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Technical Assistance for Improving Chronic Care Practices

Under Pay for Performance

November 2002

Prepared for the California HealthCare Foundation

by

Neil A. Solomon, M.D. Margie Powers, M.S.W., M.P.H.

NAS Consulting Services

Copyright © 2002 California HealthCare Foundation

Additional copies of this and other publications may be obtained by calling the CHCF publications line toll-free at 1-888-430-CHCF (2423) or by visiting us online (www.chcf.org).

The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems. For more information, visit us online (www.chcf.org). California HealthCare Foundation 476 Ninth Street Oakland, CA 94607 Tel: 510.238.1040 Fax: 510.238.1388 www.chcf.org

Technical Assistance for Improving Chronic Care Practices under Pay for Performance 2

Executive Summary

In order to inform potential investments in chronic condition management at the level of medical groups and independent practice associations (IPAs), NAS Consulting Services developed a list of technical assistance options. Each option was graded for likelihood of impact, relative cost, scalability, and medical group demand.

To evaluate demand, NAS Consulting Services conducted semi-structured telephone interviews with fifteen representative medical groups and IPAs in California during September 2002. Interviewees were asked about their medical group’s response to the Integrated Healthcare Association (IHA) Pay for Performance initiative, current quality improvement activity and infrastructure, and likelihood of participation in various types of technical assistance.

Based on literature review, our own experiences, and interviews with experts, we developed nine technical assistance options. None of the options is likely to yield immediate large changes in clinical outcomes. Several are expected to develop a foundation for change—such as in technical skills and cultural shifts among medical groups. Those assistance programs that provide training and skill development were generally in greater demand than were those requiring purchase of a service (such as use of an external disease management company) or the use of technology (such as a Web portal). There was high demand for a “dry run” of Pay for Performance measures to audit computer code and to provide medical groups with an indication of their current standing on the measures.

Among the methods that are intended to provide training and collaboration, there was greatest demand for facilitated collaboration (modeled after the current California Cooperative Healthcare Reporting Initiative’s “Diabetes Continuous Quality Improvement [CQI] Project”), then daylong quality improvement training workshops (in topics such as registry development and strategies to change physician behavior), and finally intensive collaborations (modeled after the Institute for Healthcare Improvement’s “Breakthrough Series”). The condition with greatest current internal activity and highest demand for assistance was diabetes, followed by coronary artery disease and then asthma. Of the preventive measures, interest was equally high in childhood immunizations and mammography, but neither rated as high as the three chronic conditions.


Medical groups favored collaborative models of technical assistance, and expressed willingness to share their quality improvement methods with other groups. Most groups also indicated desire to participate concurrently in multiple activities, as long as the potential financial payoff from Pay for Performance justified the investment of staff resources in the projects. Overall, Pay for Performance appears to be a strong motivator of clinical priorities and investments in technical infrastructure for quality improvement.


I. Project Overview

Project Description

The California HealthCare Foundation (CHCF) is exploring strategies to enhance the care of chronically ill patients in California, especially through technical assistance to medical groups, independent practice associations (IPAs), and other provider organizations.1 The Pay for Performance initiative, organized and managed by the Integrated Healthcare Association (IHA), represents a major impetus for medical groups to develop and expand chronic care programs. The Pay for Performance initiative will provide incentive payments for medical groups who reach targets in each of six clinical areas: asthma care, diabetes care, coronary disease care, rate of prevention in childhood immunization, rate of prevention in Pap smears, and rate of prevention in mammography. In this study, NAS Consulting Services describes technical assistance options to support medical groups in their development of programmatic options to enhance chronic illness care. Medical groups have the capacity to perform aspects of quality improvement (QI), such as registry development, population management, and guidelines implementation, for which individual physicians or small offices are ill equipped. We looked at whether the Pay for Performance initiative will likely motivate change in medical groups, the current QI infrastructure of medical groups, and which types of technical assistance would be in greatest demand.

1 Independent practice associations are networks of physicians, usually practicing in small separate offices, with common contracting and claims processing. Through delegation by contracted health plans, an IPA may also perform some of the functions of credentialing, utilization management, benefits adjudication, and handling of grievances and appeals. Although not a formally delegated function, most IPAs also initiate some quality improvement activities. By contrast, medical groups typically practice at a single office or a few sites, pool their financial resources and pay doctors on a partnership model, and routinely internalize all the delegated and QI functions. For the purposes of this report, unless otherwise specified, we use the term medical groups to include both IPAs and true medical groups.


