1. Quality of Care in Physician Groups Do Larger Integrated Systems Deliver Higher Quality Care? Ateev Mehrotra MD MPH RAND Pittsburgh & University of Pittsburgh AcademyHealth Annual Research Meeting June 5 th 2007

2. AcademyHealth 2007 2 06/03/2007 Background  Organization of Physician Groups  Integrated Medical Groups  Individual Physician Associations (IPAs)  Many believe that integrated medical groups provide higher quality care  Centralized decision making  Closer affiliations with physicians  Pooled resources

3. AcademyHealth 2007 3 06/03/2007 Previous Evidence Large medical groups generally more likely to implement QI –Provide health promotion –Smoking cessation –Patient reminders for preventive care McMenamin, Medical Care, 2003 Schmittdiel, Prev Med, 2004 Rittenhouse, Medical Care, 2006

4. AcademyHealth 2007 4 06/03/2007 Two Studies Does P4P impact relationship between organizational structure and use of QI initiatives Relationship between organizational structure, QI initiatives, and performance on quality measures

5. AcademyHealth 2007 5 06/03/2007 Will Increasing Use of P4P Impact the Relationship between Organization and QI Strategies

6. AcademyHealth 2007 6 06/03/2007 Study Sample 100 groups on Massachusetts 2005 publicly released physician group report card Interviewed leaders of 79 groups between May and September 2005 Semi-structured phone interviews lasting 30-60 min

7. AcademyHealth 2007 7 06/03/2007 Prevalence and Magnitude of P4P in Massachusetts Groups with P4P incentives in health plan contracts 89% Overall revenue tied to P4P 2.2% (0.3 – 8.0)

8. AcademyHealth 2007 8 06/03/2007 Use of QI Initiatives

9. AcademyHealth 2007 9 06/03/2007 Variables Associated with Increased Use of QI Initiatives Odds Ratio (95% CI) P Value Pay-for-performance incentive 1.6 (1.1-2.5) 0.04 Physician Group employs majority of physicians (vs. employs minority) 3.9 (1.7-8.8) 0.002 Larger group (>median of 39 physicians vs. <median) 2.6 (1.1-6.2) 0.03

10. AcademyHealth 2007 10 06/03/2007 Findings Even in a setting of widespread use of P4P, larger physician groups that utilize employed physicians are more likely to utilize QI efforts Limitation that P4P not financially important to most groups

11. AcademyHealth 2007 11 06/03/2007 Differences in Quality?

12. AcademyHealth 2007 12 06/03/2007 Hypotheses Integrated medical groups provide higher quality care than other types of physician groups Higher quality is due to increased use of QI initiatives and EMR

13. AcademyHealth 2007 13 06/03/2007 Study Population Examined quality of care delivered by 119 California physician groups to 1.7 million enrollees of PacifiCare

14. AcademyHealth 2007 14 06/03/2007 Survey of Physician Groups 45 minute interview with CEO or Medical Director (6/99 – 7/00) Interviewees self-identified the type of physician group –Integrated medical group –IPA –Hybrid physician groups - core integrated medical group with associated IPA

15. AcademyHealth 2007 15 06/03/2007 Quality Indicators 6 HEDIS quality measures (7/99-6/00) 1.Mammography 2.Pap smear 3.Chlamydia screening 4.Diabetic eye screening 5.Asthma controller medication use 6.Beta-blocker use after MI

16. AcademyHealth 2007 16 06/03/2007 Other Covariates If There are Quality Differences, Why? 1.Use of EMR 2.Use of QI initiatives 3.Different physicians  % of physicians board certified 4.Larger size  Volume of patients - # of pts in the group eligible for each quality measure regardless of payor

17. AcademyHealth 2007 17 06/03/2007 Unadjusted Quality Scores ** ** P < 0.05 difference from IPA **

18. AcademyHealth 2007 18 06/03/2007 Greater Use of EMR and QI initiatives Among Integrated Medical Groups Integrated Medical GroupsHybridsIPAs EMR37%18%2% Remind eligible women of missed mammogram 74%51%28% Asthma disease management program 63%62%41%

19. AcademyHealth 2007 19 06/03/2007 Surprisingly, Adjusting for Covariates Did Not Change Relationship Predicted outcomes shown ** P< 0.05 difference from IPA Adjusted for: Use of QI Use of EMR % of board certified Volume of care ** 10% 36% 12% 16%

20. AcademyHealth 2007 20 06/03/2007 Relationship Between Other Variables and Quality Scores No clear relationship with quality scores: –EMR –QI initiatives –% physicians board certified Exception –Volume of care

21. AcademyHealth 2007 21 06/03/2007 Volume – Quality Relationship Predicted outcomes shown ** P< 0.05 difference from lowest quartile **

22. AcademyHealth 2007 22 06/03/2007 Limitations Cross-sectional study California physician groups different Labels do not capture heterogeneity of groups Limited number of quality measures Measurement of EMR & QI initiatives limited –Decision support in EMR?

23. AcademyHealth 2007 23 06/03/2007 Overall Implications of Both Papers Findings illustrate importance of organizational setting on quality of care Need for better understanding of why Do we need policy interventions that encourage integration?

24. For More Information Ateev Mehrotra RAND Pittsburgh University of Pittsburgh School of Medicine mehrotra@rand.org

25. AcademyHealth 2007 25 06/03/2007 Difference in Quality Groups with and without QI strategy MeasureQI StrategyUnivariateMultivariate Mammograms Patient reminder program10% **6% Pap smears Collect data9%5% Beta blocker after AMI Collect data-1%-2% Diabetic Eye Screening Diabetes disease management program8% *1% Feedback to doctors on screening rates-3% Guidelines for diabetic eye screening used-1%0% Patient reminder program5%1% Asthma Med Use Asthma disease management program1%0% Feedback program to doctors on asthma medication use5% **6% **

26. AcademyHealth 2007 26 06/03/2007 Difference between groups with EMR and those without EMR UnivariateMultivariate Mammogram8% *-1% Pap Smears-4%-17%** Chlamydia8%**5% Diabetic Eye Screening7%0% Asthmatic Medication Use1% Post-AMI Beta Blocker Use12% *6% *

27. AcademyHealth 2007 27 06/03/2007 Statistical Methods Hierarchical multivariate logistic regression to account for the clustering of patients within physician groups All covariates included in final model