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

2. Presentation Introduction – P4P Study Methods Findings Conclusions

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

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

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

6. Pay for Performance –Reimbursement mechanisms designed to reward physicians for achieving quality 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

7. 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

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

9. 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.

10. 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)

11. 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

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

13. 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

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

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

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

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

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

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

20. “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

21. Non-Primary Care Physicians' Preferences on Incentive Designs Design Mean 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***

22. 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

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

24. Community Quality Initiatives as an Quality Improvement Incentive

25. Public Disclosure of Comparative Performance Data

26. Decline in Reimbursement as a Quality Improvement Incentive

27. 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)

28. 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.

29. 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).

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

31. 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

32. 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

33. 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

34. Community Quality Initiatives Should Work!

35. 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

36. 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).

37. 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

38. 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

39. 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