Forum Focus – PCPs drive reduction in Cleveland hospitalizations


This article first appeared on Internal Medicine News ( on March 8, 2013.

By Mary Ellen Schneider, Internal Medicine News Digital Network,

Doctors in Cleveland are offering proof that a robust primary care system is the way to reduce health care costs.

Better Health Greater Cleveland – a group of 55 primary care practices across eight health systems – reduced hospitalizations for patients with diabetes, hypertension, angina, or heart failure by 10% between 2009 and 2011 by improving the quality of primary care in the region.

Over this 3-year period, residents in Cuyahoga County, the area served by Better Health Greater Cleveland, experienced 2,624 fewer hospital stays than expected based on trends in the next five largest Ohio counties. The coalition estimates that the reduction saved nearly $20 million during that time.

It’s a different way to preserve health care resources, said Dr. Randall D. Cebul, director and president of Better Health.

Previously, “we spent a lot of money and a lot of time trying to change hospitals, and we felt as though that wasn’t our sweet spot,” said Dr. Cebul, who is also a professor of medicine at Case Western Reserve University in Cleveland. “We’re … essentially demanding better transitions of care when patients are hospitalized unavoidably, but we feel that avoiding hospitalizations is mostly our responsibility and the patient’s.”

The group’s results show that primary care offices, staffed by a team of doctors, nurses, and allied health professionals, will be at the center of health care going forward, said Dr. Ronald Adams, senior physician for population health at Kaiser Permanente Ohio and a learning instructor for Better Health.

There’s already physical proof of this in Northeast Ohio, where new hospitals are few but Kaiser – a coalition member – has built several new primary care centers.

“Hospitals really are going to have a challenge because as we continue to do this good work, the number of people who are going to roll through [hospital] doors is going to decrease,” Dr. Adams said. “They’re going to have to rethink which services they provide.”

Better Health, which was established in 2007 and began its major activities in 2008, relies on a few key strategies: the use of electronic health records (EHRs), public reporting of performance measures, and sharing of best practices.

The coalition also provides practice coaches who provide free on-site technical support on everything from getting the most out of an EHR to submitting data for patient-centered medical home recognition.

The assistance is supported by a grant from the Robert Wood Johnson Foundation, membership fees, local businesses, and philanthropy. Better Health is one of 16 communities chosen to be part of the RWJF’s Aligning Forces for Quality initiative.

EHR use, public reporting

As of 2012, all groups within Better Health Greater Cleveland were using EHRs to target their treatment of diabetes, heart failure, and hypertension. EHRs also collect performance data on the three conditions, which are publicly reported twice a year. The reports, which can be viewed at, show the performance of individual practices, regional performance, and change over time.

While they don’t know if patients are using the data, Dr. Cebul said, physicians certainly are. “They care as a point of pride, if nothing else, about doing better.”

For physicians and other health care providers at the Louis Stokes Cleveland Veterans Affairs Medical Center, the ability to benchmark their performance against the local community was a big draw to participate in the collaborative, said Dr. Brook Watts, the Cleveland VAMC’s chief quality officer. Having data on the local health care environment was an important addition to national benchmarking data, she said.

And the data sharing was done in a nonthreatening way, she said. “We all agreed to put our data out there, and we’re not using it to point fingers,” Dr. Watts said. “People have been very willing to share what they’re doing to try to improve the care of others.”

Sharing ideas across systems

To share best practices, representatives from all the primary care practices gather twice a year to highlight what is working for the top performers.

“We are teaching one another how to do things smartly,” Dr. Cebul said.

Even the world-renowned Cleveland Clinic has learned a few things from being part of the Better Health collaborative.

Dr. Michael Rabovsky, interim chairman of the Cleveland Clinic’s family medicine department, said he’s heard some great ideas while attending the learning sessions, whether it’s a protocol for improving pneumococcal vaccination rates or the successful hypertension control guidelines developed by Kaiser Permanente Ohio. And Cleveland Clinic providers have shared their expertise too. Dr. Rabovsky and his colleagues have provided insight on patient-centered medical home accreditation as well as strategies for improving care transitions.

The Cleveland Clinic’s 17 family medicine sites also have used the practice coaches to assist with their quality improvement projects, said Dr. Rabovsky, who chairs Better Health’s Clinical Advisory Committee.

Dr. Corinna Falck-Ytter, director of the Diabetes Group Clinic at MetroHealth Medical Center, part of Case Western Reserve University, said the practice coaches helped her improve group educational sessions at her clinic.

Since she started the clinic years before on a tight budget, she and her team never had formal training in group dynamics or on motivational interviewing. The practice coach helped them learn how to get the most out of the teaching sessions, she said.

Paying for improvement

So far, Better Health’s success has come without offering bonuses or other financial incentives to physicians for improved performance. But Dr. Cebul said the improvement would be faster if the payment system encouraged physicians to provide patient-centered primary care rather than just office visits.

For instance, having a nurse call patients if they miss a test or fail to fill a medication leads to better patient care, Dr. Cebul said, but it’s not paid for by insurance. And if those reminder calls help keep patients healthy and out of the office in the future, that only costs the practice more money under the fee-for-service system.

“The payment system is screwed up, and we’re getting exactly what we pay for – too many tests, too many visits, and too many treatments without regard to outcomes,” Dr. Cebul said.

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