One Health Plan's Initiatives to Improve Patient Experiences: What the Physicians Had to Say

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Slide 1

One Health Plan's Initiatives to Improve Patient Experiences: What the Physicians Had to Say

Ron D. Hays, Ph.D.
Professor of Medicine, UCLA
CAHPS® PI, RAND
Denise D. Quigley, Ph.D.
CAHPS Quality Improvement Team, RAND

AHRQ Conference
September 10, 2012 (3:30-5:00pm session)

Image: The RAND HEALTH logo is shown.

Slide 2

Presentation Outline

• Quality Improvement initiatives.
• Evaluation approach.
• Findings.
• Lessons learned.

Slide 3

Presentation Outline

• Quality Improvement initiatives.
• Evaluation approach.
• Findings.
• Lessons learned.

Slide 4

Health Plan Saw Opportunity to Improve Patient Experience

• CAHPS Clinician and Group Survey provided tool for:
  • Breaking down data.
  • Indicating where improvements were needed.
  • Giving plan leverage.
• Pay-for-performance allowed plan to reward physicians for meeting CAHPS score objectives.

Slide 5

Plan Focused on its Contracted Primary Care Physicians

• Eight physician-hospital organizations (PHOs).
• Contracted with PHOs for participation of primary care physicians in initiatives.

Slide 6

Three Main Actions of the Health Plan

1. Provider reports—Mailed physician-level scores on annual CAHPS survey to individual providers.
2. Public reporting— Posted physicians' scores on public Web site:
   • Measured "clinical quality" and CAHPS on a scale of 1-5.
3. Pay-for-performance program created financial incentives for physicians to improve:
   • Based on CAHPS, Healthcare Effectiveness Data and Information Set (HEDIS) scores, and other measures.

Slide 7

Pay-for-Performance

• First year:
  • No financial rewards.
  • Physicians received their CAHPS survey results.
  • Told which incentive measures were to be tracked for payment.
• Second year:
  • Payments were sent to practices or PHOs for the individual doctor's performance.

Slide 8

Pay-for-Performance Measures

• Health information technology (IT):
  • Electronic prescribing.
  • Patient registry (HEDIS).
• Efficiency:
  • Generic usage rate.
  • Use of emergency room (non-emergency).
• Member experience:
  • Global rating of physician.
  • Doctor-patient communication.
  • Office staff courteousness and friendliness.

Slide 9

Member Experience was 20% of Payment

• Health IT:
  • Electronic prescribing 20%.
  • Patient registry 20%.
• Efficiency:
  • Generic usage rate 20%.
  • Use of emergency room 20%.
• Member experience:
  • Global rating of physician 10%.
  • Doctor-patient communication 5%.
  • Office staff 5%.

Total 100%

Slide 10

Presentation Outline

• Quality Improvement initiatives.
• Evaluation approach.
• Findings.
• Lessons learned.

Slide 11

Examined Effect of Initiatives on Physician Behavior and Motivation

• RAND interviewed 110 plan physicians (43%):
  • Were they aware of and understand performance reports and pay-for-performance?
    • If so, what did physicians do?
  • Did QI initiatives motivate improvements?
    • If so, what did physicians do?

Slide 12

Presentation Outline

• Quality Improvement initiatives.
• Evaluation approach.
• Findings.
• Lessons learned.

Slide 13

93% of Physicians Were Aware of Their Provider CAHPS Report

• Aware of reports 93%.
• Received a report 69%.
• Of those aware of reports:
  • Understood contents 32%
  • Limited, incorrect knowledge 20%
  • No content knowledge 48%
    • Some thought CAHPS reports included clinical measures

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49% of Physicians Reported No Change in Actions After Provider CAHPS Report

• Positive (41%):
  • Areas for improvement.
  • Good information not otherwise available.
  • Comparisons with other physicians.
• Neutral/no opinion (31%).
• Negative (28%):
  • Inaccurate reflection of office visit experience:
    • Invalid or old data.
  • No actionable recommendations for improvements.

