they've been discharged from the hospital."
Dr. Thomas Bellavia, the CEO of Osler Health IPA, a primary care physician-centered, owned and managed health network, cited four key metrics in the ongoing care of patients with diabetes, for example. They include reducing what is known as a patient's A1C levels - the amount of sugar coating the oxygen-carrying hemoglobin molecules in red blood cells; lowering blood pressure; performing eye examinations, as deteriorating vision is a symptom of the disease worsening; and, conducting a test for symptoms of kidney disease, which is also associated with diabetes.
"Doctors will report these metrics, as well as health outcomes," said Bellavia, who is also a practicing physician with Heights Medical Associates, a family medicine practice in Hasbrouck Heights. "They will need to show that 75 percent of their entire population of diabetes patients has achieved normal numbers. Under the new system, a doctor would be compensated for doing a good job by keeping his patients healthy."
He added, "Without practice transformation, this won't happen, however."
NJII's Healthcare Innovation Lab is one of 39 health care networks around the country to win a portion of the $685 million allotted to the TCPI program by the Center for Medicare and Medicaid Services (CMS). NJII receives $11.9 million in the first year to launch the program in New Jersey. Over the four years of the grant, the team and its affiliates will work with 11,500 clinicians, including primary and specialty care providers, to meet the identified health outcome targets.
NJII's practice transformation program builds on the success of an NJIT-led health IT startup, NJ-HITEC, formed in 2010 to train 5,000 primary care providers in the state to adopt electronic health record (EHR) systems in order to keep better track of their patients and improve the quality of their care.
NJ-HITEC met and exceeded that milestone more than a year ago, demonstrating to federal health officials that the providers had not only installed their systems, but meaningfully used them to collect, store and act on key data such as medications, allergy lists, diagnoses, vital signs and clinical quality measures, among other health metrics. Under the new program, NJII will revisit these practices to analyze the quality data that they have been collecting and educate providers on best treatment practices nationally to further improve health outcomes.
"The data these providers are collecting electronically will allow them to show they are meeting quality metrics. Their EHR systems will also enable them to exchange patient information with other providers and care facilities, thus improving the continuity of patients' care," said Balavignesh Thirumalainambi, director of meaningful use for the former NJ-HITEC who will oversee implementation of practice transformation measures under the new grant.
"This award allows us to turn the technological innovation that we led through the introduction of electronic health records to over 7000 New Jersey physicians into healthcare innovation that will be measured in improved patient outcomes across major disease categories," said Donald Sebastian, president of NJII.
Physicians say the government initiative will give a needed shot in the arm to primary care practices, which have struggled to survive in New Jersey under the current fee-for-service model as reimbursements from insurers have declined.
"It is time to focus on the primary care needs of the community, as well as the infrastructure and the workforce to support that. New Jersey has become a desert for primary care, exporting more physicians than we keep because the cost to practice here is so high and doctors are not paid sufficiently to provide effective preventive care and disease management," said Dr. Thomas Ortiz, a physician with Newark-based Forest Hill Family Health Associates, who has practiced family medicine in the city for more than three decades.
"We need to identify the most vulnerable patients, those with complex health problems who have been neglected and proved costly to the system as a result. We can't keep getting paid for keeping people sick," Ortiz added. "We need to stabilize those existing practices that are committed to staying in New Jersey and to make the state attractive again to younger practitioners willing to come back to the neighborhoods."
Through the initiative, CMS aims to improve health outcomes for the five million beneficiaries in Medicare, Medicaid and its Children's Health Insurance Program (CHIP). The agency has set a goal of moving at least 75 percent of Medicare, Medicaid and CHIP providers that complete the TCPI program to participate in incentive programs and practice models that reward value. The agency projects that it will save money over the next four years through reduced expenditures and believes it likely that commercial payers will see some savings as well.
"Supporting doctors and other health care professionals change the way they work is critical to improving quality and spending our health care dollars more wisely," said U.S. Health and Human Services Secretary Sylvia M. Burwell, in announcing the grants last week. "These awards will give patients more of the information they need to make informed decisions about their care and give clinicians access to information and support to improve care coordination and quality outcomes."