1. Impact of Clinic Systems and Improvement Strategies On Costs of Care for Adults with Diabetes Todd P Gilmer PhD Patrick J O’Connor MD MPH William A Rush PhD A Lauren Crain PhD Robin R Whitebird PhD Anne M Hanson BA Leif I Solberg MD University of California, San Diego HealthPartners Research Foundation

2. Clinic Characteristics Related to Efficiency in the Production of Health Output = Health Measured by clinical outcomes important in diabetes: –Glycemic control, BP control, lipid control PJ O’Connor presenting tomorrow @ 9 Inputs measured by costs for services = this paper Next step: –Use clinical outcomes as inputs into a health utility model to calculate QALYs Regression methods to identify clinic characteristics related to efficiency

3. Quest for Health Multi - level survey of patients, providers, clinic managers and medical directors, medical group administrators and medical group medical directors Medical record review Merged to 3 years of health care encounters/claims Goal = to identify provider & system characteristics associated with care and outcomes for patients with DM & CHD

4. Clinic Systems and Improvement Strategies Care Management Strategies Patient Education Registries Information Support Overall QI Efforts Specific QI Strategies

5. Cost Estimation 43% Capitated, 29% FFS, 28% Cap/FFS Encounter + claims data RVUs for outpatient services DRGs for hospitalization National payment rates Simulated outlier payment Drugs priced at 68% of AWP GLM: f(gam) l(log) robust cluster(clinic) Standard errors by Delta method

6. Study Subjects: 1624 Adults with Diabetes

7. Care Management Strategies

8. Care Management Strategies - Theories Improves communication across physicians Expands an individual physician's repertoire of effective clinical management strategies Anticipating and sometimes avoiding hospitalization when a moderately ill patient encounters a series of providers in a single episode of illness Forum for physician-nurse communication that may benefit care

9. Registries

10. Information Support

11. Specific QI strategies

12. “Clinical Economics” Estimates of cost impacts associated with the use of specific office systems and improvement strategies in medical group practices Physician meetings, “smart registries,” resource and pharmacy-based strategies Mechanisms by which these office systems and QI strategies affect costs of care and the relationship of costs to clinical outcomes of patients deserve further investigation