From Data to Delivery: Measuring Advanced Primary Care in California
January 11th, 2024
The health care delivery system in the United States faces significant challenges, ranking poorly in quality, efficiency and outcomes among peer countries. Despite high spending on health care, primary care, a crucial element for better population health, is underfunded in the U.S. In California, over 65% of physicians work in solo or small practices and primary care providers often lack resources and technology, contributing to subpar patient outcomes.
Through the California Advanced Primary Care Initiative, PBGH’s California Quality Collaborative (CQC) and partner Integrated Healthcare Association (IHA) are working to understand and address these issues to help strengthen the state’s primary care delivery system. To that end, CQC and IHA executed a pilot project in California, bringing together four large health care purchasers — Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System — and 13,055 primary care practices.
Measurement Pilot Goals
The measurement pilot’s goal was to test the effectiveness of a measure set outlining key attributes of high-quality, comprehensive and patient-centered care and to test the use of existing IHA data to measure the performance of individual primary care practices. This data includes a significant portion of the commercial market and some Medicare Advantage and Medi-Cal data from health plans and providers in California. This would then help determine how well primary care practices performed when assessed against these rigorous patient care measures.
Key Findings
The analysis evaluated the performance of practices and observed which practices scored highest, average and lowest for each measure. This provided a picture of how practices are doing in California and helps identify measures where data collection can be improved.
The measure set was developed through a multi-stakeholder process that included input from purchasers, health plans, providers and patients. Measures focus on outcomes, represent both adult and pediatric patients and avoid redundancy. The measure set also aligns with other existing measurements where possible to reduce the reporting and administrative burden for providers.
Summary of the results for each measure:
- Controlling High Blood Pressure (CBP): Out of the 13,055 practices in the pilot, 2,352 had enough patients to assess CBP in a statistically significant way. 35 practices performed above the 66th percentile while others had zero success with this measure. This highlights the need for solid clinical data for practice-level measurement.
- Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8%): 1,639 practices had a high enough number of patients to be statistically significant and 77 performed above the 66th percentile. This measure could be improved with more complete data.
- Colorectal Cancer Screening (COL): 4,089 practices had enough patients to demonstrate valid results. This measure had more practices receive an average score (199) compared to other measures.
- Childhood Immunization Status (CIS): Only 221 practices had enough patients for this measure to be assessed, and those who were scored poorly. More data, especially from the California Immunization Registry, would help improve this measure.
- Risk Adjusted Acute Hospital Utilization (AHU): 1,720 practices were identified as average performers. On average, there were 18 hospital discharges per thousand member years, which is equivalent to the highest national benchmark.
- Risk Adjusted Emergency Department Utilization (EDU): 2,419 practices had high enough patient populations to be statistically significant for this measure. On average, there were 129 emergency department visits per thousand member years. 1,154 practices performed at the average score, showing that this measure performed better overall than other clinical quality measures that were assessed.
Recommendations for the California Health Care Delivery System
Examining how individual practices performed on the Advanced Primary Care Measure Set revealed the following needs within the California health care system. Each of the identified opportunities for improvement listed below can be addressed by leveraging partnerships between payers, purchasers, providers and data exchange organizations.
- Expansion of Clinical Data Exchange: Enhance reporting capabilities and foster payer/purchaser collaboration to reduce administrative hassles for providers, such as logging into multiple interfaces to view and assess data. Refer to the California Advanced Primary Care Initiative for an example of multi-payer alignment work.
- Comprehensive Views of Practice-Level Data for Providers: Interoperability of systems, standard data specifications and alignment of formats can facilitate bringing data together for improved insight. Full views of performance with more of a provider’s population included will result in clear goals for enhancing patient care and reducing disparities.
- Improved Performance: Focus on practice-level improvement for key primary care quality indicators with low scores, especially the quality indicators with the overall lowest scores in this pilot (blood pressure control, depression screening and childhood immunizations).
- Additional Resources: Boost care delivery quality by providing shared tools, technical assistance programs such as CQC’s Practice Transformation Initiative and team support for practices.
For a more detailed look at the results and recommendations, read our latest issue brief.
Study Finds Person-Centered Care Improves with Level of Provider Financial Risk
August 2nd, 2022
Medicare Advantage providers, particularly larger organizations, that are paid using full-risk capitation models outperform their lower risk counterparts when it comes to delivering person-centered care, a new study shows.
As the health care industry strives to increase equity and decrease disparities, person-centered care should be a focal point. Person-centered care is a holistic clinical approach that focuses on patient goals and preferences and is considered as a key catalyst for healthcare transformation. When evidence-based care incorporates a patient’s goals, preferences and values and is pursued through shared decision-making and patient engagement, clinician satisfaction rises, and patient outcomes improve.
Assessing Care by Reimbursement Type
The recent study, conducted by the Integrated Healthcare Association (IHA) and Purchaser Business Group on Health (PBGH) through a grant provided by The SCAN Foundation, evaluated provider performance by financial risk model against an array of person-centered measures. The goal was to determinate if any correlation existed between a provider organization’s mode of reimbursement and their success in delivering person-centered care.
