A National Healthcare Predicament: Most PCPs Are Not Involved in Managing the Top 10 Medical Conditions with Significant Practice Variations


Primary care physicians (PCPs) need to become more active participants in treating the Top 10 medical conditions with significant practice variations. Nationally, PCPs are solely involved in treating less than 25% of medical condition episodes with the most practice variations, stated Dr. Douglas G. Cave, President of Cave Consulting Group (CCGroup). And these medical conditions “ such as low back pain, degenerative joint disease, headaches, sleep apnea, cataracts, and heartburn “ drive well over 50% of all potential patient cost and quality improvements.

Dr. Cave continued, This means that specialists, and not PCPs, manage 75% of patients with these medical conditions. And because specialists order and perform the expensive procedures and services used to treat these patients, we observe large practice variations for the following reason. Some specialists are more conservative, while others are more generous in treating these conditions.

A question is whether the fox is guarding the henhouse with respect to performing potentially unnecessary services and procedures?

Even in HMO managed care environments, PCPs often are not involved in the Top 10 medical conditions with significant practice variations, stated Yuri Alexandrian, COO/CIO of CCGroup. When PCPs are involved, they tend to readily refer to specialists, and specialists then manage these patients over time. Therefore, PCP practice transformation executives at health systems and physician organizations need to focus transformation efforts on these Top 10 medical conditions.

Our national studies on commercial, Medicare Advantage, and Medicare MSSP/NextGen populations show the following, defined Dr. Cave. For routine heartburn, the average episode cost is $425 when only a PCP is involved in treatment, but dramatically increases to $1,600 with any specialist involvement. Furthermore, for routine low back pain, the average episode cost is $625 with only PCP involvement, but significantly increases to $2,200 with any specialist involvement. When a specialist is involved (even if a PCP is present in the episode), the costs per episode skyrocket.

CCGroup healthcare economic models show hundreds-of-millions in potential savings in national healthcare expenditures, if PCPs increase their sole involvement from the current 25% to just 35% (a 10% higher sole PCP involvement percentage). Dr. Cave went on, For every 250,000 at-risk covered members, a 1% increase in ˜sole PCP involvement in these Top 10 medical conditions results in savings of about $800,000. Therefore, a health system recognizes about $8 million in annual savings “ with a 10% increase in sole PCP involvement.

Mr. Alexandrian explained, For the remaining 20+ million beneficiaries covered by Medicare fee-for-service (not in Medicare Advantage plans), the savings may be over $640 million annually “ if PCPs on average increase sole PCP involvement to just 35%. Comprehensive Primary Care Plus (CPC+) is designed by the federal government to strengthen primary care through payment reform and care delivery transformation. The CPC+ payment design gives PCP practices additional financial resources to improve quality of care and reduce the number of unnecessary services their patients receive. CPC+ and PCPs really need to focus efforts on those medical conditions that matter most “ the Top 10 medical conditions with the most practice variations.

About Cave Consulting Group, Inc. (CCGroup)

Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 28 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.

CCGroup identifies and monitors medical condition practice variations using MedMarkers„¢ and Clinical MedMarker Protocol Ranges„¢. MedMarkers„¢ are process of care quality measures, well-defined in clinical guidelines. However, MedMarkers„¢ also are the key services and procedures most associated with cost-of-care in treating a medical condition. Clinical MedMarker Protocol Ranges„¢ are achievable and clinically appropriate ranges of clinical practice for a MedMarker„¢. These ranges are developed by presenting the CCGroup National Comparative MedMarker Database„¢ results to the CCGroup National Specialist Panels.

Mr. Yuri Alexandrian, CCGroup
[email protected]