Comprehensive Care Physician: Integrated Inpatient and Outpatient Care for Patients at High Risk of Hospitalization

The investigators' project has 5 aims:

Aim 1: To implement an innovative Comprehensive Care Physician (CCP) Model of
multi-disciplinary team-based care at the University of Chicago Medical Center (UCMC) in
which care for patients at high risk of hospitalization is led by CCPs who focus their
practices on patients at high risk of hospitalization so that they can personally care for
these patients both in clinic and in the hospital, with savings to Medicare shared with the
AMC.

As noted above and supported by theory and data below, the key justification for this goal
is based on the value of the doctor-patient relationship. Building on 15 years experience
developing our hospitalist program (IRB protocol 9967) from 2 to 30 clinicians, the
investigators provide detailed plans to efficiently implement the investigators' model to
improve care within 6 months. To incentivize and assess cost-savings, the investigators
propose:

Aim 2: Among patients who meet clinical eligibility criteria for the CCP model and express
willingness to receive care in the model, to assess the utilization and quality of health
care, health outcomes, and cost of care of patients randomly assigned to be offered CCP care
compared to patients randomly assigned not to be offered CCP care.

Evaluation is important in the investigators' project both to ensure that the investigators
meet the triple-aim and because assessment of cost savings is needed to implement the shared
savings model that the investigators think is important to incentivize cost savings. The
investigators recognize that the use of randomization to assess out-comes cannot be the
basis for a long-term payment model in Medicare but select this approach to evaluation
because the investigators think it will provide the most accurate estimate of the effects of
the program. Assuming capitated payments to Accountable Care Organizations (ACOs) become a
major payment approach for Medicare, cost savings from CCPs would create sustainable
incentives for their use. CCPs might also work well in ACOs because selection of high risk
patients into a CCP program might not be a concern if those patient came from within the
ACO's covered population. Sustained incentives to use CCPs could also exist if high-risk
persons selected into ACOs with CCPs, but risk adjustment was adequate. Shared savings
programs with adequate risk adjustment would produce similar incentives. To address
dissemination and risk adjustment, the investigators propose:

Aim 3: To use data collected by UHC from 4 Chicago-area AMCs with linked Medicare data to
support evaluation and potential local and national dissemination of the CCP model

UHC (previously University HealthSystem Consortium) includes over 100 AMCs nation-wide and
has exceptional data on hospital resource use to support risk-adjustment. UHC also houses
laboratory and Medicare data to enhance risk-adjustment and outcomes assessment. The
investigators will use this data to inform potential local dissemination and testing of our
model by helping the other participating Chicago-area AMCs identify the segments of their
patient populations that are frequently admitted enough to be suitable for the CCP model. If
the model is successful at UCMC, and perhaps in later local dissemination and evaluation,
UHC's national scope creates opportunities for dissemination of the investigators' work to
almost all US AMCs. The risk-adjustment data will also allow us to evaluate alternative
strategies to assess program savings to estimate shared savings that do not require
randomization. Thus the investigators propose:

Aim 4: To compare the results obtained in Aim 2 to three alternative assessment strategies
that: 1) compare patients in UCMC treated in the CCP model to patients in UCMC who meet CCP
clinical eligibility criteria but receive usual care, 2) compare patients in UCMC who meet
CCP clinical eligibility criteria to historical patients in UCMC who met CCP clinical
eligibility criteria, 3) compare patients in UCMC eligible for the CCP model to current
patients in 4 other Chicago-area AMCs who meet CCP clinical eligibility criteria.

The investigators propose to evaluate these alternative approaches for selection of a
control group because the investigators think they might be feasible approaches to estimate
savings in a shared-savings model and because they differ in potential threats to validity
(e.g., 1 must address patient selection into the intervention and 2 must address time trends
in costs), outcomes assessment (patient outcomes will be harder to assess in 2 and 3), and
generalizability (1 requires local patients treated outside the model and 2 requires
historical data, which becomes less relevant over time). All models will be adjusted with
the CMS-Hierarchical Condition Category (HCC) risk adjustment model for our base analysis
but the investigators will also explore other approaches to risk adjustment, such as using
prior year total Medicare expenditures and patient-reported variables as risk adjusters. The
investigators propose to use our randomized control group for our shared savings incentive,
but to work with CMMI in our cooperative agreement to assess how these control groups and
approaches to risk adjustment could be used in shared savings incentives. Patient-reported
outcomes will be assessed from enrolled subjects. Finally, since workforce development is
key to implementing and disseminating this model, the investigators propose:

Aim 5: To develop skills of a multidisciplinary team of providers to execute the CCP model,
and expose medical students, residents and fellows, and other health professions trainees to
the model.

Because the investigators are an AMC with a rich pipeline of health professions trainees and
excellent record of training national leaders, the investigators are excellently situated to
train clinicians in the investigators' model who have the potential to help disseminate its
core principles both locally and nationally.

Inclusion Criteria:

- Medicare recipients and were hospitalized at least one time in the past year

Exclusion Criteria:

- Non-Medicare recipients and/or were not hospitalized in the past year