Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 5. Physician Networks


The four organizations also illustrate different ways that physician networks can influence care for high-risk seniors. In particular, the two group models, Aspen and Kaiser Colorado, recruited physicians comfortable with the philosophy of managed care and the flexibility and constraints it brings. Both the Aspen and the Kaiser Colorado physicians in our focus groups indicated that they and their colleagues were committed to finding ways to improve the delivery and quality of care. In Aspen’s case, the acquisition of another medical practice failed because its culture clashed with that of the Aspen physicians.

One example of the innovation produced in these physician networks is the cooperative health care clinic program developed by physicians at Kaiser Colorado. These clinics have received national attention and represent a new paradigm for delivering primary care to people with chronic illnesses. The clinics schedule a group visit for persons who have chronic illnesses but who are still capable of traveling to a Kaiser Colorado clinic. Groups have 15 to 20 members who all see a particular primary care physician. The groups meet each month for two and a half hours for an education presentation, a group discussion, a question-and-answer session, and time to check vital signs and provide flu shots or other brief appropriate preventive interventions. Group participants also have an opportunity to meet briefly with their primary care physician, typically for five minutes or less. If more physician time is required, a follow-up visit is scheduled. These clinics appear to increase primary care costs, decrease total costs, and lead to higher levels of satisfaction among participants and physicians (Beck et al. 1997). Particularly relevant to high-risk seniors, the clinics seem to enhance participants’ sense of self-efficacy and increase their willingness to ask questions of physicians.

The cooperative health clinics came about because Kaiser Colorado physicians were looking for more efficient ways to treat chronically ill patients who often scheduled monthly office visits. It also came about because Kaiser Colorado was receptive to new ideas and gave the physicians the opportunity to experiment with new service delivery methods.

It would be more challenging for an IPA or mixed model like Keystone East or HMO Oregon to encourage this type of innovation. First, they typically cover only a small or modest fraction of their network physician’s patients. As a result, their policies are likely to have a smaller effect on the overall practice patterns on the physicians. Second, the clinic- based systems of the group models mean that they often have the critical number of chronically ill or high-risk patients required to support special targeted programs. Individual physicians may have only a few such patients, not enough to support development of a program aimed at those patients’ specific needs. We will return to this structural difference between the group and IPA models when we look at the experiences of high-risk seniors in the next two chapters.

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