The Spokane-based Rockwood Clinic, the largest multispecialty group between Minneapolis and Seattle, has launched an effort to enhance its physicians’ adherence to a set of Choosing Wisely® recommendations, with plans to provide feedback, coaching and, eventually, financial rewards.
Rockwood has 73 clinic locations in Washington and Idaho, and about 300 clinicians providing primary, specialty and urgent care services. It also has a long history of tracking clinician performance on quality metrics, according to Robert Benedetti, MD, the system’s chief medical officer. To motivate quality improvement, Rockwood uses data feedback and 5 to 10 percent incentive payments.
Health coaches, usually registered nurses, have been an essential part of Rockwood’s quality projects. They review patients’ records to see whether they have failed to receive essential care and ensure that the practice’s physicians are aware of those gaps. “The coaches helped us improve our care and our bottom line,” Benedetti said.
Rockwood recently decided to apply its quality improvement expertise to Choosing Wisely. It has created a Choosing Wisely registry that draws on data from the group’s electronic medical record and billing systems to analyze its physicians’ performance. To do this, Rockwood has relied on Choosing Wisely measures developed by the Washington State Choosing Wisely Task Force, which includes the Washington Health Alliance, the Washington State Medical Association and the Washington State Hospital Association. (Some of the Task Force’s work has been supported by the ABIM Foundation and the Robert Wood Johnson Foundation.)
Rockwood is analyzing its clinicians’ utilization of 12 tests and treatments referenced in Choosing Wisely, including:
- the use of MRI tests for low back pain and headache;
- the use of Pap smears for women who have undergone hysterectomies; and,
- the overuse of nonsteroidal anti-inflammatory drugs (NSAIDS) in a number of contexts.
The preliminary results are strong. For example, in August 2014, of 179 patients who presented with uncomplicated headache, 175 of them (97.7 percent) did not receive a CT or MRI. For the past 12 months, approximately 92 percent of 5,127 women with hysterectomies did not receive a Pap smear, showing that there is an opportunity for improvement of nearly 8 percent, or about 225 potentially unnecessary Pap smears.
These Choosing Wisely recommendations are being incorporated into Rockwood’s existing quality program, alongside HEDIS measures and the other quality metrics it tracks. Performance on all of these metrics is included in a “quality dashboard,” with results refreshed monthly and transparently shared internally. Once they are fully tested for accuracy, the Choosing Wisely measures will also be incorporated into Rockwood’s quality bonus program, most likely in late 2015. Adherence to the Choosing Wisely recommendations will also be reinforced by Rockwood’s health coaches.
For a system such as Rockwood, which operates in a primarily fee-for-service environment, the reduction of overuse also represents a potential loss of revenue. But Dr. Benedetti said that this factor does not discourage him. “We want to be the value provider of choice,” he said. “We think we’re going to gain market share by being of the highest quality and get better contracts from payers if we deliver better value.”