Factors Influencing Non-Primary Care Physicians’ Views on P4P

Karen M. Murphy, Ph.D.The Sixth Annual Quality Colloquium

Cambridge, 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 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

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

Type of IncentiveFinancial

Non-Financial

Practice Size& Ownership

Quality MeasuresStructuralProcess

OutcomeProfessional Age

Specialty SocietyInformation

Non-Primary Care Physicians’ Views On Office-Based

Quality Incentive and Improvement Programs

Payer Dominance

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

33

25

42

05

1015202530354045

Disagree Not Sure Agree

“ P4P promotes the delivery of care according to evidence - based

medicine.” % Strongly disagree and disagree/ agree and strongly agree

28

17

54

0

10

20

30

40

50

60

Disagree Not Sure Agree

“ P4P is a means for payers to decrease physician reimbursement .”

% Strongly disagree and disagree/ agree and strongly agree

1724

58

0

10

20

30

40

50

60

Disagree Not Sure Agree

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

40

35

48

51

0 10 20 30 40 50 60

P4P

Clinical quality measures Icould use in my office to

measure quality

Structural measures ofqualtiy like EMR

How to improve my patientsexperiences of care in my

office practice

“I would favor a P4P that is based on….”

% Responses agree and strongly agree

3140 42

68

0

10

20

30

40

50

60

70

Publicly discloses myperformance

Reimburses on patientsatisfaction

Reimburses on clinicalquality

Offers EMR Funding

“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

34

40

40

46

52

54

0 10 20 30 40 50 60

Public Disclosure to Patients

Public Disclosure to OtherPhysicians

P4P by Medicare

Community QualityInitiative

Decline in current level ofreimbuersemnt

Physicians in My areaimplmenting EMR

Non-Primary Care Physicians' Preferences on Incentive Designs

Design Mean SE t statistic p valuePaymentsBonus Payments 3.63 .074Infrastructure Grants 3.57 .066 .644 p <.520MeasuresClinical Measures 3.12 .090Pt. Experiencesof 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

Community Quality Initiative

0 10 20 30 40 50 60 70 80

Less than 5 years

11-15 Years

21 - 25 Years

Over 30 Years

Year

s si

nce

com

plei

ton

of

spec

ialty

trai

ning

Percentage "Agree or Strongly Aggree"

Public Disclosure of Comparative Performance Data

Public Disclosure as a Change Agent

18

37

47

24

4351

41

0

10

20

30

40

50

60

Less than5 years

6-10 Years 11-15Years

16-20Years

21 - 25Years

26-30Years

Over 30Years

Professional Age

% P

hysi

cian

s A

gree

d

Decline in Reimbursement as a Quality Improvement Incentive

Change to meet Quality Target if Current Reimbursement Declines

0 10 20 30 40 50 60 70 80

Less than 5 years

6-10 Years

11-15 Years

16-20 Years

21 - 25 Years

26-30 Years

Over 30 Years

Prof

essi

onal

Age

Percentage "Agreed or Strongly Agreed"

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