A field experiment on the impact of physician-level performance data on consumers' choice of physician.

BACKGROUND: In 2008, HealthPlus of Michigan introduced an online primary care provider (PCP) report that displays clinical quality data and patients' ratings of their experiences with PCPs on a public web site. DESIGN AND PROCEDURE: A randomized encouragement design was used to examine the impact of HealthPlus's online physician-quality report on new plan members' choice of a PCP. This study evaluated the impact of an added encouragement to utilize the report by randomizing half of new adult plan members in 2009-2010, who were required to select a PCP (N=1347), to receive a 1-page letter signed by the health plan's chief medical officer emphasizing the importance of the online report and a brief phone call reminder. We examined the use of the report and the quality of PCPs selected by participants. RESULTS: Twenty-eight percent of participants in the encouragement condition versus 22% in the control condition looked at the online report before selecting a PCP. Although participants in the encouragement condition selected PCPs with higher patient experience ratings than did control participants, this difference was not explained by their increased likelihood of accessing the online report. CONCLUSIONS: Health plan members can be encouraged successfully to access physician-level quality data using an inexpensive letter and automated phone call. However, a large proportion of missing data in HealthPlus's online report may have limited the influence of the physician-quality report on consumer choice.

The current state of quality of care measurement in the California Department of Corrections and Rehabilitation.

The quality of health care in prisons is lacking in many states. In particular, the California Department of Corrections and Rehabilitation (CDCR) is in the midst of an extreme legal remedy to address problems related to access to and quality of care; it now operates under the direction of a federally appointed receiver for medical care. To understand the current state of access and quality measurement and to assess strengths and weaknesses of current activities, the RAND Corporation conducted a series of interviews and site visits in the CDCR and related offices as well as document reviews (December 2008 to February 2009). Findings supported RAND's larger project goals to identify measures for use in a sustainable quality measurement system.

A review of quality measures used by state and federal prisons.

In response to deficiencies in the delivery of health care in prisons, a number of state correctional systems and the Federal Bureau of Prisons (BOP) have established quality of care monitoring systems. In 2009, the California Department of Corrections and Rehabilitation and the federal receiver overseeing the system asked the RAND Corporation to identify existing indicators of quality performance and to recommend a set of indicators applicable to the prison population. An environmental scan of quality measures being used by other state correctional systems and the BOP found substantial variation in the number and type of measures being used and the underlying data systems used to construct measures. Explicit quality measures were being used, as were measures of disease prevalence and standards.

Selecting performance indicators for prison health care.

Improving prison health care requires a robust measurement dashboard that addresses multiple domains of care. We sought to identify tested indicators of clinical quality and access that prison health managers could use to ascertain gaps in performance and guide quality improvement. We used the RAND/UCLA modified Delphi method to select the best indicators for correctional health. An expert panel rated 111 indicators on validity and feasibility. They voted to retain 79 indicators in areas such as access, cardiac conditions, geriatrics, infectious diseases, medication monitoring, metabolic diseases, obstetrics/gynecology, screening/prevention, psychiatric disorders/substance abuse, pulmonary conditions, and urgent conditions. Prison health institutions, like all other large health institutions, need robust measurement systems. The indicators presented here provide a basic library for prison health managers developing such systems.

Taking stock of pay-for-performance: a candid assessment from the front lines.

Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician organizations involved in the California Integrated Healthcare Association's (IHA) P4P program reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened their organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future.

Pay for performance in the hospital setting: what is the state of the evidence?

More than 40 private sector hospital pay-for-performance (P4P) programs now exist, and Congress is considering initiating a Medicare hospital P4P program. Given the growing interest in hospital P4P, this systematic review of the literature examines the current state of knowledge about the effect of P4P on clinical process measures, patient outcomes and experience, safety, and resource utilization. Little formal evaluation of hospital P4P has occurred, and most of the 8 published studies have methodological flaws. The most rigorous studies focus on clinical process measures and demonstrate that hospitals participating in the Centers for Medicare and Medicaid Services-Premier Hospital Quality Incentive Demonstration, a P4P program, had a 2- to 4-percentage point greater improvement than the improvement observed in control hospitals. There is a need for more systematic evaluation of hospital P4P to understand its effect and whether the benefits of investing in P4P outweigh the associated costs.

