COLLABORATING OUTSIDE THE BOX - WHEN EMPLOYERS AND PROVIDERS TAKE ON ENVIRONMENTAL BARRIERS TO GUIDELINE IMPLEMENTATION

Background: In 1992 15 employees in Minneapolis/St. Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-in sured plans. To successfully bid for the BHCAG contract, three competi ng group practices and a health plan cooperated, operating functionall y like a fully integrated care system to measure outcomes, develop pra ctice guidelines, and meet other BHCAG requirements. To accomplish thi s, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. Providers and employers collaborate: To reduce costs ICSI has implemented 16 of 80 planned guidelines. Teams includin g members from clinics and BHCAG develop best-practice algorithms. Eac h guideline is then reviewed and piloted before being implemented in a ll ICSI clinics. Managing external environment: The guideline on cysti tis in healthy women eliminated two costly practices-obtaining a urine culture and visiting the doctor. Yet many physicians and the clinics were afraid of losing significant revenue because they were reimbursed by BHCAG on a free-for-service basis. In turn, BHCAG's hands were tie d. If they changed to a capacitated payment system, they would face on erous state insurance requirements. The solution lay in collaborating at a higher level. ICSI and BHCAG leaders persuaded the state legislat ure to pass a new law that allowed BHCAG to capitate providers without state regulation. As a result, the cystitis guideline is now widely i mplemented in ICSI clinics. Lessons learned: The cystitis guideline ex perience highlights the need to manage the external environment so tha t it reinforces, rather than inhibits, quality improvement in medical practices. Guidelines will not be implemented unless the macro-environ ment into which they are introduced is supportive.