SAN MATEO, Calif.--(BUSINESS WIRE)--Primary care physicians (PCPs) need to become more active participants in treating medical conditions with significant practice variations. “Currently, PCPs are involved in treating only 40% of the top 10 medical condition episodes of care with the most practice variations. Some of these medical conditions include low back pain, degenerative joint disease, sleep apnea, and headaches,” stated Dr. Douglas G. Cave, President of Cave Consulting Group (“CCGroup”).
He continued, “For a covered patient population, the initial step is to identify the top 10 medical conditions and services (called MedMarkers™) with the most practice pattern variability. These identified medical conditions – which are different for every client – often drive over 50% of all patient cost and quality improvements.”
“Assume we have a covered population of 300,000 members. If we effectively increase PCP involvement from the existing 40% to at least 50% (in the top 10 medical conditions), then healthcare expenditures are reduced by at least $3.5 million. Increasing PCP involvement is a key component of the Targeted Gatekeeper Model developed by CCGroup,” outlined Dr. Cave. The obtained savings are not a one-time feat, but compound over time.
What supports this return on implementing the Targeted Gatekeeper Model? “When PCPs are involved in treating the top 10 medical condition episodes, the per episode costs are about 45% lower as compared to when specialists alone are involved in these episodes,” defined Dr. Cave. If PCPs marginally increase their involvement in the top 10 medical condition episodes, significant savings and patient care continuity both occur.
Yet, the savings opportunities do not conclude here. Of the 40% of top 10 medical condition episodes that PCPs are currently involved with, PCPs refer over 35% of these episodes to specialists.
“What if PCPs reduced this 35% specialist referral rate to 20%? Going back to the covered population of 300,000 members, there is an additional conservative savings of $3.0 million. Specialists are trained to perform expensive tests and services. With each referral, specialists may perform marginal, potentially unwarranted services. For this reason, episode costs generally are significantly lower with only PCP involvement – as compared to when PCPs and specialists are both involved. Referring at the right time, for the appropriate service, in the proper setting has merit,” detailed Dr. Cave.
One reason PCPs may refer more often than necessary is that they are not empowered to understand what to do next for the patient. This is why the Targeted Gatekeeper Model implores the need for quantitative clinical pathway development – another area of strength CCGroup brings to the table. Dr. Cave stated, “CCGroup applies the Cave Grouper™ software that groups ICD.10 diagnosis codes into 538 meaningful medical conditions. We examine what services are currently delivered to patients with the top 10 medical conditions. Then, clinical leaders decide those services that are, and are not, appropriate to perform. This information is presented to PCPs to enable better shared decision-making with their patients.”
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 27 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.