Lise Rybowski The Severyn Group Yale CAHPS Team AHRQ Annual Meeting September 10, 2012

1. The Impact of Pay-for-Performance Incentives forPrimary Care Practices toImprove Patient Experience Lise Rybowski The Severyn Group Yale CAHPS Team AHRQ Annual Meeting September 10, 2012

2. Agenda for Presentation • Context for this case study within the CAHPS program • Goals of the study: What we hoped to learn • Overview and key components of the pay-for-performance program • Study methodology • What we found • Key takeaways

3. Context for this Case Study • CAHPS surveys as measures of patients’ experiences with care: • Patient-provider communication • Access to care and information • Courtesy and respect from office staff • Use of the CAHPS Clinician & Group Survey • To inform health care consumers/patients when choosing providers • To inform health care providers about their own performance

4. Research Questions How does a program designed to drive and support improvements in patient experience with primary care affect the participating medical practices? • What did the practices do to improve their performance? • What challenges did the practices face? • What contributed to the results? • What could have made this program more effective?

5. Overview of Contractual Relationships Health Plan Education and Consulting Service Other Payers Large Provider Network Public Report Regional Organizations Regional Organizations Practice 1 Practice 9 Regional Organizations Regional Organizations Practice 2 Practice 10 Practice 5 Practice 13 Practice 3 Practice 11 Practice 6 Practice 14 Practice 4 Practice 12 Practice 7 Practice 15 Practice 8 Practice 16

6. Key Components of the Pay-for-Performance Program • Multi-year withhold • Payment tied to performance on multiple measures • Biennial measurement of patient experience • Free educational and consulting support from internal center • Challenging goal: No one paid unless “group” meets specified objectives

7. Methods • Interviews with leadership in participating organizations: • Health plan • Provider network • Internal center supporting quality improvement • Public reporting organization • Interviews with practice leaders: administrative and clinical • Seven practice sites • One practice representing four sites

8. What Happened? The Bottom Line • Overall, patients’ experiences with primary care improved • But not enough: Didn’t achieve the goal needed to qualify for payment

9. Did the Incentive Work? Not likely: • Practice leaders not aware of incentive to improve patient experience. • Practice leaders not aware of ongoing goal of improving patient experience at the network level. • Practice leaders not paying attention to public report. • Mixed awareness and use of free services to support QI efforts.

10. Major Challenges Posed by P4P Program • Nature of the incentive: How much was at stake? For whom? • Timing of the performance assessment • Questions about the measure • Performance of individual practice versus all participants • Inadequate communication

11. More Challenges for Practices • Multiple demands for attention; competing priorities • Access versus communication/office staff • Nature of the requirements • Inadequate infrastructure, skills to support quality improvement efforts

12. Key Takeaways and Implications for Policymakers • Have to compensate for the multiple layers between the payer (source of incentive) and the people responsible for improving patient experience (recipients of incentive) • Need clear and ongoing communication about: • Merits of the measures • Goals • What’s at stake and for whom • Available educational and consulting support • Need to consider context and competing priorities: Are there ways to coordinate?