One Health Plan’s Initiatives to Improve Patient Experiences: What the Physicians Had to Say Ron...

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One Health Plan’s Initiativesto 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,

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

session)1

• Quality Improvement initiatives

• Evaluation approach

• Findings

• Lessons learned

Presentation Outline

• Findings

• Lessons learned

Health Plan Saw Opportunity to Improve Patient Experience

• CAHPS Clinician and Group Surveyprovided 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

Plan Focused on its Contracted Primary Care Physicians

• Eight physician-hospital organizations (PHOs)

• Contracted with PHOs for participation of primary care physicians in initiatives

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 website

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

• 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

Pay-for-Performance

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

Pay-for-Performance Measures

Health IT Electronic prescribing

20% Patient registry

Efficiency Generic usage rate

20% Use of emergency room

20% Member experience

Global rating of physician10%

Doctor-patient communication 5%

Office staff 5%

Total 100%

Member Experience was20% of Payment

• Findings

• Lessons learned

• 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?

Examined Effect of Initiatives on Physician Behavior and Motivation

• Findings

• Lessons learned

• Aware of reports93%

• Received a report 69%

• Of those aware of reports Understood contents

32% Limited, incorrect knowledge

20% No content knowledge

Some thought CAHPS reports included clinical measures

93% of Physicians Were Aware of Their 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

49% of Physicians Reported No Change in Actions After Provider

CAHPS Report

• 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

58% Aware of Public Reporting but Most Had Negative Opinion

Of those aware of website (n=64)

• Understood website 20%

• Visited site, little knowledge 8%

• Never visited website and no 72%content knowledge

Physician Understanding of Website Contents Was Limited

• Motivated to improve (20%)

• No change in actions (42%)

• Did not need to improve (39%)

Most Physicians Made No Change

as a Result of Public Reporting

• 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

35% of Physicians Were Motivated

by Pay-For-Performance Initiative

CAHPS Performance level

Low Medium High

Received pay-for-performance payment?

Physician said yes 72% 84% 92%

Actual data 28% 39% 69%

• Program rewards for high CAHPS performance

• Most physicians reported receiving a payment

More Physicians Said They Received Pay Than Actually Did

Physicians Focused on a Range of Patient Experience Areas

Access Getting routine appt. quickly 23%

Getting urgent appt. quickly 12% Other access issues 7%

Lab test results 31%

Wait time 23%

Office staff courteousness 19%

Doctor-patient communication 13%

Answering questions after office hours 10%

Referrals to specialists 8%

CAHPS patient experience area

% of physicians who focused on

given CAHPS area

• 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

58% of Physicians Interviewed Had Ideas for Improving Reports

• Address data issues Timeliness of data reported on the

website 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 website

Physician Advice About Public Reporting

• 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%)

Physician Advice AboutPay-for-Performance

• Findings

• Lessons learned

• Improve data quality

• Simplify and improve design of reports

• Implement initiatives more consistently

• Communicate with and educate physicians

Common Themes

Improve the Data Quality

• Accuracy

• Timeliness

• Representativeness

• Computerization

Simplify and Improve Design of Individual and Public Physician

Performance 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

Implementation of Initiatives Is Important

• 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 To Increase Awareness

and Understanding

• 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

One Health Plan’s Initiatives to Improve Patient Experiences: What the Physicians Had to Say Ron...

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