Small and medium-size physician practices use few patient-centered medical home processes.

The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

Relationship between quality improvement processes and clinical performance.

OBJECTIVES: To examine the association between performance on clinical process measures and intermediate outcomes and the use of chronic care management processes (CMPs), electronic medical record (EMR) capabilities, and participation in external quality improvement (QI) initiatives. STUDY DESIGN: Cross-sectional analysis of linked 2006 clinical performance scores from the Integrated Healthcare Association's pay-for-performance program and survey data from the 2nd National Study of Physician Organizations among 108 California physician organizations (POs). METHODS: Controlling for differences in PO size, organization type (medical group or independent practice association), and Medicaid revenue, we used ordinary least squares regression analysis to examine the association between the use of CMPs, EMR capabilities, and external QI initiatives and performance on the following 3 clinical composite measures: diabetes management, processes of care, and intermediate outcomes (diabetes and cardiovascular). RESULTS: Greater use of CMPs was significantly associated with clinical performance: among POs using more than 5 CMPs, we observed a 3.2-point higher diabetes management score on a performance scale with scores ranging from 0 to 100 (P <.001), while for each 1.0-point increase on the CMP index, we observed a 1.0-point gain in intermediate outcomes (P <.001). Participation in external QI initiatives was positively associated with improved delivery of clinical processes of care: a 1.0-point increase on the QI index translated into a 1.4-point gain in processes-of-care performance (P = .02). No relationship was observed between EMR capabilities and performance. CONCLUSION: Greater investments in CMPs and QI interventions may help POs raise clinical performance and achieve success under performance-based accountability schemes.

Higher health care quality and bigger savings found at large multispecialty medical groups.

The belief that integrated delivery systems offer better care at lower cost has contributed to growing interest in accountable care organizations. These provider-led delivery systems would accept responsibility for their primary care populations and would have financial incentives for improving care and reducing costs. We investigated this belief by comparing the costs and quality of care provided to Medicare beneficiaries in twenty-two health care markets by physicians who did and did not work within large multispecialty group practices affiliated with the Council of Accountable Physician Practices. In most markets, and after adjustment for patient factors, group physicians affiliated with the council provided higher-quality care at a 3.6 percent lower annual cost ($272 per patient).

Improving chronic illness care: findings from a national study of care management processes in large physician practices.

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations-medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

Quality-based payment for medical groups and individual physicians.

This paper measures the extent to which medical groups experience external pay-for-performance incentives based on quality and patient satisfaction and the extent to which these groups pay their primary care and specialist physicians using similar criteria. Over half (52%) of large medical groups received bonus payments from health insurance plans in the period 2006-2007 based on measures of quality and patient satisfaction. Medical groups facing external pay-for-performance incentives are more likely to pay their primary care physicians (odds ratio [OR] 4.5; p<.001) and specialists (OR 2.5; p=.07) based on quality and satisfaction. Groups facing capitation payment incentives to control costs are more likely to pay member physicians on salary and less likely to pay based on productivity (p<.001 for primary care; p<.05 for specialists) than groups paid by insurers on a fee-for-service basis.

Is integration in large medical groups associated with quality?

OBJECTIVE: To test the relationship between the presence of recommended chronic care model systems and the degree of integration among large medical groups. STUDY DESIGN: Cross-sectional survey in 2007 completed by medical directors of medical groups nationally with at least 100 physicians and a range of medical services and who had also participated in the National Survey of Physician Organizations. METHODS: We recruited 111 medical directors among 123 who were eligible. The survey asked about the medical group's structural, financial, and functional aspects of integrated care, as well as the presence and use of practice systems for chronic disease care as measured by the Physician Practice Connections-Readiness Survey (PPC-RS). The analysis tested the association between integration measures and the presence of practice systems, controlling for medical group attributes. RESULTS: Ninety-seven completed surveys were returned (89.0% of 109 medical directors eligible). Measures of integration and practice systems varied widely among the medical groups. The total PPC-RS score correlated with each measure of integration but most highly with functional integration (r = 0.53, P <.01). The strongest PPC-RS component score correlations were for delivery systems redesign (r = 0.27-0.52, P <.01) and for decision support (r = 0.21-0.46, P <.05). Adjusting for organizational characteristics had little effect on these relationships. CONCLUSION: As measured by these scales, integration seems to be related to the presence of practice systems components of the chronic care model, although simply having the potential for integration (structure and finance) is much less strongly related than evidence of functional integration.

Financial incentives, quality improvement programs, and the adoption of clinical information technology.