Methodology

NAS Consulting used the following methodology to complete the analyses for this report:

1. Identified and examined existing quality improvement interventions. Based on information gathered through literature review (medical journals and trade publications) and interviews with industry leaders such as quality improvement experts, relevant academics, and healthcare consultants, we created a matrix of technical assistance options and characteristics.

2. Interviewed industry leaders. In order to clarify overall medical group needs and interests, we interviewed leaders from medical group organizations such as the California Association of Physicians Organizations (CAPO) and The IPA Association of America (TIPAAA).

3. Designed an interview guide to gather information from medical group leaders. The instrument included questions about the medical group regarding awareness about and activity related to the Pay for Performance Initiative; current QI activities, priorities and infrastructure; preferences for technical assistance options; level of confidence and trust in different sponsors and suppliers of that assistance; and willingness to share methods in collaborative environments. Appendix A contains the interview guide.

4. Performed telephone interviews. Using a sample of fifteen medical groups, we conducted telephone interviews of 30 to 45 minutes. The sample was stratified according to (1) group model (medical group [including foundation model] versus IPA); (2) environment (urban or rural); (3) size (large, medium, or small); (4) geographic location (northern, southern, and central California); and (5) participation in an existing statewide collaborative improvement effort (i.e., the California Cooperative Healthcare Reporting Initiative [CCHRI] Diabetes CQI Project). In all instances but two, we interviewed the chief medical officer or medical director responsible for quality improvement at each group. Where possible (i.e., in ten out of fifteen groups), we also interviewed the director of quality improvement programs. Appendix B contains a list of medical groups contacted and the individuals who were interviewed.

5. Analyzed results. This research is qualitative, and therefore no quantitative statistics are presented. We teased out repeated themes and observed common versus uncommon responses to reach our conclusions. Our work is therefore intended to provide CHCF, IHA, and other leadership organizations with a general picture of the current status of activity and demand for quality improvement in chronic condition management among medical group leadership.


II. Technical Assistance Options

We identified nine forms of technical assistance that held potential for supporting the activities of medical groups. They are listed below with brief descriptions of what they are intended to accomplish, how likely we believe they are to effect change, and our judgment of the relative costs and scalability.

1. Intensive Collaboration

Intensive collaboration is modeled on the Institute for Healthcare Improvement (IHI) Breakthrough Series approach. In this approach, each organization assigns responsibility to a team that meets regularly, chooses defined interventions from a menu of options provided at the outset by the collaborative, uses a rapid-cycle testing approach to refine and implement change, and communicates with other similar teams to share methods. A project manager oversees the activities of all groups and a clinical expert provides consultation when needed. The approach has been extensively used in hospital settings and, more recently, among community clinics. It has been used for chronic conditions in concert with the Chronic Care Model espoused by Ed Wagner and colleagues. The Breakthrough Series model is currently being studied through several AHCPR grants; the results of independent evaluations of its effectiveness are not yet available. Few of the medical groups we interviewed were familiar with this model or with IHI. This is probably the most resource-intensive approach among our technical assistance options.

2. Facilitated Collaboration

Facilitated collaboration is modeled on the CCHRI’s Diabetes CQI Project, including its Quality Improvement, Learning and Training (QUILT) program. In this model, medical groups are provided with QI information and resources through actively facilitated monthly teleconferences and quarterly in-person meetings. The Diabetes CQI Project also provides clinical practice guidelines, comparative outcomes studies, a tool kit of interventions, and expert speakers on relevant topics. There are currently 23 medical groups participating in the Diabetes CQI Project; there is no fee to medical groups to join. There are varied levels of participation and attendance. Teleconferences typically have attendance of 80–90 percent; usually about 60–70 percent of participating groups attend the statewide meetings. This model is less prescriptive and requires less resource allocation by a participating medical group than does the IHI Breakthrough series


model. An evaluation of the QUILT program is being planned. Anecdotal feedback from participants is positive, but there is no objective evidence of whether the intervention has impact.

3. Day-long QI Staff Workshops

These workshops would cover topics to support quality improvement and population management (for example, care management, registry development, and change processes). The intention of such workshops would be to teach skill sets and to provide methods education to the quality improvement teams in medical groups. This approach is less intensive than those listed above, and requires no longitudinal commitment. The effects of such workshops are not known. Generally, didactic medical education provided outside of a clinician’s regular work environment (standard model continuing medical education) is not effective in changing behavior. These workshops could be made more interactive than typical CME, but might still lack persistent effect. We found no programs of this type available in California today.

