Factors Influencing Non-Primary Care Physicians’ Views on P4P

Factors Influencing Non-Primary Care Physicians’ Views on P4P Karen M. Murphy, Ph.D. The Sixth Annual Quality ColloquiumCambridge, MA August 20, 2007

Presentation • Introduction – P4P • Study Methods • Findings • Conclusions

Introduction • Quality improvement in health care national imperative • Institute of Medicine Reports: • “To Err is Human” • “Crossing Quality Chasm”

Economic sustainability of a less than optimal system“Dave & Fran”

Introduction • IOM Recommendations on quality improvement • Misaligned payments mechanisms • Align incentives for quality • Current payment schemes do not pay quality differential

Pay for Performance • Reimbursement mechanisms designed to reward physicians for achievingquality goals and motivate quality improvement • Quality Measures • Structural measures • Example: EMR; Diagnostic test tracking systems; • Process Measures • Preventative screening according to EBM. • Outcome Measures • Patient experiences of care

Introduction • Pay for Performance Programs • Over 100 in the US • Medicare engaged in the movement • Designed for primary care physicians • Pediatrics • Family medicine • Internal medicine • Limited for non-primary care physicians

Introduction • Non-primary care physicians • 41% of physician office visits • 70-80% of national health care expenditures • Move to include in P4P

Literature Review • Physician Incentives • Lack of empirical studies related to the use of incentives in health care • P4P moving forward in the absence of empirical evidence of its effectiveness • Physicians’ views on P4P • Two published studies • Young et al 2007; Casalino et al 2007.

Introduction • Studies related to Office-Based Quality • 55% received care according to evidence-based guidelines (McGlynn et al 2003) • Adoption to technology could lead to safer environments (Chaudhry et al 2006) • Only 24% of physicians currently are utilizing an electronic medical record (Jha et al 2006) • Most physicians in private practices do not utilize QI practices in their offices (Audet et al 2005) • 12% of Academic programs reported to have robust QI programs (Maio et al 2004)

Methods • Primary Data Collection • Study Sample • Physicians in PA practicing • Cardiology • OBGYN • Hematology/Oncology • Orthopedic Surgery • Urology • 35- Item Survey • Based on items identified in previous studies that influence physicians’ views on reimbursement and quality

Non-Primary Care Physicians’ Views On Office-Based Quality Incentive and Improvement Programs Type of Incentive Financial Non-Financial Practice Size & Ownership Quality Measures Structural Process Outcome Professional Age Payer Dominance Specialty Society Information

Results • 251 surveys returned • Surveys eliminated due to specialties outside of sample; separation from medical practice • N= 211 • Physician characteristics • Majority under age 54 • 47% in practice < 15 years • 50% < small group practices • 51% Physician - owned

“ P4P is the best way to reimburse physicians for quality.”% Strongly disagree and disagree/agree and strongly agree

“ P4P provides payers and patients a way to differentiate the quality care”% Strongly disagree and disagree/agree and strongly agree

“ P4P promotes the delivery of care according to evidence - based medicine.”% Strongly disagree and disagree/ agree and strongly agree

“ P4P is a means for payers to decrease physician reimbursement .”% Strongly disagree and disagree/ agree and strongly agree

“Information received from specialty society in the past 12 months.”

“I would favor a P4P that is based on….”% Responses agree and strongly agree

“Events that would serve as an incentive to change the way I practice medicine in order to meet a target goal….”% Agree and strongly agree

Non-Primary Care Physicians' Preferences on Incentive Designs DesignMean SE t statistic p value Payments Bonus Payments 3.63 .074 Infrastructure Grants 3.57 .066 .644 p <.520 Measures Clinical Measures 3.12 .090 Pt. Experiences of Care 2.78 .094 3.98 p <.000***

Statistical Analysis • Factors that influence positive views • Information from specialty society predictor of positive views • Physicians receiving information on structural (OR=4.32,p< .01), clinical (OR=2.67, p< .05) and patient experiences of care measures (OR= 4.25, p< .05) were more likely to view P4P positively • No other factors were significant

Statistical Analysis • Professional Age significantly influenced Non-Primary Care Physicians’ Views on quality improvement and incentive programs.

Community Quality Initiatives as an Quality Improvement Incentive

Public Disclosure of Comparative Performance Data

Decline in Reimbursement as a Quality Improvement Incentive

Discussion • Study is the first study to examine non-primary care physicians’ views • Support findings by Casalino et al (2007) and Young et al (2007)

Discussion • Non-primary care physicians identified key objectives of P4P • Differentiated quality • Promoted evidence–based practices • Physicians’ attitudes toward adopting technology, infrastructure appear to be changing.

Discussion • Incentive Design • Non-primary care physicians appear to have more confidence in: • Office based clinical indicators (despite limitations) as opposed to: • Patient experiences of care (the most commonly available measure of quality in a physicians practice).

Discussion • Findings in this study support Casalino et al (2007) • Physicians supported financial incentives • Opposed public reporting

Discussion • Role of Specialty Societies in quality improvement • Findings offer opportunity for key role for specialty societies to advance the quality movement • Specialty Societies that have established a leadership position should be used as model • American College of Cardiology • American Society of Hematology • AMA Physician Consortium for Performance Improvement

Discussion • Study found physicians are motivated by different events at different times in their career • Physicians early in their career more supportive of community quality initiatives and implementation of electronic medical record • Suggests that resistance to implementation of technology is time limited • Implication to develop • short term quality improvement strategies that would be accepted by broad groups of physicians • Long term strategies focused at engaging physicians in graduate medical education and those early in their career

Discussion • Professional Norms/Community Standards • Previous studies have demonstrated geographic variations in practice patterns (Fisher et al 2003, Wennberg, 2004) • Studies suggest that physicians generally practice according to the standards established within their individual communities • This study indicates the apparent impact of community standards offers promise for elevating quality

Community Quality Initiatives Should Work!

Study Limitations • Non-primary care physicians have had limited experience with incentive payments • Multi-faceted collection method • Geographic and specialty restriction limits generalizability • Information limited to compare respondents/nonrespondents

Conclusion • Successful implementation of P4P will require innovative strategies • Past attempts to improve quality and cost have not been successful • Founded on strong principals accompanied ineffective execution • “Strategy fatigue” lead to premature abandonment of tenants that offered significant long term impacts on quality and cost (Robinson, 2001).

Conclusion • P4P may follow similar course • Inherent complex execution • Non-primary care physicians more diverse services (number and type) as compared to primary care • Lack of vetted measures • Attribution issues (Pham et al 2007) • No apparent short term solution

Conclusion • Short Term Strategies: • Support incentive programs that reward for investments in infrastructure such as ambulatory electronic medical record • Engage specialty societies • Identify effective community-based strategies • Long Term Strategy: Continue to pursue development of robust, evidence-based quality measures

Take away messages • Studied supported results found by Young et al (2007) and Casalino et al (2007) • Physicians identify some positive aspects of P4P • Continue to develop quality improvements grounded by evidence based medicine

Factors Influencing Non-Primary Care Physicians’ Views on P4P