Physician Performance Projects

Problem:   A host of forces including rapid and unabated increases in healthcare costs at the same time that serious quality deficits are noted underscore the urgent need to reengineer healthcare delivery.  Substantial practice variation without related differentials in outcome implies there is opportunity to impact cost and quality when efficient and effective practices are rewarded with patient volume and commensurate compensation.  Doing so requires the measurement of physician performance.   Moreover, feedback to physicians about standards of performance for both process and outcome supports quality improvement.  Lastly, consumers currently have little information upon which to base quality-oriented and cost-effective decision-making about physician selection.  Publicly reporting comparable metrics informs physician selection and rewards higher performing providers.

PBGH's Physician Performance Project (P3) was launched in 2003 with the goal of meeting the challenge of the Consumer-Purchaser Disclosure Group to have information available to California consumers by 2007 that will enable them "to select physicians based on reporting of nationally standardized measures for clinical quality, patient experience, equity and efficiency." Recognizing that this ambitious agenda will both influence and be influenced by the evolving science of physician measurement and that robust political support will be needed from many stakeholders, the project is proceeding in phases.   To that end, all of the efforts PBGH has engaged in have been linked to national efforts such that lessons learned can be shared with others working in similar areas and so as to foster the creation of national standards.  

PBGH Role and Project Description: The Physician Performance Project has three measurement components: efficiency of care, clinical quality of care, and patient experience. The goals of the projects, either directly or indirectly through health plans, are to:

• Develop a sustainable, ongoing measurement and reporting system at the individual physician or practice site level.
• Provide physicians with the performance information and related tools needed for quality and efficiency improvement.
• Provide consumers with useful information and related tools for selecting physicians for their care.
• Through benefit design, health plan contracting decisions, and pay-for-performance programs, reward physicians who provide high quality, efficient care.

PBGH is working with health plans and other partners to achieve these goals.

Preliminary Project Documents:

"Advancing Physician Performance Measurement:  Using Administrative Data to Assess Physician Quality and Efficiency" summarizes the current state-of-the-art concerning physician-level quality and efficiency measurement as well as documenting approaches being used in various efforts around the country to advance the practice of physician-level measurement.   This report resulted from a meeting of key leaders and policy-makers from the public and private sectors that was convened in Washington, D.C., by PBGH and Lumetra.

"Aligning Physician Incentives: Lessons and Perspectives from California," summarizes key learnings from a workshop convened at PBGH in which industry leaders addressed the issues around physician-level incentive payments in our market.   The report describes successful programs and documents the need for further collaboration among plans – both HMO and PPO – as well as groups in further aligning financial incentives to encourage physician performance improvement.

Pacific Business Group on Health partnered with the California Medical Association to develop a consensus statement affirming the need for a Medicare Value Purchasing program that rewards physicians for providing the right care at the right time, supports prevention and ongoing care for the chronically ill, rewards both better performance and physicians who improve, and in which both physicians and patients have the tools and information necessary to ensure high-quality, appropriate care.

Efficiency Measurement

Proof of Concept – Medicare & Commercial Claims Analysis (2003-2004).   In 2003, PBGH completed a proof-of-concept study on an efficiency method, funded mainly by the federal Agency for Healthcare Quality and Research and the members of PBGH through its Quality Improvement Fund.   The study of physician efficiency used a sample of Medicare claims data and, separately, data from a large commercial PPO plan.   Results from the Medicare data analysis revealed that from 2% to 12% of physicians (depending on the specialty) were performing less efficiently and statistically differently from their peers and that if these physicians were to perform more like their peers, or consumers were to choose the more efficient physicians, the savings opportunity would range from 1.5% - 4.8% of costs.   To our knowledge, this was the first study of physician cost-efficiency performance conducted using Medicare claims data.  