4. Day-long Physician Workshops

These workshops would provide clinical information to physicians on appropriate practices. They would be presented in a standard format CME, with curriculum predicated on the clinical topics measured in the Pay for Performance program. The purpose of such workshops is to impart knowledge to clinicians who might not otherwise be aware of best clinical practice for a given topic. As stated above, most research on CME programs indicates that they have limited ability to change clinical practice. There already exists a large market for CMEs, which are of variable content quality. An investment in this area could either subsidize (and possibly reform) the content of an existing CME or develop an entirely new program.

5. On-site Technical Assistance

Medical groups would receive on-site assistance from quality improvement experts, data systems specialists, or other clinical management consultants. This approach allows expertise to be tailored to each medical group’s unique needs. The impact of the intervention would be highly variable, depending on the skills of the consultants and the match with client needs. This approach would be expensive and not easily scalable to the needs of California. Many health care consulting firms offer services in California, but very few claim expertise in this specialized area. Most that do offer such services are small firms.

6. Audit of Data Source Codes and Analysis of 2002 Results

The purpose of this option is to offer medical groups a preliminary glimpse of their current status relative to Pay for Performance targets and compared to other medical groups. It would also ensure that medical groups are equipped to measure correctly for the Pay for Performance program. This program would not, in itself, affect quality of care because it is solely focused on measuring existing outcomes. It would, however, show medical groups where to focus their efforts, and could more quickly move the discussion away from measurement problems and into the hard work of changing systems of care. This intervention is moderately scalable because all medical groups would rely on similar technical specifications but would likely require much customized work to extract the relevant information from databases. A pilot project of this type is being planned for future implementation.


7. Web Portal of Quality Improvement Materials

The purpose of this program is to make available an array of resources to all medical groups across the state. The proposed Web site would describe methods, offer downloadable tools and documents, and offer electronic discussion groups with other individuals facing similar challenges. A program to provide such services in currently in planning phase by IHI, though not tailored to California’s marketplace or to Pay for Performance conditions/measures. Advantages of such a program are that it would offer great economies of scale (essentially no added cost for more medical groups to utilize it), would have excellent reach across the state, and could provide access to the information and resources outside California, too. The benefits of the program, especially if provided without link to other face-to-face resources is questionable. Many medical groups across the state appear to be in an early phase of program development and implementation; providing resources with little guidance or support is not likely to stimulate successful program development. No formal research has been conducted to evaluate the effects of such a Web site, though there is evidence that physicians are increasingly using the Internet in their professional lives (and presumably would use it to find QI resources). The IHI Web site would cost at least a couple of hundred thousand dollars per condition. Alternatively, a less expensive (but not “turn-key”) Web site could be created to meet California needs.

8. Expanding Technological Capabilities

The purpose of expanding capabilities such as provider computer connectivity, clinical decision support, or other information technology resources is to enhance the infrastructure needed for medical groups to use technological methods for quality improvement. Currently, most medical groups in California (especially IPAs) lack a standard way to communicate electronically with their member physicians. Before technology can be used to convey messages and influence behaviors, the medical offices must have such basics as computers, Web browsers, email, and high-speed Internet connections. An investment in this approach would lay the groundwork for future programs; we would not expect to see quality improvements based on this investment alone. This program could be expensive, and would likely require some kind of matching funds from the medical groups or physicians.

9. Outsourcing Disease Management Functions

There is a private market to deliver elements of chronic care management to patients; usually, remote nurses deliver care over the telephone to the sickest patients. Disease management companies have had a difficult time coordinating their work with practicing physicians, and this approach could really only show significant success if the medical groups embraced the programs. The medical literature shows disease management programs improving outcomes in some of the conditions measured for Pay for Performance, but these programs are developed and implemented in either academic medical centers or integrated delivery systems (such as Kaiser Permanente). The programs implemented in the delegated group model of California medicine have not been studied. These programs would likely be expensive to purchase, though there might be opportunities for health plans to subsidize these costs.


