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Here’s two approaches to investing in physician-driven care
The well-entrenched notion that quality improvement efforts cause more contention than cooperation between health care plans/payers and physicians probably isn’t going away completely any time soon. Old attitudes die hard, including those of plans and doctors.
But progress is being made in getting both parties moving in the same direction on issues of quality measurement and improvement. At least some of this progress is due to the actions of the plans themselves; a couple of them are seeing the potential benefits of supporting physician quality improvement efforts through investments of time, staff, resources, and dollars.
In those instances, one plan emphasizes providing physicians with necessary information and staff support. Another has taken the approach of directly funding physician QI. And the common thread linking both approaches is the realization that all health care is delivered by physicians, and their buy-in and involvement from the start is crucial to the success of any quality improvement effort.
One way for health plans to support physician QI efforts is by giving them useful information. But there is more to this than just instituting a one-way flow of practice guidelines and other types of bureaucratic edicts.
"In our experience, collaboration is key," says Roseanne Waters, director of operations for Aetna U.S. Healthcare (formerly Prudential) Research Center in Atlanta. "Our interactions with providers have always been positive, in part, because we go to the physicians themselves and ask them what they feel are the key issues they need to get information about," she says. And guided by this input, "We provide them with the scientifically sound information they need to improve the care they are giving."
The Research Center also often combines the role of information provider with that of a support organization in efforts to improve the quality of care provided by physicians, Waters explains. For example, in a still-active study targeting pediatric vaccination coverage levels, "We began by performing the chart reviews for patients under the age of two at seven practice sites, with the objective of providing the physicians and nurses with feedback on their performance in this area."
Feedback and consultation
But rather than merely generate reports on individual and aggregate physician performance, Research Center personnel utilized a collaborative, supportive approach. "We took the results of our chart reviews and presented them [to participating physicians] in a number of small-group meetings," says Waters, "which allowed for in-person discussion of the reviews and the findings."
Based on these discussions, the Research Center then collected a variety of types of information, including national and state-level vaccination coverage data; lists of their pediatric patients not up-to-date on immunizations; and data on how other plans and providers had improved pediatric immunization rates. The information was then distilled and channeled to the physician/nurse group. "This, in turn, led to further discussions on potential interventions that could be used to improve performance in this area," notes Waters, who adds that preliminary study results show much improvement in immunization coverage rates for the subject population.
This kind of collaborative, information pro-vider/staff support approach is effective in all physician quality improvement efforts, adds Waters. "It is a lot more comprehensive than just coming up with performance measures. Instead, we put ourselves in the role of providing the physicians with the information and tools they need to help them identify the best ways to improve, and we are there to give them feedback and consultation as needed."
Health Alliance Plan (HAP), a Detroit-based nonprofit managed care plan serving 500,000 members and 3,000 employer groups, has taken what is widely considered to be a unique approach to improving the quality of care provided by physicians. HAP has awarded grants totaling $3.9 million to affiliated physicians in its largest provider networks to both improve and track the quality of medical care patients receive. The Invest in Quality grant program funds new or expanded programs — as proposed and drawn up by physician groups — that stand to improve the group’s performance in clinical measures of quality care.
"We’re creating a health care paradigm where physicians and health plans collaborate to make sure members are getting enough medical care," says Cleve Killingsworth, HAP president and CEO. "Our vision is that Invest in Quality will spur a new paradigm in health care that reaches beyond the current political debate and demonstrates that physicians and health plans can and do work together to achieve the highest standards of health care."
"There has been a widespread perception that the managers and providers of care have not necessarily been partnering, cooperating, or collaborating on these kinds of quality improvement efforts," says Ann Waters, director of quality management at HAP. " My own feeling is that this has been taking place on an informal basis, but maybe not in ways that are readily visible."
HAP’s Invest in Quality has provided financial support for a number of high-profile quality improvement efforts. Recipients and efforts funded through the program to date include:
- Mercy Oakland Physician Network (MOPN) in Pontiac/Bloomfield Hills, MI received an Invest in Quality grant for support of a computerized system that simplifies the process physicians use to order medications for hospitalized patients. Instead of the typical, multistep process involving physician order sheets, nurse transcription, and clerical input, MOPN physicians can place a medication order directly into the computer at the point of care, eliminating several steps and reducing the chances for error. MOPN also received funds for a disease management center to improve the treatment of congestive heart failure, pediatric asthma, and adult diabetes.
- Henry Ford Medical Group (HFMG) in Detroit received grants to support mechanisms that ensure patients receive preventive services in mammography and cervical cancer screening, childhood immunizations, diabetes management, smoking cessation, and beta-blocker usage. A centralized call center will target at-risk patients who need these medical services and contact them for appointments, while automated medical record workflow software will enable HFMG physicians to call up background information and quickly determine which preventive services a patient should receive during office visits. Meanwhile, the HFMG mammography and cervical cancer screening initiative will also address access issues, missed opportunities due to lack of patient awareness, appropriate documentation and triggers, and patient education.
- Providence Medical Group (PMG) in Southfield, MI, received a grant to implement a project that will increase the diabetic eye exam rate to 65% in an effort to screen for diabetic retinopathy, the leading cause of blindness among American adults. PMG is implementing a system where a project coordinator works with physicians, ophthalmologists, and patients to expedite referrals. Ophthalmologists will generate monthly reports listing referred patients who have had exams, as well as those who either did not schedule visits or did not show up for appointments. After two unsuccessful attempts by the ophthalmologist to schedule and complete the eye exam, the project coordinator will contact the patient directly via certified mail. The coordinator will also audit patient records to ensure that ophthalmologists’ reports are received by the physician and kept in the patient’s medical records.
All projects funded under the Invest in Quality program originate with physician groups, and have to tie in with positive impacts on HAP’s HEDIS scores, according to Ann Waters. "Projects must demonstrate evidence that HAP and its providers do indeed provide the highest — and possibly the benchmark — quality of care available." And by working in partnership with the physicians who provide the care, she adds, "We are making sure that our members receive a standard of care that is both proposed and supported by members of the medical community."
[For more information, contact:
• Roseanne Waters, Director of Operations, Aetna U.S. Healthcare Research Center, 2859 Paces Ferry Road, Atlanta, GA 30339. Telephone: (770) 801-7145.
• Ann Waters, Director of Quality Management, Health Alliance Plan, Detroit. Telephone: (313) 872-8100. E-mail: email@example.com.]