Lessons From the Group Practice Demonstration for ACOs: Q&A with University of Michigan's Dr. Caroline Blaum

University of Michigan Health System saved more than $15 million on the cost of care over four years while participating in a demonstration project considered by many to be the precursor for accountable care organizations. Caroline Blaum, MD, MS, is the UMHS project leader in the Medicare Physician Group Practice Demonstration Project. Here she shares some insight into what initiatives UMHS launched to reduce readmissions, save money and improve the coordination of care.

Q: It said in a news release that, as a result of the project, UMHS already has an ACO in place. Can you tell me some things that have had to change within your system to carry out this model of care?

Dr. Blaum: An ACO is not based on the hospital — it's based on physicians working with hospitals. We are an integrated academic health center, and our physicians are employed by the health system. They are all aligned, and that’s the easiest model for an ACO. Several other groups that participated in the PGP Demonstration are integrated but several are not. AT UMHS, we were able to use the fact that our physicians are using same electronic medical records as the hospital. With a uniform EMR, primary care doctors are easily able to refer within the system.

Still, we had to strengthen our internal coordination. Some of the interventions we're continually putting in place are meant to strengthen communication between primary care and specialist physicians and between the physicians caring for patients in the hospital. We're focusing on coordination of care, helping patients see other specialties and providing high quality care.

Q: With ACOs right around the corner, many providers are discussing "preventive care" with a focus on taking care of patients before they become ill. Can you share how UMHS undertook preventive care efforts?

CB: [Preventive care is] really important for primary care, which is the basis of ACOs, but the management of patients with chronic disease is also important. They are the highest cost. We tried to improve chronic disease management in the primary care setting as well as in the specialty setting. We want to prevent patients with chronic disease from getting worse.

Q: Can you talk a bit about the adjustment in culture that came with this transition to preventive care?

CB: Again, I would say that a health system culture is different from that of a hospital. One of the cultures we are trying to strengthen within our entire healthcare system, including our ambulatory clinics and our hospitals, is a culture of cooperation. We are trying to have physicians in ambulatory care think about teamwork. Nurses and care coordinators help patients with self-management, and they also help physicians and make sure they're keeping up with quality care.

You need more than a physician for healthcare. You need a nurse to answer questions, someone to call the patient when they go home, a pharmacist to help with drugs. We do think teamwork is part of the culture, but it's slow to change. No matter what role people have in the system, people are used to their silo. To get people to work together is very important.

Q: As part of this program, UMHS launched quite a few programs/services, such as complex care coordination programs designed to reduce unnecessary tests and treatments. Can you tell me more about these initiatives?

CB: Improving transitional care was key. We focused on patients coming in and out of hospital. Some of them are pretty sick when they come in, and when they are discharged they may still not be up to par. Many patients need a nurse or caregiver to help afterwards. Our transitional program makes sure every patient is called the day after they're discharged. When local patients go home, we call them up to make sure their treatment plan is correct. They have a lot of questions about home-care, medication and appointments. So we've found that patients find it very helpful.

The other intervention is care coordination for our most complex patients. We have decided the most effective way to coordinate care is when the patient comes out of the hospital. We then refer patients to complex care coordinators, who are well-connected to primary care clinics and specialty clinics. These coordinators can access physicians with questions, or promptly get the patient an appointment.
We put some resources into this. We invested six to eight positions to work on care coordination, transitions, and improving quality of care.

Q: UMHS saved $15 million over the four years of the project.  That's a considerable amount of money. Why do you think that is?

UMHS benefitted to some degree by being a large system with some resources. We have many patients, skilled clinical and non-clinical staff, an electronic medical record, and some quality improvement and care coordination programs in place.  We believe investments in quality improvement and care coordination helped our system become efficient and high performing. We've been studying our data and trying to figure out why we saved money. It's related to decreasing hospital admissions and readmissions in general, and we think that translates to us taking better care of patients.

Learn more about University of Michigan Health System.

Read more about ACOs:

- 7 Ways for a Hospital to Align with Physicians

- 3 Challenges for Physician Integration in 2011

- 8 Points on Hospital-Physician Integration From Stephen Moore at Catholic Health Initiatives

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