III. Medical Group Interview Responses

Understanding the Pay for Performance Initiative

Most medical groups were aware of the Pay for Performance initiative, with thirteen of fifteen groups stating that they knew about the initiative. Of these thirteen, ten felt well briefed, and three felt that they needed additional information in order to understand the initiative more fully. Only two medical groups had not heard of the initiative; both these groups were small in size, with one group located in a remote part of the state and the other serving an ethnically diverse population in an urban area. Of the fifteen groups, thirteen stated that they would be participating in the initiative, and two had not decided. The two that had not decided were the same groups that had not previously heard of Pay for Performance. Of the thirteen groups that said that they plan to participate, three felt that they had no choice, as it is “participation by default.” One group said that they plan to participate only if there are significant changes in how data is collected from the health plans.

When questioned about the potential financial incentives, five groups stated that the incentives justified investing internal quality improvement resources to effectively participate in the initiative. Nine groups either haven’t decided whether the incentives are adequate, or need additional, specific information about the incentives in order to make a decision. One group said that the incentives are not large enough to justify investment.

Seven out of fifteen groups stated that the Pay for Performance Initiative is significantly affecting their QI agenda. Five of those groups said it is influencing them already, and two said they expected the influence to increase in the near future. Seven groups stated that their agenda is not influenced at all by Pay for Performance. Most of these groups stated that this is because their quality improvement work is already in alignment with the Pay for Performance measures, and therefore changes are not required to their QI agenda. As a result, almost all medical groups interviewed currently have or are moving toward an agenda that mirrors the performance measures of the Pay for Performance initiative.

While the Pay for Performance is significantly influencing many medical groups’ work, it is important to note that there are other forces that also motivate quality improvement initiatives. Groups mentioned three other main motivators for selecting a new initiative: clinical or cost data


indicates the need for a new program (nine groups); the Quality Committee or Board selects a new initiative (three groups); or there is an identified need in the community for a new program (three groups).

Overall, the groups appear well informed and motivated to participate in the Pay for Performance initiative. There is some skepticism about the amount of financial incentives available for payout, but this does not seem to be deterring participation.

Medical Group Preparedness for the Pay for Performance Initiative

The majority of groups are already engaged in some level of formal preparation for the initiative, with eleven of fifteen groups already actively preparing. The most common types of activities are making presentations to medical group boards, creating an oversight group or task force, meeting with health plans, and performing an audit of 2002 data. Some groups have also hired a consultant to clean and analyze their data in order to be prepared for the 2003 measurement process.

Every medical group has some quality improvement initiatives of their own in the works that are to be used to improve performance on the clinical quality measures. These activities range from disease-specific population management programs to expansion of technology infrastructure. Out of fifteen groups, thirteen have some type of disease-specific program, with the most common disease being diabetes (twelve out of thirteen groups). Current diabetes activities include contracting with an outside vendor and participation in the DCQI Collaborative. Technology activities include expanding a clinical data warehouse and installing an electronic medical record. Also mentioned were increased focus on HEDIS measures, chart reviews, and customer satisfaction initiatives.

Despite the fact that all groups have QI programs, less than half (six of fifteen) of the groups have a registry in one of the six clinical conditions measured in Pay for Performance. Of the groups with registries, five of the six are located in Northern California. All six of the groups with registries have at least a diabetes registry; some have registries in other conditions such as asthma, childhood immunizations, and mammography. Five groups have no registry now, but are either building one or have plans to do so. Four groups have no registry and do not have plans to create one. When comparing urban to rural groups, none of the rural groups in the sample have active registries.

Medical Group Demand for Technical Assistance

Clinical Priorities

Groups were asked to rank their top three clinical priorities from the list of six clinical areas to be measured in the Pay for Performance initiative (asthma, childhood immunizations, coronary artery disease [CAD], diabetes, mammography, and Pap smears). Diabetes was by far the highest ranked condition, with fourteen out of fifteen including it in their list of top three, and ten ranking it the highest. The next highest ranked condition was CAD, with ten groups including it as one of their top three conditions; two ranking it as the highest, and four ranking it as second highest. Results are summarized in Table 1.


Table 1: Ranking of Clinical Priority Areas

Condition Total Points Diabetes 37 CAD 18 Asthma 12 Childhood immunizations 10 Mammography 10 Pap smears 2 Note: Condition ranked first in importance was assigned three points, second was assigned two points, and third was assigned one point for each medical group. Scores were summed across all medical groups. Highest possible score assigned would be 45 points if all fifteen groups assigned the highest ranking (three points) to this condition.