OBJECTIVE: Physician use of clinical information technology (CIT) is important for the management of chronic illness, but has lagged behind expectations. We studied the role of health insurers' financial incentives (including pay-for-performance) and quality improvement initiatives in accelerating adoption of CIT in large physician practices. METHODS: National survey of all medical groups and independent practice association (IPA) physician organizations with 20 or more physicians in the United States in 2006 to 2007. The response rate was 60.3%. Use of 19 CIT capabilities was measured. Multivariate statistical analysis of financial and organizational factors associated with adoption and use of CIT. RESULTS: Use of information technology varied across physician organizations, including electronic access to laboratory test results (medical groups, 49.3%; IPAs, 19.6%), alerts for potential drug interactions (medical groups, 33.9%; IPAs, 9.5%), electronic drug prescribing (medical groups, 41.9%; IPAs, 25.1%), and physician use of e-mail with patients (medical groups, 34.2%; IPAs, 29.1%). Adoption of CIT was stronger for physician organizations evaluated by external entities for pay-for-performance and public reporting purposes (P = 0.042) and for those participating in quality improvement initiatives (P < 0.001). DISCUSSION: External incentives and participation in quality improvement initiatives are associated with greater use of CIT by large physician practices.

Measuring the medical home infrastructure in large medical groups.

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.

The impact of health plan delivery system organization on clinical quality and patient satisfaction.

OBJECTIVES: The purpose of this study was to examine the extent to which measures of health plan clinical performance and measures of patient perceptions of care are associated with health plan organizational characteristics, including the percentage of care provided based on a group or staff model delivery system, for-profit (tax) status, and affiliation with a national managed care firm. DATA SOURCES: Data describing health plans on region, age of health plan, for-profit status, affiliation with a national managed care firm, percentage of Medicare business, total enrollment, ratio of primary care physicians to specialists, HMO penetration, and form of health care delivery system (e.g., IPA, network, mixed, staff, group) were obtained from InterStudy. Clinical performance measures for women's health screening rates, child and adolescent immunization rates, heart disease screening rates, diabetes screening rates, and smoking cessation were developed from HEDIS data. Measures of patient perceptions of care are obtained from CAHPS survey data submitted as Healthplan Employer Data and Information Set, Consumer Assessment of Health Plans 2.0 H. STUDY DESIGN: Multivariate regression cross-sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics with measures of clinical performance and patient perceptions of care. PRINCIPAL FINDINGS: The form of delivery system, measured by percent of care delivered by staff and group model systems, is significantly related (p < or = .05) with four of the five clinical performance indices but none of the three satisfaction performance indices. Other variables significantly associated with performance were being geographically located in the Northeast, having nonprofit status, and for patient satisfaction, not being part of a larger insurance company. CONCLUSIONS: These comparative results provide evidence suggesting that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. These findings underscore the importance of the form of the delivery system and the need for further inquiry that examines the relationship between organizational form and performance.

The routine use of health risk appraisals: results from a national study of physician organizations.

PURPOSE: To document use of health risk appraisals (HRAs) by U.S. physician organizations as part of their overall approach to health promotion and to identify associated organizational characteristics. METHODS: Telephone survey of 1590 physician organizations in the United States; surveys were conducted in organizations comprising 20 or more physicians and were conducted between September 2000 and September 2001 (70% response rate). Chi-square tests and logistic regression analysis were used to examine the association between organizational characteristics and routine administration of HRAs. RESULTS: Only 22.5% of physician organizations in the United States routinely administer HRAs. External quality incentives, information technology capabilities, and status as a medical group vs. an independent practice association are associated with greater odds of the routine use of HRA. DISCUSSION: Increased use of external quality incentives and information technology in physician organizations may be important in supporting the use of HRAs.

Brief report: The prevalence and use of chronic disease registries in physician organizations. A national survey.

OBJECTIVE: Disease registries are lists of patients with a particular chronic illness, including clinical information, to improve the care of individuals and populations. The objective of this study was to determine the prevalence of disease registries in physician organizations and the extent to which they are used to improve care. DESIGN: A cross-sectional national telephone survey with a response rate of 70%. SETTING: All physician organizations in the United States with 20 physicians or more. PARTICIPANTS: Chief executive officers, presidents, or medical directors of 1040 physician organizations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-seven percent of organizations reported having a registry for at least 1 chronic illness, with diabetes registries being the most common. Half (51%) of the registries were not linked to clinical data. Organizations with at least 1 registry were more likely to have implemented other chronic care improvements (P < .0001). Factors associated with the presence of registries in physician organizations include external incentives for quality and extent of information technology capabilities. CONCLUSIONS: Disease registries are not utilized by half of physician organizations. This finding is disturbing because registries have the potential to catalyze needed improvement in chronic care management.

An empirical assessment of high-performing medical groups: results from a national study.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performing medical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

The use of patient and physician reminders for preventive services: results from a National Study of Physician Organizations.