Pooled Private Purchaser Claims Analysis (2004-2005).  PBGH, in partnership with Lumetra (the California Medicare QIO), combined the claims databases from Blue Shield of California and several large PBGH members and produced physician-level efficiency performance scores.   This information is currently being used in quality improvement activities with the measured physicians.  Other activities of the collaborative included:

• Generating estimates of the size of the health care dollar savings opportunity under varying assumptions, if physicians were to change their practices or consumers were to choose different physicians as a result of changes in plan or benefit design and/or physician network tiering.
• Assembling a Physician Advisory Group to provide input on the design of reports to physicians as well as recommendations for use of this information by health plans and physician organizations to support physician performance improvement.   The Advisory Group included representatives from the California Medical Association (CMA) and California physician groups.

Full Medicare Analysis (proposed):  Simultaneous with the physician measurement work on the commercial side of the market, we are engaged in ongoing discussions with the Centers for Medicare and Medicaid Services (CMS) concerning a pilot collaborative project to measure physicians using the full-sample, physician-identified California Medicare claims database.   As with our previous work, results from the analysis would be used for quality improvement work directly with physicians and modeling of potential health care cost savings (in this case, for Medicare).   Additionally, the study would allow a comparison of Medicare vs. commercial findings, and would produce quality measures that could be used together with efficiency scores to evaluate the performance of physicians on both quality and efficiency in the delivery of their care.   The collaborators on this project would include Lumetra and the CMA.  

Clinical Quality Measurement

PBGH and its project partners seek to produce robust measures of quality performance using claims data, and to subsequently combine quality and efficiency scores to produce a composite physician performance score.   To this end, we have conducted a market assessment of claims-based physician quality performance measurement tools.  Generally, these tools contain an adequate number of measures for most primary care specialties as well as a few other physician specialties (e.g., cardiology).   Other specialties will be difficult to measure with the existing measures and tools.  

Patient Experience Measurement

The patient survey project evaluated the methods and value of brief surveys of patients' experiences with their doctor. The approach uses medical group data to identify patients who have visited their doctor at least once in the past year. Patients are surveyed on the following:

• Patient-physician interactions - Communications, knowledge of patient, and trust.
• Coordinated care - Follow-up with test results, doctor informed about other care, and physician having all needed information about patient.
• Access - Getting appointments for care when needed, visits start on time, after-hours care, and getting callbacks when calling about a medical problem.

Phase I of the patient survey project demonstrated the technical strengths of the patient survey and found that web-based surveys are an affordable and valid means of producing meaningful measures. Major funding support for the project came from the California HealthCare Foundation.

Phase II of the patient survey project evaluated use of the patient experience ratings by individuals who were selecting a physician.   Patients who were newly joining a medical group or leaving a retiring physician were invited to log on and use a doctor directory that included physician-specific patient ratings. The study found that patients highly valued the information, considered it an important aspect of choosing a physician and would recommend its use to others.   This work was supported by the Robert Wood Johnson Foundation.

Impact:  The potential impact of the Physician Performance Projects on quality and costs is enormous. A recent comparison of 306 metropolitan areas in terms of their Medicare costs and quality of care found that quality is as good or better in the low-cost 20 percent of areas as in the high-cost 20 percent—but costs vary up to 60 percent. If all the areas were delivering care as efficiently as the low-cost areas, the Medicare budget could be reduced 30 percent (read this Annals of Internal Medicine article ). At the same time, recent studies show that physicians tend to adopt efficient care management processes that improve clinical quality when there is public reporting of performance and when they are offered appropriate financial incentives. As appropriate physician performance information becomes available to consumers, market pressure will become an effective mechanism for improving health care quality and efficiency.

Current Activities:  PBGH is working to build support for a data aggregation and analysis collaborative in California and continuing discussions with physician leaders on how quality and efficiency information should be communicated to physicians, as well as exploring how to enlist physician participation and support.   Meanwhile, PBGH is engaging in national efforts, such as those sponsored by the Ambulatory Care Quality Alliance (AQA) and the National Quality Forum, aimed at standardizing physician performance measures and bringing them to the market.

Return to Quality Measurement