The Transition of Primary Care Group Practices to Next Generation Models: Satisfaction of Staff, Clinicians, and Patients.

INTRODUCTION: Restructuring primary care is essential to achieve the triple aim. This case study examines the human factors of extensive redesign on 2 midsized primary care clinics (clinics A and B) in the Midwest United States that are owned by a large health care system. The transition occurred when while the principles for patient-centered medical home were being rolled out nationally, and before the Affordable Care Act. METHODS: After the transition, interviews and discussions were conducted with 5 stakeholder groups: health system leaders, clinic managers, clinicians, nurses, and reception staff. Using a culture assessment instrument, the responses of personnel at clinics A and B were compared with comparison clinics from another health system that had not undergone transition. Patient satisfaction scores are presented. RESULTS: Clinics A and B were similar in size and staffing. Three human factor themes emerged from interviews: responses to change, professional and personal challenges due to role redefinition, and the importance of communication. The comparison clinics had an equal or higher mean culture scores compared with the transition clinics (A and B). Patient satisfaction in improved in Clinic A. CONCLUSIONS: The transition took more time than expected. Health system leaders underestimated the stress and the role adjustments for clinicians and nurses. Change leaders need to anticipate the challenge of role redefinition until health profession schools graduate trainees with more experience in new models of team-based care. Incorporating experience with team based, interprofessional care into training is essential to properly prepare future health professionals.

The role of medical group practice administrators in the adoption and implementation of Medicare's physician quality reporting system.

BACKGROUND: Although there are numerous studies of the factors influencing the adoption of quality assurance (QA) programs by medical group practices, few have focused on the role of group practice administrators. PURPOSE: To gain insights into the role these administrators play in QA programs, we analyzed how medical practices adopted and implemented the Medicare Physician Quality Reporting System (PQRS), the largest physician quality reporting system in the United States. METHODOLOGY: We conducted focus group interviews in 2011 with a national convenience sample of 76 medical group practice administrators. Responses were organized and analyzed using the innovation decision framework of Van de Ven and colleagues. FINDINGS: Administrators conducted due diligence on PQRS, influenced how the issue was presented to physicians for adoption, and managed implementation thereafter. Administrators' recommendations were heavily influenced by practice characteristics, financial incentives, and practice commitments to early adoption of quality improvement innovations. Virtually, all who attempted it agreed that PQRS was straightforward to implement. However, the complexities of Medicare's PQRS reports impeded use of the data by administrators to support quality management. DISCUSSION: Group practice administrators are playing a prominent role in activities related to the quality of patient care--they are not limited to the business side of the practice. Especially, as PQRS becomes more nearly universal after 2014, Medicare should take account of the role that administrators play, by more actively engaging administrators in shaping these programs and making it easier for administrators to use the results. PRACTICE IMPLICATIONS: More research is needed on the rapidly evolving role of nonphysician administration in medical group practices. Practice administrators have a larger role than commonly understood in how quality reporting initiatives are adopted and used and are in an exceptional position to influence the more appropriate use of these resources if supported by more useful forms of quality reporting.

The role of nurse practitioners in primary healthcare.

OBJECTIVES: The employment of more nurse practitioners (NPs) is one of the most promising ways to expand the capacity of medical group practices. The objective of this study was to determine the association of NPs with patient-level cost and quality of care. STUDY DESIGN: Eighty-five primary care medical group practices were matched with 315,000 Medicare patients. Per beneficiary per year total costs and quality of care were calculated from Medicare claims data. Data were analyzed using multivariate regression analysis. METHODS: A national sample of primary care medical group practices based on responses to the 2009 Medical Group Management Association Performance Survey. The cost variable was annual risk-adjusted Medicare expenditures per capita for patients attributed to a practice. There were 5 quality of care measures. RESULTS: Employing NPs in primary care practices is associated with increased risk-adjusted patient cost for up to 1 NP for every 2 physicians, but cost decreases as the number of NPs per physician increases. There was little evidence of systematic association of NPs with quality of care or the practice's net revenue. CONCLUSIONS: Primary care medical group practices need to evaluate the alternate clinical roles of their NPs and develop models that optimize cost and quality of care. Practices that have employed more than 1 NP for every 2 physicians appear to have lower per capita Medicare spending with no adverse effects on quality. Research now needs to explore these causalities.

