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

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

Presentation Outline • Quality Improvement initiatives • Evaluation approach • 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 • Provider reports –Mailed physician-level scores on annual CAHPS survey to individual providers • Public reporting – Posted physicians’ scoreson public website • Measured “clinical quality” and CAHPS on a scale of 1-5 • 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

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

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

Member Experience was20% 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 physician10% • Doctor-patient communication 5% • Office staff 5% Total 100%

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?

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

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

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

Physician Understanding of Website Contents Was Limited Of those aware of website (n=64) • Understood website 20% • Visited site, little knowledge 8% • Never visited website and no 72%content knowledge

Most Physicians Made No Changeas a Result of Public Reporting • Motivated to improve (20%) • No change in actions (42%) • Did not need to improve (39%)

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

More Physicians Said They Received Pay Than Actually Did 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

Physicians Focused on a Range of Patient Experience Areas % of physicians who focused on given CAHPS area CAHPS patient experience area 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%

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

Physician Advice About Public Reporting • 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 AboutPay-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%)

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

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

Simplify and Improve Design of Individual and Public Physician Performance Reports • Improve data quality • Simplify and improve design of reports • Implement initiatives more consistently • Communicate with and educate physicians • 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 • Improve data quality • Simplify and improve design of reports • Implement initiatives more consistently • Communicate with and educate physicians • 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 • 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

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