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) 1

Quality Improvement initiatives Evaluation approach Findings Lessons learned Presentation Outline 2

Quality Improvement initiatives Evaluation approach Findings Lessons learned Presentation Outline 3

Health Plan Saw Opportunity to Improve Patient Experience 4 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

Plan Focused on its Contracted Primary Care Physicians 5 Eight physician-hospital organizations (PHOs) Contracted with PHOs for participation of primary care physicians in initiatives

Three Main Actions of the Health Plan 6 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 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 7

 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 Pay-for-Performance Measures 8

 Health IT  Electronic prescribing20%  Patient registry20%  Efficiency  Generic usage rate20%  Use of emergency room20%  Member experience  Global rating of physician10%  Doctor-patient communication 5%  Office staff 5% Total100% 9 Member Experience was 20% of Payment

Quality Improvement initiatives Evaluation approach Findings Lessons learned Presentation Outline 10

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 11

Quality Improvement initiatives Evaluation approach Findings Lessons learned Presentation Outline 12

Aware of reports93% Received a report 69% Of those aware of reports  Understood contents32%  Limited, incorrect knowledge20%  No content knowledge48%  Some thought CAHPS reports included clinical measures 93% of Physicians Were Aware of Their Provider CAHPS Report 13

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 14 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 15

Of those aware of website (n=64) Understood website20% Visited site, little knowledge8% Never visited website and no72% content knowledge Physician Understanding of Website Contents Was Limited 16

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 17

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 18

CAHPS Performance level LowMediumHigh 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 More Physicians Said They Received Pay Than Actually Did 19

Physicians Focused on a Range of Patient Experience Areas 20 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 21

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 22

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 About Pay-for-Performance 23

Quality Improvement initiatives Evaluation approach Findings Lessons learned Presentation Outline 24

Improve data quality Simplify and improve design of reports Implement initiatives more consistently Communicate with and educate physicians Common Themes 25

Improve data quality Simplify and improve design of reports Implement initiatives more consistently Communicate with and educate physicians Improve the Data Quality 26 Accuracy Timeliness Representativeness Computerization

Improve data quality Simplify and improve design of reports Implement initiatives more consistently Communicate with and educate physicians Simplify and Improve Design of Individual and Public Physician Performance Reports 27 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

Improve data quality Simplify and improve design of reports Implement initiatives more consistently Communicate with and educate physicians Implementation of Initiatives Is Important 28 Include office staff in quality improvement and data reports Get and keep physicians attention Simplify documentation (HEDIS) Pay promptly and directly to physicians

Improve data quality Simplify and improve design of reports Implement initiatives more consistently Communicate with and educate physicians Communicate with and Educate Physicians To Increase Awareness and Understanding 29 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

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