A day in the life of an urban emergency department.

IMPORTANCE: The annual number of patient visits to emergency departments (EDs) continues to increase. Patients seen in the ED for nonemergent conditions potentially increase the cost of health care and lead to overcrowding in EDs. OBJECTIVE: To gain insights into the factors leading to nonemergent use of hospital EDs. DESIGN, SETTING, AND PARTICIPANTS: During a 24-hour period, we interviewed 67 patients in an urban ED. A total of 232 patients were seen in the ED and the hospital provided all claims data. INTERVENTION: None. MAIN OUTCOMES AND MEASURES: Elicit and record patient-stated reasons for seeking care in the ED. RESULTS: Interview results showed that 90% of patients had a primary care clinic although 23% of those clinics were not affiliated with the hospital. Of the 67 interviewed patients, 72% reported they came to the ED because their condition was an emergency, 79% had spoken to someone prior to going to the ED, but only 30% consulted medical personnel. CONCLUSIONS AND RELEVANCE: Patients did not go to the ED because they lacked a primary care clinic. Most patients did not discuss their condition with medical personnel prior to going to the ED. Informing patients of clinic and hospital affiliations may improve continuity of care and access to electronic health records.

The relationships of physician practice characteristics to quality of care and costs.

BACKGROUND: Medical group practices are central to many of the proposals for health care reform, but little is known about the relationship between practice-level characteristics and the quality and cost of care. METHODS: Practice characteristics from a 2009 national survey of 211 group practices were linked to Medicare claims data for beneficiaries attributed to the practices. Multivariate regression was used to examine the relationship between practice characteristics and claims-computable measures of screening and monitoring, avoidable utilization, risk-adjusted per-beneficiary per-year (PBPY) costs, and the practice's net revenue. RESULTS: Several characteristics of group practices are predictive of screening and monitoring measures. Those measures, in turn, are predictive of lower values of avoidable utilization measures that contribute to higher PBPY costs. The effects of group practice characteristics on avoidable utilization, cost, and practice net revenue appear to work primarily through improved screening and monitoring. CONCLUSIONS: Practice characteristics influence costs indirectly through a set of statistically significant relationships among screening and monitoring measures and avoidable utilization. However, these relationships are not the only pathways connecting practice characteristics to cost and those additional pathways contain substantial "noise" adding uncertainty to the estimated direct effects. Some of the attributes thought to be important characteristics of accountable care organizations and medical homes appear to be associated with lower quality and no improvement in cost.

Do integrated health care systems provide lower-cost, higher-quality care?

A study Looking at quality and cost issues for integrated vs. non integrated physician practices yields some interesting findings.

Sources of information used in selection of surgeons.

OBJECTIVES: We explored the process of physician selection, focusing on selection of surgeons for knee and hip replacement to increase the probability of a new relationship, making cost and quality scorecard information more relevant. STUDY DESIGN: We collected data using a mailed survey sent to patients with knee or hip replacement surgery shortly after March 1, 2010. This time period followed a period of publicity about the new cost and quality scorecard. METHODS: We used multivariate probit models to predict awareness of the scorecard and willingness to switch providers. Multinomial logit methods were used to predict the primary factor influencing the choice of surgeon (physician referral, family or friend referral, surgeon location, previous experience with the surgeon, or other). RESULTS: Internet access and higher neighborhood incomes are associated with an increased probability of being aware of the scorecards. Male patients and patients with Internet access or in highly educated neighborhoods are more likely to be willing to switch providers for a reduced copay. Urban residents are more likely to rely on physician referrals, and rural patients on family/friend referrals when selecting a surgeon; Internet access reduces importance of surgeon location. CONCLUSIONS: Additional research is needed to determine whether Internet access is causal in improved responsiveness to market information and incentives, or a proxy for other factors. In addition, we see evidence that efforts to improve healthcare quality and costs through market forces should be tailored to the patient's place of residence.