Technical Assistance Options A variety of technical assistance resources could be made available to assist medical groups in meeting their clinical goals, with varying degrees of effectiveness. In addition to being clinically effective, technical assistance should be cost effective, should be scalable across widely dispersed physician offices, and should also be in demand by the medical groups. A range of technical assistance options is evaluated across these domains and presented in Table 2.

Table 2. Summary of Technical Assistance Interventions

Intervention Supporting Evidence / Information

Time Interval for Improvement* Scalability

Expected Costs

Medical Group Demand

Intensive collaboration (modeled on the IHI Break-through Series approach

Participating organizations achieved substantial in-creases in evidence-based practice and, in diabetes, improvements in glycemic control a

Medium Medium High Low

Facilitated collaboration (modeled on the CCHRI Diabetes CQI Project)

In one major collaborative (ICSI), all participating organizations demon-strated significant, measurable improvements in quality of care and health outcomes b

Long Medium Medium High

Day-long QI staff workshops

- CME events of one day or less generally effect no change. Combining educational materials and CME enhances effectiveness, as do peer discussions and “practice rehearsals” c - Printed materials only do not effect changes in performance or health outcomes d

Long Medium Low High

Day-long physician workshops

See “Daylong QI staff workshops” above

Long Medium Low Medium

Table continues * Short = 6 months or less; Medium = 6–18 months; Long = 18 months+ a Wagner, E.H. et al., “Improving chronic illness care: Translating evidence into action,” Health Affairs, 2002, 20(6): 64–78. b Oswald, N., Structured Collaboratives: Accelerating Quality Improvement in California, California HealthCare Foundation, 2002. c Davis, D.A. et al., 1995. d Oxman, A.D. et al., “No magic bullets: A systematic review of 102 trials of interventions to improve professional practice,” CMAJ, 1995, 153(1): 1423–31. e American Medical Association Web site. Report excerpt: “2002 AMA Study on Physicians’ Use of the World Wide Web,” 2002. f Health Technology Center, PriceWaterhouse Coopers, Institute for the Future. Survey on Internet Use by Medical Groups, March 2002. g E-Disease Management, California HealthCare Foundation, 2001.


Table 2. Summary of Technical Assistance Interventions (continued)



Expected Costs


On-site technical assistance (provided to medical groups by means of QI experts, data systems specialists, or other clinical management consultants)

Efficacy highly dependent upon source delivering intervention

Medium Low High High

Audit of data source codes and analysis of 2002 results

Short, depending on how information used

Medium Medium High

Web portal of QI materials

Almost half of all physicians report that the Internet has had a major impact on the way they practice medicine e

- 78% of physicians now make use of the Internet - Two-thirds of online physicians access the Web daily, an increase of 24% since 1997

Long High - High, if IHI - Medium, if internal

Low

Table continues * Short = 6 months or less; Medium = 6–18 months; Long = 18 months+ a Wagner, E.H. et al., “Improving chronic illness care: Translating evidence into action,” Health Affairs, 2002, 20(6): 64–78. b Oswald, N., Structured Collaboratives: Accelerating Quality Improvement in California, California HealthCare Foundation, 2002. c Davis, D.A. et al., 1995. d Oxman, A.D. et al., “No magic bullets: A systematic review of 102 trials of interventions to improve professional practice,” CMAJ, 1995, 153(1): 1423–31. e American Medical Association Web site. Report excerpt: “2002 AMA Study on Physicians’ Use of the World Wide Web,” 2002. f Health Technology Center, PriceWaterhouse Coopers, Institute for the Future. Survey on Internet Use by Medical Groups, March 2002. g E-Disease Management, California HealthCare Foundation, 2001.


Table 2. Summary of Technical Assistance Interventions (continued)



Expected Costs


Expanding technological capabilities (such as provider computer connectivity, clinical decision support, or other information technology resources)

- Expanding technological capability creates an infrastructure for future QI activities; alone it is unlikely to change provider behavior - Half of provider groups utilize the Internet to access guidelines or protocols; approximately 30% use the Internet to communicate with patients.f

Medium Low High Medium

Outsourcing disease management functions

About 20% of health plans continue to build in-house programs, with 40% outsourcing in some way to a disease management company, and 25% using a program that involves a pharmacy benefits manager. The remainder administer programs through some combination of these options.g

