Congratulations to all CMS PGP Demonstration participants, especially Geisinger Health Systems and Dartmouth-Hitchcock (DH), both of whom have shared their strategies for population health management with HIN.

Early on in the PGP demo, DH targeted patients with CHF, CAD, and diabetes; it then developed two ‘super registries‘ to monitor both chronic disease markers and preventive care needs in its population. It created training for new roles for nurses and case managers, focusing on health coaching, motivational interviewing and bridging care across transitions. DH then created reports comparing its MDs’ performance with those of their peers. In the end, they received about $13 million in shared savings from CMS.

Says Barbara Walters, senior medical director, “What did we do to make a difference? It was our admission rate, cost of care for CHF patients and our clinical quality compared to the comparison group. We didn’t even realize it but we had created a medical home, which is a very important cornerstone for all of this.”

And Geisinger achieved 100 percent on the PGP program’s quality measures, the only one of the 10 organizations to do so for the last four years of the demonstration. “By focusing on improving quality, we were able to reduce the total costs of treating Medicare beneficiaries. Our costs at Geisinger rose only 1.4 percent, compared to the typical 4 to 6 percent increase observed nationwide,” said Thomas Graf, M.D., associate chief medical officer, population health, chairman, community practice, Geisinger Health System.

You can read more about CMS' PGP Transitions Demo and other healthcare issues in last week’s Healthcare Business Weekly Update.