By Tim Bonfield
The Cincinnati Enquirer

Greater Cincinnati will soon become a case study in a national debate about one of medicine's toughest problems - how to provide consistent, high-quality care to people with chronic disease.

The Bridges to Excellence program, announced this week in Boston, promises to dole out millions nationwide in bonuses to doctors who improve quality in three areas: diabetes care, heart disease treatment and modernizing the medical office.

The diabetes care project will be piloted in Cincinnati, Louisville and Boston. The modern-office initiative will be rolled out in Boston. The cardiac care program will be launched later this year.

Recruitment information goes to Tristate doctors who treat diabetics next week.

DOCTORS & STANDARDS

"Recognized" diabetes doctors These are the local physicians who have been recognized as meeting the standards of diabetes care set by the American Diabetes Association and the National Committee for Quality Assurance: Dr. Vina Bajaj (Edgewood), Dr. Ron Hsieh (Cincinnati), Dr. Kenneth Kreines (Cincinnati), Dr. Ferdinand Niehaus Jr. (Cincinnati), Dr. Robert Osborne (Cincinnati), Dr. Deborah Pillow (Addyston), Dr. James Pritchard (Cincinnati), Dr. David Vance (Cincinnati), Dr. Timothy Williams (Cincinnati) and Dr. David Wilson (Cincinnati). Diabetes standards: The Diabetes Physician Recognition Program assesses physicians on 11 key measures of adult diabetes care and eight key measures of pediatric diabetes care. Among those measures: Required: At least 93 percent of patients get the HbA1c blood test once a year. Required: At least 61 percent get annual eye exams, 80 percent get annual foot exams, and 97 percent get annual blood pressure checks. Required: At least 85 percent get annual lipid profile tests, and 73 percent get kidney function assessments. Bonus points: Asking at least 76 percent of patients about smoking habits, then counseling the smokers to quit. At least 90 percent get education about self-management of diabetes symptoms. At least 58 percent of diabetes patients rate care as good, very good or excellent in patient satisfaction surveys. Source: NCQA

The potential influence of the Bridges to Excellence program goes far beyond better management of one disease.

"Overall, (health care) reform has been fairly timid. Our mission is to encourage leaps in quality, not just baby steps," said Francois de Brantes, program leader for health care initiatives at General Electric and the leading voice for the Bridges to Excellence experiment.

Unlike reforms of years past, which often focused on hospital management, this program's focus on the individual doctor is "exciting and relatively new," said Margaret O'Kane, president of the nonprofit National Committee for Quality Assurance (NCQA).

Doctors, policymakers and health care consumer groups will watch the Bridges project closely because it is backed by some of America's most visible employers. Among those in the diabetes management program are General Electric, Procter & Gamble, Ford Motor Co., United Parcel Service and Cincinnati Children's Hospital Medical Center. Participating insurers include Aetna, Anthem Blue Cross and Blue Shield of Ohio and Kentucky, Humana and United Healthcare.

These companies pay a lot of medical bills. They have a lot of resources to analyze their own spending. And they say everybody touched by the medical system would benefit if doctors tried harder to eliminate wide variations in how people get treated for chronic illnesses.

"Today, the existing system doesn't give appropriate incentives to focus on chronic conditions," de Brantes said. "To make the health care system work, we need to reduce the waste."

This project pushes doctors to make changes much as the Iameter project - launched a decade ago - pushed local hospitals to reorganize and become more efficient. P&G and GE Aircraft Engines inEvendale, a unit of GE, were among the Iameter project sponsors.

The Bridges project was inspired primarily by a 2001 Institute of Medicine study that reported huge numbers of people suffering from medical errors, de Brantes said. The goal: to reduce errors by reducing the underuse, overuse and misuse of medical resources.

Doctors who have complained for years that the health care system hasn't paid them for spending extra time on patient education or for making sure patients come in for regular checkups remain skeptical of the bonus program.

"One hopes that quality is the primary interest here," said Dr. Yank Coble, president of the American Medical Association.

A shakeup in diabetes care

In addition to being a leading cause of death, diabetes is a leading cause of blindness and disability from limb amputations. It also is the main reason thousands of people spend years tethered to dialysis machines while a lucky few get kidney transplants.

To get bonus checks from the Bridges program, doctors must be on a list of doctors recognized by the American Diabetes Association (ADA) and the NCQA as officially meeting national care standards.

Of the hundreds of Tristate doctors who treat people with diabetes, 10 are on the ADA/NCQA list.

Becoming recognized means that doctors have audited their records to show that their patients are getting annual blood sugar tests, eye exams, kidney function checks and other key services.

Some of those doctors gave cautious praise to the Bridges initiative.

"The research data are plentiful. If you adhere to the ADA criteria, you do a better job," said Dr. Ron Hsieh, an internal medicine specialist who made the ADA list in June 2002, nearly three years before the Bridges initiative.

"If the business community decides they want quality care and they are willing to pay for it, that's good," Dr. Hsieh said. "But I will believe it when I see it."

At Eastern Hills Internal Medicine, three of the group's five physicians got on the ADA list last year. But the group was disappointed at how few health plans rewarded their recognition with better rates or efforts to promote the group to covered patients, said Jerry Bishop, practice administrator.

He hopes attitudes will change as the Bridges program develops.

"We did it to demonstrate our quality. We felt it was the right thing to do, " said Bishop. "We would like to think that all of this work we have done would result in some favorable incentives from managed care plans."

Recruitment begins

In Cincinnati, doctors can collect $100 per year per patient who is covered by a participating employer. For a doctor who treats 100 covered diabetic patients, the bonuses could add up to $10,000 a year.

In addition, the program offers products and tools to help diabetics get more involved in their care, achieve better outcomes and identify local physicians who meet the high performance measures. Overall, the program is estimated to generate savings of $350 per diabetic patient per year, and cost employers no more than $175 per diabetic patient per year.

Some doctors may be quick to join because they know they meet the quality standards, even though they haven't bothered with the paperwork. On the other hand, the bonuses may not make up for what some doctors say has been years of below-market reimbursement rates for Cincinnati physicians.

Doctors have argued for years that health plans haven't paid them to spend the necessary time with patients to discuss diabetes self-management, nutrition and smoking cessation.

Despite physician concerns, sponsors of the Bridges program say much improvement can be made.

"We all pay a heavy price for chronic illnesses like diabetes," said O'Kane.

Had all Americans with diabetes, asthma, depression and heart disease been treated according to known, established best practices, employers could have avoided an estimated 23 million sick days, and millions of people would have enjoyed healthier lives, she said.

E-mail tbonfield@enquirer.com