Back to the Future with the Comprehensive Care Physician

In our August 3rd blog we introduced various alternative models of care as a window into potential visions of the future. In this blog, we explore one of those models, the Comprehensive Care Physician (CCP) in greater detail. The CCP model was created by Dr. David Meltzer at the University of Chicago and highlighted in a New York Times article in 2018. The core principle employed was maximizing direct interaction between the patient and their physician.  

A Randomized Control Trial

The original model was implemented as a randomized control trial.  Two thousand Medicare members with at least one hospitalization in the prior year were enrolled, with estimated annualized costs of $100,000 each. They agreed to be randomly assigned to the CCP practice or to continue with their current provider. The five physicians in the intervention group each had a panel of 200 patients, but because these patients were so high risk, there were sufficient volumes in the hospital to justify rounding every morning and sufficient demand for appointments to keep their afternoon office schedules full. The five doctors rotated afternoon hospital coverage and weekend coverage among themselves and depended on hospitalists for night coverage only. 

The Healthcare Team

There is also a critically important team component to this model. The practice includes an advanced-practice nurse, registered nurse, social worker and clinic coordinator. Each patient is assigned a team tailored to their needs.. The emphasis is on having the smallest appropriate group to promote continuity and patient engagement. A differentiator of this model is a focus on cross-training rather than practicing at “the top of license.”

With maximization of patient engagement as a singular focus, it’s not surprising that physicians are often directly involved in care transitions. They make outbound calls to all patients post-discharge from the hospital, and are notified whenever their patient is in the Emergency Department. 

Training

As part of being a CCP, there is specific training in effective team care, culturally competent care and palliative care. There is also psychological support for team members, acknowledging the stresses of caring for seriously ill and “difficult” patients. The team meets frequently and employs rapid cycle process improvement to encourage innovation.

Results

The randomized trial over three years demonstrated more than 15% reduction in hospitalization for the intervention group compared to controls, with significantly higher patient satisfaction in the intervention group as well. Interestingly, the practice was reimbursed under a classic fee-for-service (FFS) model and generated essentially the same annualized revenue as a typical Internal Medicine practice. In addition to the improvements in care and despite the continued reliance on FFS revenue, provider satisfaction with this model has remained high. 

This approach demonstrates significant movement toward achieving the “quadruple aim” of: improved care experience, improved health of the community, reduction in cost trend, and improvement in physician morale. That said, it is a model tailored to very specific circumstances. There must be a population of extremely high-risk patients living fairly close to a full-service hospital, a physician practice located on or next to the hospital campus, and a hospitalist program willing and able to coordinate coverage with the practice. Those attributes might also allow for a specialist to serve as a CCP for those high-risk patients with a single predominating disease. 

This one example suggests that the future should not be defined by a “one size fits all” model, but by a range of approaches that meet the specific needs of the populations served. In future blogs, we will continue to describe other alternative care model examples.