Center for Studying Health System Change

Clinical decision making still appears to be very much in the hands of physicians, although strong influences from insurers have altered -- to a degree -- how care is delivered. Local HMO products reportedly rely heavily on primary care providers, some of whom are capitated, for care management decisions. As physician groups become better equipped to accept full risk, it appears likely that physicians will retain control over clinical decision making. While informants generally felt positive about this scenario, they also expressed fear that new managed care companies might enter the market and exert greater control. Some health plans expressed doubts that physicians in this market are sufficiently experienced to manage care under capitation, while other plans were developing strategies to pass risk along to physicians.

As noted, the introduction of Regence Washington Health’s Selections product in 1992 had a significant influence on clinical practice. Selections sent the message to physicians that they may not be included in networks if their practice patterns are deemed too expensive. Several informants attributed a rapid decline in hospital utilization to Selections.

Informants from all sectors believe that Seattle-area physicians historically have practiced in a thrifty manner. Accordingly, attempts to influence medical practice have been few. "Physicians historically have preferred keeping patients out of the hospital" was a common observation. No examples were found of health plans that penalized or dropped physicians from networks for overuse of specialists or inpatient services (Selections was a new product that created a network by including selected physicians). Instead, informants indicated that Seattle hospitals and physician groups are beginning to use rewards to influence care. For example, Medalia, Everett Clinic and Virginia Mason Medical Center are offering bonuses and merit-based salary increases to reward high patient satisfaction. Several providers also consider patient volume as a measure of productivity in establishing bonuses, salaries or both.

The predominance of the University of Washington Medical School and School of Nursing in local clinical education and research is another important influence on care delivery. Many local physicians and nurses were trained there. In addition, respondents cited a consistent emphasis on primary care associated with the medical school.

Certain improvements in information technology and development of clinical protocols are held out as examples of clinical improvement. Virginia Mason Medical Center, for example, has an electronic medical record that allows real-time information sharing with physicians at the hospital as well as with all of the Virginia Mason Medical Center practice sites.

Several area organizations have formulated practice guidelines and are beginning to see them implemented. Group Health has developed clinical pathways for 10 to 15 conditions; two of the pathways were cited and praised by competing health plans. In addition, Medalia (the Sisters of Providence primary care physician group), Harborview and Virginia Mason Medical Center are implementing clinical pathways. The University of Washington Medical Center and University of Washington Physicians have established common clinical pathways, which now apply to 80 percent of their patients. Blue Cross has developed protocols for diabetes, asthma, congestive heart failure and AIDS for use in its HMO product.

Overall, informants were pleased with early evidence on the impact of these guidelines. For example, the University of Washington reports that length of stay was shortened 15 percent, and $10 million was saved in operating expenses. Moreover, Group Health found that the application of clinical pathways is an important part of a comprehensive approach that can result in better clinical management and improved quality.

Examples of organized disease management or outcome analyses in Seattle are limited. Providence Seattle Medical Center has developed a series of protocols around cardiac care and total joint replacement procedures that involve the collection of background information from patients that may affect care decisions, and (in the case of cardiac care) two-year patient follow-up. Virginia Mason Medical Center and at least one community health center have implemented clinical reminder systems to apprise physicians of their patients’ specific chronic diseases, and to prompt them to obtain specific information or schedule follow-up visits.

Despite interest in outcomes data, the consensus is that consumers have no more information today than they did 20 years ago, in part because reportedly there has been little private sector support for information sharing. In addition, the electronic infrastructure needed to facilitate collection and dissemination was not in place, respondents said. Outcome data have been gathered from hospitals as part of statewide studies on obstetrics and coronary artery bypass graft procedures. Data from these studies have been shared with the participating hospitals, but have not been analyzed for or broadly distributed to the public.

However, a new Seattle-based organization called the Health Information Institute plans to use Internet technology to disseminate community health information. New data strategies are also taking shape, including plans by public health agencies and private providers to establish a statewide immunization tracking system.

Informants were more enthusiastic about data collected from -- and reported at -- the provider level than about data reported at the plan level. For example, they almost universally believe that HEDIS data are not useful in Seattle, where provider networks are frequently broad and overlapping.

Finally, respondents generally credit managed care with certain care delivery improvements. For example, managed care reportedly is improving the quality of clinical documentation. In addition, as physicians accept risk, they reportedly are becoming more interested in prevention and health promotion and have increased their control over the utilization review processes. There is, however, little systematic documentation that these or other efforts have improved access to or quality of care.