A unique physician "pay-for-performance" program at
Montefiore Medical Center has reduced blood sugar and cholesterol levels
significantly among many of the patients in South Bronx.
Physicians in each of Montefiore Medical Group's (MMG) 21
community-based centers are given targets to reach for blood sugar and
cholesterol levels in their diabetes patients and can be rewarded up to $3,200
annually for attaining these targets, an incentive paid for by the MMG
"To improve blood sugar and cholesterol in diabetes patients
requires a lot of invisible work, follow-up phone calls, counseling, developing
rapport with patients and staying on their case over time," said Sophia Au, MD,
an internal medicine specialist in the Montefiore Medical Group for 13 years.
She says it takes about two months to bring sugar levels down considerably for
most diabetes patients through diet, exercise, medications, and home
self-monitoring with a glucometer.
"Physicians are not paid for follow-up care; but, if we
don't follow-up, we will not succeed and more importantly neither will our
patients. The incentive pay, while not much, is recognition of the invisible
care and doing the right thing," said Au. "There is another incentive. Because
each physician has formalized scores for her patients, and we share these
scores, I want to be in the top tier among my peers. I am competitive and being
in the top tier is a professional reward."
"Outcome-based medicine, with comparison scores and monetary
incentives, works in this setting where we care for 14,000 diabetes patients,"
said Arthur Hopkins, MD, medical director of Montefiore Medical Group 1. "We
have been able to keep one standard measure of blood sugar, called HbA1C, below
a recognized level of 9 in 85% of our patients, who have some of the most
severe diabetes in the nation. Other programs caring for the same population of
diabetes patients in the Bronx - e.g. HIP and Oxford have kept HbA1C levels
below 9 for only 67-75% of their patients." (Data from a state report titled
"2006 New York State Managed Care Plan Performance"). Dr. Hopkins noted that
54% of patients under care at MMG had HbA1C levels under 7.
Similar ranges apply in effectively lowering LDL (bad)
cholesterol: 56% of diabetes patients at Montefiore kept LDL below 100, whereas
the range in other programs was 36-42%, said Hopkins.
Lee Berk, MD, an internal medicine specialist at MMG for the
past four years, like all physicians in the group is paid an annual salary. He
consistently gets additional income for bringing down blood sugar and
cholesterol levels in his diabetes patients. "My clinical curiosity kicks in when
a first time patient comes in who is overweight by 60 pounds and no one ever
did anything about it. I know that to succeed, however, I have to stay on this
patient - make sure lab results are done before visits, change medications when
needed, use insulin early on. This takes extra hours of phone calls and
follow-up monitoring. I know that you cannot let the patient control the agenda
if you want success. Being committed to success for each individual patient
means riding them a bit, and the extra pay I receive is professional
recognition for doing that."
Montefiore's pay-for-performance program started 10 years
ago and over time built up a caseload of 1,700 diabetes patients who were
monitored manually. Last year, however, Montefiore Medical Group began using a
unique software developed by Montefiore researchers, called Clinical Looking
Glass, and now all 14,000 diabetes patients who are cared for by the group's
129 physicians can be monitored, scores compared and incentives paid. MMG now
provides a total of $250,000 annually in incentive payments.
While the Montefiore pay-for-performance program is self
financed and operates independently, next year it will become part of a larger
project at Montefiore in pay-for-performance. This project, funded by a $2.4
million grant from the New York State Department of Public Health, will look at
controlling heart disease risk factors.
Dr. Au divides her patients into two categories. For those
with an A1C level under 7, who represent about 20% of patients, she gives them
general guidelines and tells them to "keep doing what they are doing." For the
80% who are above an A1C level of 7, she first develops trust and rapport, so
they will do what she asks. During the initial visit, she gets blood tests and
tells them to come back in two weeks.
For patients who are uneducated, she translates information
about A1C levels into grades, of A, B, C, D, and underscores that if they do
not change their grades they will be at risk for heart attacks and other
problems. She gets them to change diets, puts them on medications and exercise
plans. Then she monitors their home glucometer readings. First she gets them to
lower their "fasting sugar levels," a measurement taken when they get up in the
morning. She may adjust medications and diet to do so. Then she works with
patients to get their "before lunch" levels down, then "before diner" levels
down and lastly get their glucose under control before they go to bed.
She repeats the process for cholesterol levels, which she
says is more difficult to do these days because there are fewer statin drugs
available on the market and there has been bad press about some drugs, such as
Zetia. It takes about 2 months of this tightly controlled monitoring to bring
glucose levels down, she says.