Experiences of Agency for Healthcare Research and Quality-funded projects that implemented practices for safer patient care.

OBJECTIVES: To synthesize lessons learned from the experiences of Agency for Healthcare Research and Quality-funded patient safety projects in implementing safe practices. DATA SOURCES: Self-reported data from individual and group interviews with Original, Challenge, and Partnerships in Implementing Patient Safety (PIPS) grantees, from 2003 to 2006. STUDY DESIGN: Interviews with three grantee groups (n=60 total) implementing safe practice projects, with comparisons on factors influencing project implementation and sustainability. DATA COLLECTION: Semi-structured protocols contained open-ended questions on lessons learned and more structured questions on factors associated with project implementation and sustainability. PRINCIPAL FINDINGS: The grantees shared common experiences, frequently identifying lessons learned regarding structural components needing to be in place before implementation, components of the implementation process, components of interventions' results needed for sustainability, changes in timelines or activities, unanticipated issues, and staff acceptance/adoption. Also, fewer Original grants had many of the factors related project to implementation/sustainability than the PIPS or Challenge grantees had. CONCLUSIONS: Although much of what was reported seemed like common sense, surprisingly few projects actually planned for or expected many of the barriers or facilitators they experienced during their project implementation. Others implementing practice improvements likely will share the experiences and issues identified by these implementation projects and can learn from their lessons.

Training a patient safety work force: the patient safety improvement corps.

OBJECTIVE: Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality­sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices. DATA SOURCE: Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later. STUDY DESIGN: Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice). DATA COLLECTION: Semistructured interviews; faxed forms. PRINCIPAL FINDINGS: One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools. CONCLUSIONS: The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important.

Understanding the reporting practices of CAHPS sponsors.

This article examines the reporting of Consumer Assessment of Healthcare Providers and Systems (CAHPSO) consumer experience data by sponsors, those that fund data collection and decide how information is summarized and disseminated. We found that sponsors typically publicly reported comparative data to consumers, employers, and/or purchasers. They presented health plan-level data in print and online at least annually, usually in combination with non-CAHPS information. Many provided trend data, comparisons to individual plans, and summary scores. Most shared information consistent with known successful reporting practices. Areas meriting attention include: tailoring reports to specific audiences, assessing literacy, planning dissemination, educating vendors, and evaluating products and programs.

Will financial incentives stimulate quality improvement? Reactions from frontline physicians.

Pay-for-performance is being applied at the physician level to stimulate improvements in quality of care and cost efficiency; however, little is known about how physicians will respond. We interviewed physicians exposed to a financial incentive program in California to identify possible barriers to the successful application of financial incentives by exploring physicians' opinions of and experiences with pay-for-performance programs. Reasons physicians cited for quality deficiencies included insurance coverage limitations and lack of patient compliance, time, and proper physician oversight. Physicians believe that they play a significant role and have a moderate to high degree of control over quality of care and that it is important to self-monitor. Physicians expressed the need for accurate and timely data, peer comparisons, and more patient time, staff support, and consultations with colleagues to successfully monitor and deliver quality care. Many support increased pay for delivering high-quality care but question measurement accuracy, bonus payment financing, and health plan involvement.

Direct-to-consumer advertising of COX-2 inhibitors: effect on appropriateness of prescribing.

Spending on direct-to-consumer advertising (DTCA) of prescription drugs has increased dramatically in the past several years. An unresolved question is whether such advertising leads to inappropriate prescribing. In this study, the authors use survey and administrative data to determine the association of DTCA with the appropriate prescribing of cyclooxygenase-2 (COX-2) inhibitors for 1,382 patients. Treatment with either a COX-2 or a traditional nonsteroidal anti-inflammatory drug (NSAID) was defined as appropriate or not according to three different definitions of gastrointestinal risk. Patients who saw or heard a COX-2 advertisement and asked their physician about the advertised drug were significantly more likely to be prescribed a COX-2 (versus a NSAID, as recommended by evidence-based guidelines) than all other patients. Findings also suggest that some patients may benefit from DTCA. The authors discuss the need for balanced drug information for consumers, increased physician vigilance in prescribing appropriately, and further study of DTCA.