Slide 15

58% Aware of Public Reporting but Most Had Negative Opinion

• Positive (14%):
• Good to give consumers information on physician performance.
• Neutral, no opinion (28%).
• Negative (58%):
  • Data are inaccurate; based on:
    • patients who are upset with physician.
    • small sample size.
  • Measures do not account for complex treatments.

Slide 16

Physician Understanding of Website Contents Was Limited

Of those aware of Web site (n=64):

• Understood Web site 20%.
• Visited site, little knowledge 8%.
• Never visited Web site and no 72% content knowledge.

Slide 17

Most Physicians Made No Change as a Result of Public Reporting

• Motivated to improve (20%).
• No change in actions (42%).
• Did not need to improve (39%).

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35% of Physicians Were Motivated by Pay-For-Performance Initiative

• Did not affect motivation (47%):
  • Already doing high quality medicine.
  • Already optimizing performance.
  • Payment too small to have effect.
• Neutral, no comment (18%).
• Did affect motivation (35%):
  • Made aware of areas to improve.
  • Incentive to follow up with patients.
  • Made aware of patients' views.
  • Paid attention to benchmarks.

Slide 19

More Physicians Said They Received Pay Than Actually Did

• Program rewards for high CAHPS performance.
• Most physicians reported receiving a payment.

Slide 20

Physicians Focused on a Range of Patient Experience Areas

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58% of Physicians Interviewed Had Ideas for Improving Reports

• Address accuracy, representativeness, and timeliness of CAHPS performance reports.
• Shorten the report.
• Include information about the patients who were surveyed in the CAHPS sample.
• Educate physicians about CAHPS measures, calculation of composite scores, and sampling issues.

Slide 22

Physician Advice About Public Reporting

• Address data issues:
  • Timeliness of data reported on the Web site.
  • Provide more data on patients queried.
  • Have data reflect entire population of physician's patients, not just one health plan's.
• Allow for physician feedback before posting data on Web site.

Slide 23

Physician Advice About Pay-for-Performance

• Address data issues for HEDIS:
  • Accuracy of information collected by the health plan compared to patient charts.
  • Include measures of patient behaviors and patient non-compliance.
  • Computerize data collection of the measures required by the health plan.
• Increase size of payment to at least 8% of salary (was about 2-3%).

Slide 24

Presentation Outline

• Quality Improvement initiatives.
• Evaluation approach.
• Findings.
• Lessons learned.

Slide 25

Common Themes

• Improve data quality.
• Simplify and improve design of reports.
• Implement initiatives more consistently.
• Communicate with and educate physicians.

Slide 26

Improve the Data Quality

• Improve Data Quality:
  • Accuracy.
  • Timeliness.
  • Representativeness.
  • Computerization.
• Simplify and improve design of reports.
• Implement initiatives more consistently.
• Communicate with and educate physicians.

Slide 27

Simplify and Improve Design of Individual and Public Physician Performance Reports

• Improve Data Quality.
• Simplify and improve design of reports:
  • Explain data sample.
  • Include performance comparisons, trends, benchmarking, and succinct patient care measures.
  • Identify areas for improvement.
  • In Pay-for-Performance:
    • explain payment amounts & methods.
    • differentiate between clinical care and patient experience.
• Implement initiatives more consistently.
• Communicate with and educate physicians.

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Implementation of Initiatives Is Important

• Improve Data Quality.
• Simplify and improve design of reports.
• Implement initiatives more consistently:
  • Include office staff in quality improvement and data reports.
  • Get and keep physicians attention.
  • Simplify documentation (HEDIS).
  • Pay promptly and directly to physicians.
• Communicate with and educate physicians.

Slide 29

Communicate with and Educate Physicians To Increase Awareness and Understanding

• Improve Data Quality.
• Simplify and improve design of reports.
• Implement initiatives more consistently.
• Communicate with and educate physicians:
  • Education physicians before rollout of programs.
  • Provide specific training to physicians on measures.
  • Hold discussions with physicians about performance and quality improvement.
  • Send reports and communicate data trends regularly.

Slide 30

Image: The RAND HEALTH logo is shown.