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Stanford University School of Medicine

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

Many of us know first-hand that expensive, substandard health care abounds in America. The problem has been analyzed and bemoaned, measured and critiqued. Solutions, bright spots and success stories are less abundant—in fact they are downright rare. That's why recent findings from a partnership between Stanford's Clinical Excellence Research Center and the Peterson Center on Healthcare, a new organization that aims to improve health care in the United States, are so exciting. Bucking current theories, researchers found that independent, primary care medical practices can provide superior care while saving money. And, they identified 10 principles these practices embrace, which distinguish them from their peers.

I had the chance to speak with CERC Director Arnold Milstein, MD, about the Stanford-based project:

What exactly did you do?

We examined the performance of more than 15,000 primary care practices looking for "positive outliers" or practices that provide excellent care at a lower cost. This is the first  systematic comparison of its kind and we weren't sure we'd be able to discern any differences. But we did. We found a substantial difference in measures of quality and the total annual amount of health care spending between sites. Then, we arranged for  observers (independent physicians) to visit these offices to understand what was different about care delivery at sites associated with less spending and high quality scores.  They discovered 10 distinguishing features of successful health-care practices that were present much more frequently in these positive outlier practices than in other offices. There are some major differences in how they deliver care.

What were some these features? Did any surprise you?

About two-thirds align with current national initiatives such as Choosing Wisely and the Patient Centered Medical Home, but about one-third are new ideas.

The 10 features are not abstract ideas, they are tangible and therefore more easily transferable. For example, the higher-performing sites are 'always on' — patients can reach the care team quickly 24/7. I use the word 'care teams' because I'm not referring to physicians only. These teams include nurses, nurse practitioners, medical assistants and/or office managers, developed  to the highest of their abilities. These teams often treat conditions in a gray zone between primary care and specialist care. They follow up with their patients when a case is referred to a specialist. They check in with patients to ensure they are able to follow self-care recommendations.  Their work station is shared, so they can learn from each other. These teams adhere to systems to deliver care — choosing individual tests and treatments carefully. Distribution of revenues among physicians is not  solely based on service volume. Finally, these practices invest much less in office rent and costly testing hardware.


Are these practices big or small? Are they more common in cities? On the West Coast?

There's no pattern. Their success is not related to their ownership, location or the demographics of their patients.

Many of these practices had very little knowledge about how they compared with others. Most felt that they were just doing the right thing for their patients.

What  comes next? 

Over the next three years, we will test the feasibility and impact of adopting these features. There are barriers to this, of course. But I believe many health-care providers will be interested in trying. First, Medicare in 2017 will modify how much it pays doctors based on their comparative performance in quality of care and cost of care. Second, due to legislated changes due to incept in 2018, private insurers such as Blue Cross are beginning to more actively incentivize patients to use doctors that score more favorably on cost and quality measures. If adopted nationwide, these 10 principles could save as much as $300 billion a year.

Can I check to see how my doctor did?

No. There's no sources of information that would allow the public to know how their doctor compares with other doctors on a national basis. However, many policy makers believe such transparency would improve health system performance, and I think it's likely that this will occur in less than five years.

Previously: Stanford Coordinated Care: A team approach to taming chronic illness, Making health care better and more affordable and How can we slow growth of U.S. health-care spending?

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