BACKGROUND: Clinical preventive services improve patient health, and reminder systems can increase the use of such services. However, physician organizations often underutilize clinical preventive service reminders. Little is known about the incentives, capabilities, and organizational characteristics associated with the use of reminders by physician organizations. METHODS: The predictors of patient and physician reminder system use were examined in a sample of 1,104 US physician organizations. The cross-sectional sample was obtained through a telephone survey with a 70% response rate. RESULTS: Fifty-one percent of physician organizations used mammogram reminders, 41% used influenza immunization reminders, and 26% used eye exam reminders for patients. Eighteen percent of physician organizations used computer-generated reminders to physicians. Required reporting of data (P = 0.0006), public recognition for quality (P = 0.0002), and IT capabilities (P < 0.0001) were strongly associated with patient reminder use. Medical groups were more likely to use patient-level reminders than independent practice associations (IPAs) (P < 0.0001). Physician reminder use was related to required reporting of data (P < 0.0001) and IT capabilities (P < 0.0001). CONCLUSIONS: Physician organizations have relatively low use of preventive service reminders to patients and physicians. Offering quality incentives to physician organizations and improving their IT capabilities may increase the use of preventive service reminders and improve the delivery of preventive care.

What are the facilitators and barriers in physician organizations' use of care management processes?

BACKGROUND: Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs. METHODS: Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities. RESULTS: Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy. DISCUSSION: Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.

Organizational factors affecting the adoption of diabetes care management processes in physician organizations.

OBJECTIVE: To describe the extent of adoption of diabetes care management processes in physician organizations in the U.S. and to investigate the organizational factors that affect the adoption of diabetes care management processes. RESEARCH DESIGN AND METHODS: Data are derived from the National Survey of Physician Organizations and the Management of Chronic Illness, conducted in 2000-2001. A total of 1,104 of the 1,590 physician organizations identified responded to the survey. The extent of adoption of four diabetes care management processes is measured by an index consisting of the organization's use of diabetic patient registries, clinical practice guidelines, case management, and physician feedback. The ordinary least-squares model is used to determine the association of organizational characteristics with the adoption of diabetes care management processes in physician organizations. A logistic regression model is used to determine the association of organizational characteristics with the adoption of individual diabetes care management processes. RESULTS: Of the 987 physician organizations studied that treat patients with diabetes, 48% either do not use any or use only one of the four diabetes care management processes. A total of 20% use two care management processes, and 32% use three or four processes. External incentives to improve quality, computerized clinical information systems, and ownership by hospitals or health maintenance organizations are strongly associated with the diabetes care management index and the adoption of individual diabetes care management processes. CONCLUSIONS: Policies to encourage external incentives to improve quality and to facilitate the adoption of computerized clinical information technology may promote greater use of diabetes care management processes.

Support for smoking cessation interventions in physician organizations: results from a national study.

OBJECTIVES: To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization. CONCLUSION: Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases.

CONTEXT: Organized care management processes (CMPs) can improve health care quality for patients with chronic diseases. The Institute of Medicine of the National Academy of Sciences has called for public and private purchasers of health care to create incentives for physician organizations (POs) to use CMPs and for the government to assist POs in implementing information technology (IT) to facilitate CMP use. Research is lacking about the extent to which POs use CMPs or about the degree to which incentives, IT, or other factors are associated with their use. OBJECTIVES: To determine the extent to which POs with 20 or more physicians use CMPs and to identify key factors associated with CMP use for 4 chronic diseases (asthma, congestive heart failure, depression, and diabetes). DESIGN, SETTING, AND PARTICIPANTS: One thousand five hundred eighty-seven US POs (medical groups and independent practice associations) with 20 or more physicians were identified using 5 large databases. One thousand one hundred four of these POs (70%) agreed to participate in a telephone survey conducted between September 2000 and September 2001. Sixty-four responding POs were excluded because they did not treat any of the 4 diseases, leaving 1040 POs. MAIN OUTCOME MEASURES: Extent of use of CMPs as calculated on the basis of a summary measure, a PO care management index (POCMI; range, 0-6) and factors associated with CMP use. RESULTS: Physician organizations' mean use of CMPs was 5.1 of a possible 16; 50% used 4 or fewer. External incentives and clinical IT were most strongly associated with CMP use. Controlling for other factors, use of the 2 most strongly associated incentives-public recognition and better contracts for health care quality-was associated with use of 1.3 and 0.7 additional CMPs, respectively (P<.001 and P =.007). Each additional IT capability was associated with 0.37 additional CMPs (P<.001). However, 33% of POs reported no external incentives and 50% reported no clinical IT capability. CONCLUSIONS: The use of CMPs varies greatly among POs, but it is low on average. Government and private purchasers of health care may increase CMP use by providing external incentives for improvement of health care quality to POs and by assisting them in improving their clinical IT capability.

How different is California? A comparison of U.S. physician organizations.

Data from a national study of medical groups and independent practice associations are used to examine the extent to which California physician organizations are different from physician organizations in the rest of the United States. California physician organizations are different in many ways: most notably, they are more likely to have external incentives to improve quality and more likely to use recommended care management processes for treating patients with chronic illnesses. The implications of these differences for policy and practice are discussed.