Short High High Low

* Short = 6 months or less; Medium = 6–18 months; Long = 18 months+ a Wagner, E.H. et al., “Improving chronic illness care: Translating evidence into action,” Health Affairs, 2002, 20(6): 64–78. b Oswald, N., Structured Collaboratives: Accelerating Quality Improvement in California, California HealthCare Foundation, 2002. c Davis, D.A. et al., 1995. d Oxman, A.D. et al., “No magic bullets: A systematic review of 102 trials of interventions to improve professional practice,” CMAJ, 1995, 153(1): 1423–31. e American Medical Association Web site. Report excerpt: “2002 AMA Study on Physicians’ Use of the World Wide Web,” 2002. f Health Technology Center, PriceWaterhouse Coopers, Institute for the Future. Survey on Internet Use by Medical Groups, March 2002. g E-Disease Management, California HealthCare Foundation, 2001.


This list of technical assistance options was presented to the medical groups (with supplemental descriptions of any options not familiar to the interviewee), and the groups were asked to select the three highest-ranking options for their group. Of the nine technical assistance options presented, the groups did not demonstrate a strong preference for any one method. The highest-ranking option was the audit of data source codes and analysis of 2002 results, with the next highest-ranking choices facilitated collaboration, daylong workshops, and on-site technical assistance. The ranking is presented in Table 3.

Table 3: Ranking of Technical Assistance Resources

Technical Assistance Resource Total Points Audit of data source codes and analysis of 2002 results 17 Facilitated collaboration 14 Day-long QI staff workshops 12 On-site technical assistance 12 Expanding technological capabilities 10 Day-long physician workshops 5 Intensive collaboration 4 Outsourcing disease management functions 3 Web portal of QI materials 1 Note: TA resource ranked first in importance was assigned three points, second was assigned two points, and third was assigned one point for each medical group. Scores were summed across all medical groups. Highest possible score assigned would be 45 points if all fifteen groups assigned the highest ranking (three points) to this resource.

We also asked the medical groups about the sources of technical assistance from which they would feel most comfortable receiving help (i.e., confident about the entity’s capabilities and comfortable with their motives and intentions).

The groups were asked to rank a list of eight potential sources, from highest to lowest, based on perceived credibility, trustworthiness, and caliber of work. Again, there is no clear leader; the scores appear to be fairly evenly distributed. The highest-ranking source was quality improvement experts provided or organized by the California HealthCare Foundation, with two out of fifteen ranking this the highest, and three out of fifteen ranking it second highest. The respondents acknowledged that CHCF does not offer internal expertise in this area, but the Foundation was cited as a reliable source of impartial and highly capable resources and assistance. Next highest rated were the California Cooperative Healthcare Reporting Initiative (CCHRI) and medical group and physician trade associations (such as CAPO and TIPAAA), followed by CMRI (California Medical Review Inc.). The medical groups rated health plans by far the lowest of the eight potential resources. The results are summarized in Table 4.


Table 4: Ranking of Sources of Technical Assistance

Source Total Points QI experts through CHCF 78 CCHRI 65 Medical group/physician associations 65 CMRI 59 QI experts through IHA 54 Consulting firms 49 Other medical groups 43 Health plans 21 Note: Source ranked first in importance was assigned eight points, second was assigned seven points, and so on, with the least important source awarded one point for each medical group. Scores were summed across all medical groups. Highest possible score assigned would be 120 points if all fifteen groups assigned the highest ranking (eight points) to this resource.


IV. Assessing Medical Groups’ Readiness for Pay for Performance

It is clear from the medical group interviews that simply offering assistance to groups does not guarantee that they will use it effectively. Groups must also be motivated to change their organization, be comfortable using outside resources, and have a group infrastructure that supports potentially complex quality improvement work.

Many groups do have a level of skepticism about the Pay for Performance Initiative, specifically about the amount of incentives available for payout, and whether this is “new money” above and beyond their existing capitation payments. It is yet to be determined whether this skepticism will affect motivation and interfere with the ability to actively and effectively engage in the initiative. Overall, most groups do seem motivated to engage in the initiative, although the level of motivation ranges along a spectrum of very active to very passive involvement. Of the fifteen groups, twelve demonstrated their motivation by stating that they could participate in more than one project at a time if required.

