GOOD NEWS: How Hill Physicians Medical Group Partners With Physicians (Part I)

Hill Physicians Medical Group is an independent practice association in northern California; Len Nichols and I have profiled their work partnering with physicians and improving quality in a study published this week by The Commonwealth Fund.

"Independent practice association," or IPA, is not a household phrase, even in many health policy circles. IPAs originally grew out of the physician response to the early expansion of  managed care in the 1970s. The IPAs allowed physicians to refrain from joining a staff model or physician group but still participate in managed care contracts. Hill and other IPAs "bear risk" by receiving the per member per month capitated payments from multiple HMO health plans. In turn, when a patient requires physician services, the IPA pays the doctor on a fee-for-service basis. Typically, a member-physician will see patients via the IPA as well as through other insurers. In a staff-based HMO, in contrast, the physician only sees patients from one insurer.

Hill Physicians Medical Group is the nation's largest independent practice association, with more than 2,200 physicians members. Founded in 1984, the IPA serves 332,000 patients enrolled in seven HMOs, two Medicare Advantage Plans, and Medi-Cal, California's Medicaid program.

As CEO Steve McDermott told us, Hill was started as a dare. Kaiser Permanente, the original staff-based HMO, is a big player in northern California, offering efficient, coordinated health care. McDermott and COO Darryl Cardoza, Hill's two founders, wanted to prove that independent practices could be strung together to compete, survive, and thrive in a managed care environment. In a sense, Hill is a "virtual organization." It is not fully integrated but takes on some of the characteristics of a multispecialty group. The model has not only worked, but has created enough abundance to allow considerable innovation. 

In this blog series, I'll focus on two innovations: one today and one tomorrow.  Also tomorrow, I will discuss the takeaways from this case study. 

Chronic Care Management                        

From December 2005 through December 2006, Hill recruited 21 of its practices to work on a chronic care collaborative begun the previous year. Among strategies used to influence care delivery at the practice level was the dispersal of "health educators" employed by the IPA to member physician offices to help patients and doctors manage chronic care. Let's look at diabetes.

Health educators worked with a subset of each participating physician's diabetic patients: those whose A1c (a blood sugar indicator) and LDL (low-density lipoprotein, aka "bad" cholesterol) scores were poorly controlled. The health educators helped the patients improve both their self-management skills and related clinical measures. More important, participating physicians learned about process improvements from the health educators, which  they then applied to all their diabetic patients. This helps them keep their patients healthy and run their practices both efficiently and effectively.

As Table 1 demonstrates, a year after the collaborative ended, in December 2007, the number of patients with controlled blood sugar and cholesterol levels did not revert back to their old levels. Rather, the number of patients with good levels remained high, and even continued to increase by a small amount. This proved to Hill that its intervention was "sticky," that is, the gains made in patient health were preserved because the process improvements learned by physicians and their staffs were maintained. They "stuck."

Hill continues to focus on ways of improving quality. Since December 2007, instead of the health educators being sent by the IPA, as in the previous three years, Hill staff worked to build office-based improvement teams to increase the likelihood that the improvements will "stick."

I'll be back tomorrow with more lessons from Hill Physicians.