Medical group practice characteristics influencing inappropriate emergency department and avoidable hospitalization rates.

The inappropriate use of emergency departments (EDs) and ambulatory care sensitive hospital admission rates by patients attributed to a national sample of 212 medical group practices is documented, and the characteristics of practices that influence these rates are identified. Hospital-owned practices have higher nonemergent and emergent primary care treatable ED rates and higher ambulatory care sensitive hospitalization rates. Practices with electronic health records have lower inappropriate ED rates but those in rural areas have significantly higher rates. Practices with lower operating costs have higher inappropriate ED and ambulatory care sensitive rates, raising questions about the costs of preventing these incidents at the medical group practice level.

Medical groups can reduce costs by investing in improved quality of care for patients with diabetes.

A major feature of many new contracts between providers and payers is shared savings programs, in which providers can earn a percentage of the savings if the cost of the care they provide is lower than the projected cost. Unless providers are also held accountable for meeting quality benchmarks, some observers fear that these programs could erode quality of care by rewarding only cost savings. We estimated the effects on Medicare expenditures of improving the quality of care for patients with diabetes. Analyzing 234 practices that provided care for 133,703 diabetic patients, we found a net savings of $51 per patient with diabetes per year for every one-percentage-point increase in a score of the quality of care. Cholesterol testing for all versus none of a practice's patients with diabetes, for example, was associated with a dramatic drop in avoidable hospitalizations. These results show that improving the quality of care for patients with diabetes does save money.

Factors influencing electronic clinical information exchange in small medical group practices.

PURPOSE: The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas. METHODS: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns. FINDINGS: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non-owned clinics or hospitals. CONCLUSIONS: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems.

Market power and contract form: evidence from physician group practices.

We examine how the market power of physician groups affects the form of their contracts with health insurers. We develop a simple model of physician contracting based on 'behavioral economics' and test it with data from two sources: a survey of physician group practices in Minnesota; and the physician component of the Community Tracking Survey. In both data sets we find that increases in groups' market power are associated with proportionately more fee-for-service revenue and less revenue from capitation.

Differences in the cost of health care provided by group practices in Minnesota.

This article reports the findings of a study designed to identify differences in the cost and quality of care provided by medical group practices in Minnesota. Fifty-three practices that provide services to enrollees of employer-based self-insured health plans were included in the study. Costs adjusted for case mix and payment levels were found to vary from $2,400 to nearly $4,700 per member per year. Quality of care had less variance and was not found to be related to cost. The practices that provided high-quality, low-cost care included both relatively small physician-owned practices and large, multi-clinic systems that also owned hospitals.

Health information exchange: participation by Minnesota primary care practices.

BACKGROUND: The American Recovery and Reinvestment Act of 2009 will provide $36 billion to promote electronic health records and the formation of regional centers that foster community-wide electronic health information exchange (HIE) with the ultimate goal of a nationwide health information network. Minnesota's e-Health Law, passed in 2007, mandates electronic health record and HIE participation by all clinics and hospitals. To achieve these goals, small primary care practices must participate. Factors that motivate or prevent them from doing so are examined. METHODS: From November 10, 2008, through February 20, 2009, we gathered data (through questionnaires and interviews) from 9 primary care practices in Minnesota with fewer than 20 physicians and with varying degrees of electronic health records and HIE involvement. RESULTS: No practice was fully involved in a regional HIE, and HIE was not part of most practices' short-term strategic plans. External motivators for HIE included state and federal mandates, payer incentives, and increasing expectations for quality reporting. Internal motivators were anticipated cost savings, quality, patient safety, and efficiency. The most frequently cited barriers were lack of interoperability, cost, lack of buy-in for a shared HIE vision, security and privacy, and limited technical infrastructure and support. CONCLUSIONS: Currently, small practices do not have the means or motivation to fully participate in regional HIEs, but many are exchanging health data in piecemeal arrangements with stakeholders with whom they are not directly competing for patients. To achieve more comprehensive HIE, regional health information organizations must provide leadership and financial incentives for community-wide meaningful use of interoperable electronic health records.