Using outside resources does not appear to be a barrier for groups, as most have used some form of external assistance in QI efforts. In the fifteen groups, the most commonly used outside resource is consultants, with nine groups stating that they are using them or have used them in the past. Experiences with consultants are largely positive, although many groups point out that consultants are best used when selected for specific expertise, and used in a targeted manner. The next most common resource is CCHRI, including the Diabetes CQI Project, with seven of fifteen groups using them. Other resources cited were CMRI, pharmacy companies, and disease management vendors. Of the fifteen groups, ten groups had no concerns about working with and sharing their quality improvement methods with other medical groups. Of the five groups that did have concerns, the largest concern was sharing information with directly competing medical groups. An additional concern is jeopardizing patient confidentiality.

To engage in the type of quality improvement needed for the Pay for Performance initiative, groups must have a fairly sophisticated infrastructure. This includes high-level management support of the initiative, a staff well trained in quality improvement methods, and access to


accurate, current clinical data. One of the most common ways of delivering this data to clinicians is in the form of a registry; as noted earlier, less than half of the groups have active, credible registries. This may prove to be a significant barrier to medical groups as they launch their Pay for Performance work.

It is important to note that implementation of a well defined, usable registry must occur in three phases. First, accurate, current data needs to be collected from various sources, such as claims, pharmacy, and labs. This is a lengthy, complicated endeavor that typically requires extensive time and resources. Next, the data must be collected into a data management infrastructure at the medical group level; this is typically where data is collated into some type of registry. Finally, the data must be distributed to clinicians in a way that will allow them to use the data effectively. This may require extensive training and communication with both physicians and patients throughout the distribution process. Despite the critical nature of this step, it is frequently overlooked or not considered important by the groups.


V. Conclusion

The Pay for Performance Initiative is receiving significant attention at the medical group level and is likely to drive much of the quality improvement activities and behavior over the next several years. Although many groups expressed skepticism about the total financial payout (and whether this program will lead to lower guaranteed capitation payments), almost all groups intend to participate in the initiative, and most are taking steps to prepare their physicians for the project. Despite their lack of knowledge about specifics, several groups said that if they see a business case for the efforts, they will invest significant resources in Pay for Performance.

All medical groups are engaged in quality improvement activities but are actively seeking ways to increase the effectiveness of their programs. The highest priority conditions among the IHA priority conditions are diabetes and CAD; almost every group has already implemented some type of diabetes intervention. Groups appear open to most types of technical assistance, exhibiting the strongest interest in educational workshops for QI staff, facilitated quality improvement collaboratives, and receiving audits on their current data.

Despite the emphasis on data, there is a relative dearth of registries in medical groups. Several groups that do not have a registry are making plans to build one. However the extent of the plan typically stops with the collection of data into a group infrastructure. A potential area for technical assistance is the complete registry development process: not only obtaining data and creating an infrastructure but also educating providers.


Appendix A: Interview Guide for Medical Groups

Category Question 1. Do you know about the Integrated Healthcare Association (IHA) Pay for

Performance (P4P) initiative? Do you feel well briefed about P4P?

I. IHA Pay for Performance Initiative

2. Do you plan to participate in the P4P initiative?

3. Are the financial incentives of P4P large enough to influence your design priorities or clinical resource allocation?

4. What are you doing to prepare for P4P?

II. Current QI Activities

5. What QI initiatives do you have underway right now? Which initiatives do you expect to implement in the next 1 to 3 years?

6. How much is P4P influencing your QI agenda for 2002–2003? Is that likely to change in the future?

7. Aside from P4P, what are the main motivators for selecting new QI projects?

8. Which of the following clinical areas are priorities for your organization? Rank the top three, with 1 being the area that is the highest priority for your

group: • Asthma • Childhood immunizations • Coronary artery disease • Diabetes • Mammography • Pap smears

9. Do you use a registry to manage the population in any of these six clinical areas? If yes, which ones?

10. Would your group likely embark on more than one new QI project for P4P, given staff resources?

11. What other major projects or initiatives will P4P QI activities compete with for time and resources?

III. Use of Outside Resources

12. What resources would you most likely use in preparing for P4P? Please rank the top three resources, with 1 being the intervention that you would most likely use. • Institute for Healthcare Improvement Breakthrough

Series Collaborative, which utilizes a standardized method of rapid change cycles and frequent written and telephonic reporting to drive and share progress across health care organizations.

Table continues


Appendix A: Interview Guide for Medical Groups (continued)

Category Question III. Use of Outside

Resources (continued)

• Collaborative quality improvement programs (e.g., Diabetes CQI), which bring together health care organizations such as medical groups through monthly tele- conference and quarterly in-person meetings to facilitate QI improvements in P4P clinical condition areas

• Day-long workshops on concepts of chronic care management, including registry development

• CMEs/educational workshops for physicians on clinical practice guidelines and QI best practices

• On-site technical assistance through quality improvement experts or data system consultants

• Audit of data source codes and reporting system for P4P scores, using 2002 data as “dry run” for 2003

• Web portal of quality improvement materials

• Expanding technological capabilities such as provider computer connectivity and free or reduced-price software

• Outsourcing of disease management services to private companies

• Other:

13. What other QI resources would you be interested in utilizing at your group?

14. From what sources would you most trust outside assistance?

Please rank the sources from 1 to 8, with 1 being the most trustworthy source for assistance to your group:

• California Medical Review, Inc. (CMRI)—i.e., government-sponsored quality improvement organizations

• California Cooperative Healthcare Reporting Initiative (CCHRI)—i.e., purchaser-sponsored quality improvement organizations

• Health plans—list any specific plans to include/exclude

• Consulting firms

• Medical group and physician associations, such as CAPO, MGMA, and TIPAAA

• Quality improvement experts made available by the California HealthCare Foundation (CHCF)

Table continues


Appendix A: Interview Guide for Medical Groups (continued)

Category Question • Quality improvement experts made available by the IHA III. Use of Outside

Resources (continued) • Other medical groups

15. Do you have any concerns about sharing your quality improvement methods with other medical groups? If yes, elaborate.

16. Do you have experience in using outside resources (such as collaboratives, consultants, etc.) for quality improvement initiatives?

17. If CHCF invests resources in P4P technical assistance, would you prefer that they subsidize your group’s learning how to do QI work internally, or assist in purchasing existing programs from outside vendors?

18. Approximately how much would your medical group be willing to pay for your top-ranked type of technical assistance (as stated in Question 12) with the P4P initiative (assume one year of technical assistance)?


Appendix B: List of Interviewees

Organization Name Title Medical Groups Brown & Toland Medical Group Fred Whinery, M.D.

Tammy Fisher Medical Director Quality Improvement Director

Buenaventura Medical Clinic John Keats, M.D. Medical Director Chinese Community Health Care Association

Edward Chow, M.D. Sandi Deckinger

Medical Director Quality Improvement Director

Delta IPA Medical Group, Inc. Cindy Scantling Quality Improvement Director Hemet Community Medical Group, Inc.

Alex Denes, M.D. Medical Director

Humboldt Del Norte IPA Medical Group, Inc.

Alan Glaseroff, M.D. Medical Director

Individual Practice Assoc. Medical Group of Santa Clara County, Inc.

Lawrence William, M.D. Medical Director

John Muir/Mt. Diablo Health Network Foundation

Michael Kern, M.D. Terri Jagow


La Vida Medical Group and IPA Martin Coyne, M.D. Kim Hall


Monarch Healthcare, A Medical Group

Ray Chicoine Shirley Nelson

Vice President, Operations Quality Improvement Director

Palo Alto Medical Foundation Terrigal Burn, M.D. Tomas Moran


Physician Associates of San Gabriel Valley, A Medical Group

Harry Magnus, M.D. Cathie Jaegge


San Jose Medical Group, Inc. Dean Didech, M.D. Medical Director Sante Community Physicians IPA Medical Corp.

Daniel Bluestone, M.D. Sue Essman


Sharp Community Medical Group, Inc.

John Jenrette, M.D. Nancy St. Germain


Other Sources California Association of Physicians Organizations (CAPO)

Don Crane Dirk Thornley

Executive Director Vice President

Cattaneo & Stroud Grant Cattaneo Independent Consultant Nancy Oswald Institute for Healthcare Improvement Andrea Kabcenel Integrated Healthcare Association Beau Carter Executive Director Intelligent Healthcare Paul Katz CEO Medical Management Services Walter Kopp President MEDSTAT David Shechter The IPA Association of America (TIPAAA)

Albert Holloway* President & CEO

* Attended two in-person TIPAAA meetings and obtained feedback directly from members. Organizations represented at meetings included: Children’s Hospital, Excel MSO, Marin IPA, PMG of Santa Cruz (Oakland) and Arcadian Management, Blue Cross/Blue Shield, Employee Health Sys., Meridian HC Management, Phoenix Healthcare, South Bay IPA, St. Mary Choice, and Torrance Hospital IPA (Los Angeles).

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