Is patient satisfaction influenced by the intensity of medical resource use by their physicians?

OBJECTIVE: To determine whether patients' satisfaction with their primary care is related to providers' use of medical resources. STUDY DESIGN: Sixty-two practices serving 2805 patients enrolled in BlueCross BlueShield of Minnesota were analyzed using hierarchical regression models. METHODS: Three measures of satisfaction included patient satisfaction with overall healthcare, patient satisfaction with the time spent with a physician or other provider during a visit, and the likelihood that a patient would recommend the clinic to others. RESULTS: Patient satisfaction was found to be primarily a function of patient characteristics and not of practice characteristics. Providers' use of medical resources was not significantly related to patients' overall ratings of healthcare or to patients' willingness to recommend the practice to others. However, the time spent with a physician or other provider was significantly negatively related to patient satisfaction. Physician workload was significantly related to patient satisfaction. CONCLUSIONS: To improve patient satisfaction, practices should focus on reducing physician workload. Valid measures of patient satisfaction must correct for the strong effects of patient characteristics.

Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices.

BACKGROUND: A major factor limiting efficiency and quality gains from clinical information technologies is the lack of full use by the clinicians. PURPOSE: To identify the practice and physician characteristics that influence the use of e-scripts after adoption. METHODS: Data were obtained from 27 primary care medical group practices that had e-script technology for 2 years. Physician and practice characteristics were obtained from the clinics, and the proportion of each physician's prescriptions sent electronically was calculated from the prescription records. Practice culture data were obtained from a survey of the physicians in each practice. Data were analyzed using hierarchal regression. FINDINGS: Practice-level variables explain most of the variance in the use of e-scripts by physicians, although there are significant differences in use among specialties as well. General internists have slightly lower use rates and pediatricians have the highest rates. Larger practices and multispecialty practices have higher use rates, and five practice culture dimensions influence these rates; two have a negative influence and three (organizational trust, adaptive, and a business orientation) have a positive influence. PRACTICE IMPLICATIONS: While previous studies have identified physician characteristics and product deficiencies as factors limiting the use of electronic information technologies in medical practices, our data indicate that the influence of these factors may be highly dependent on the culture of the practice. Consequently, practice administrators can improve physician acceptance and use of these technologies by making sure that there is a culture/technology fit before deciding on a product.

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

BACKGROUND: It is widely acknowledged that many prescription drug errors occur in the ambulatory care setting and that they have serious quality of care implications. Previous research examining this issue has focused on hospitals and on individual-level factors. This study adopts an organizational perspective to assess the effects of organizational culture, organizational structure, and their fit (i.e., their congruence) on medication errors in medical group practices. METHODOLOGY/APPROACH: Variables that measure the organizational culture and structure were taken from two surveys of medical group practices in Minnesota in 2001. Medication errors data were obtained using a computerized drug utilization review system. Seventy-eight medical group practices were included in the analyses. FINDINGS: Results revealed that the use of benchmarking and practice guidelines was associated with decreased error rates in group practices that encourage "patient emphasis" and "collegiality." However, the relationship between information processing capacity and the cultural dimensions was not statistically significant. PRACTICE IMPLICATIONS: The interaction between specific cultural traits and structural dimensions can help understand some of the relationships between organizational culture, structure, and medication errors. Organizational structures do not exist in a vacuum, but rather their effect on patient safety outcomes is "moderated" by the organizational culture. The implications are that medical group practice administrators and medical directors have alternate ways to prevent or reduce medication errors and that they should be attentive to the cultures of their practices when considering those options.

Medical groups' adoption of electronic health records and information systems.

We surveyed a nationally representative sample of medical group practices to assess their current use of information technology (IT). Our results suggest that adoption of electronic health records (EHRs) is progressing slowly, at least in smaller practices, although a number of group practices plan to implement an EHR within the next two years. Moreover, the process of choosing and implementing an EHR appears to be more complex and varied than we expected. This suggests a need for greater support for practices, particularly smaller ones, in this quest if the benefits expected from EHRs are to be realized.