Person-centered care measures were selected with guidance from subject matter experts from IHA and PBGH’s measurement committees, and included:
- Five Patient Experience Measures
- Seven Clinical Quality Measures
- Total Cost of Care
For more information about the measures used, read the full report.
Levels of Financial Risk and Organization Size Matter
Member data from 151 California provider organizations engaged in providing care through 406 Medicare Advantage managed care contracts for 2020 was reviewed. The financial risk categories reflected in the provider contracts included:
- No risk: All services paid through fee-for-service
- Facility risk only: Capitation paid for facility services, but fee-for-service paid for professional services
- Professional risk only: Capitation paid for professional service, but fee-for-service paid for facility services
- Full risk: Capitation paid for both professional and facility services
The study found that full-risk provider organizations slightly outperformed professional risk provider organizations on most measures. Differences were statistically significant for three clinical quality and two patient experience measures. However, full-risk provider organizations performed slightly worse than those with professional risk on measures related to access to care and total cost of care.
Because only 1% of Medicare Advantage provider organization contracts were categorized as no risk or facility risk, the data was insufficient to compare performance of provider organizations with no financial risk as a part of this study. Previous research by IHA has shown that populations cared for by providers with any level of financial risk received better quality care at a lower total cost than populations cared for by providers with no financial risk.
When looking at organization size, large provider organizations outperformed small-to-medium ones — sometimes by a wide margin — across all measures except access to care and total cost of care. For all seven clinical quality measures and four of the five patient experience measures, the differences were significant.
Click here to view the full report.
Going Forward
The new research indicated a positive relationship exists between delivering person-centered care and being paid under more flexible, population-based payment models that incorporate greater financial risk. As the health care industry strives to increase equity and decrease disparities, person-centered care should be a focal point. The use of provider financial risk arrangements through population-based payments is a key consideration in advancing person-centered care.
Strengthening Primary Care: A Pilot with Four Large Purchasers
June 10th, 2022
Extensive research and pilot programs have shown that easily accessible, person-centered and team-based primary care that integrates behavioral health and other supports can significantly improve patient outcomes and experience. It can also increase population health, reduce overall costs and serve to improve equity in our health care system.
It is for these reasons that PBGH’s California Quality Collaborative (CQC) has been working for over a decade to improve primary care. That work has culminated in the development of shared attributes and measures that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the kind of care research tells us will bring about the best results for patients.
Together with the Integrated Healthcare Association (IHA), PBGH brought together four large health care purchasers in California to pilot this set of performance measures that emphasize patient experience and outcomes. The PBGH/IHA partnership, known as the Advanced Primary Care Measurement Pilot, began in January 2022, and participating purchasers include Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System.
Partnering to Better Primary Care in California
Our already weak primary care system has been further hampered by the pandemic, and these purchasers recognize that the time to strengthen it is now. The four participating purchasers have aligned by incorporating the same Advanced Primary Care attributes and measures into their health plan contracts. The goal is to identify the primary care practices throughout the state performing at the highest levels and delivering high-quality patient care.
The set of performance measures being tested through the pilot reflect the shared standard of Advanced Primary Care as defined through a multi-stakeholder process led by PBGH’s California Quality Collaborative that included input from purchasers, health plans, providers and patients.
The outcome will be an increase in understanding of where patients are getting the highest quality primary care. The pilot will give purchasers and health plans information to help them make decisions about their provider networks, resource distribution and consumer incentives. This information can be used to better connect patients to practices delivering Advanced Primary Care and incentivize improvement for other providers, increasing the availability of Advanced Primary Care.
How the Pilot Works: Existing Data for a New Purpose
Data already available through IHA is being used, so health plans and providers do not have to report anything new. The existing data will be used for a new purpose – to assess individual practices.
Performance information can be diluted when data from multiple practices is combined. By looking at each individual practice separately, we can gain the best understanding of which practices are delivering the best primary care and which ones need improvement.
The data will also be aggregated across purchasers and health plans for the first time to provide a more complete view of each individual practice’s performance, rather than looking at small segments of patients in a vacuum. This will allow for a better assessment of whether a practice has the systems in place to consistently provide high-quality care for everyone
Currently, ways to account for socio-economic and demographic differences in the performance analysis is being explored. This lens is crucial to ensure decisions made around the pilot promote equity and do not inadvertently increase the challenges vulnerable communities already experience in accessing high-quality care.
The analysis will include data from January through December 2022, and results and findings are expected mid-2023.
Patient Experience and Telehealth During COVID-19: Investigating Key Success Factors and Obstacles
February 26th, 2021
The global COVID-19 pandemic has led to a rapid increase in virtual care delivery that will likely be long-lasting. During the height of the pandemic, fear of infection and stay-at-home orders meant that many practices stopped seeing most patients in person for routine care. Relaxing of government regulations allowed for widespread national adoption of telehealth.
Telehealth holds great promise for improving primary care through increasing access, improving patient experience and enabling team-based care models. Importantly, while telehealth expands access to all patients, it may improve health equity for lower socio-economic patients who may lack transportation or sick leave.
To gather the patient perspective on telehealth, The Purchaser Business Group on Health developed and fielded a telehealth patient experience survey as part of the Patient Assessment Survey (PAS) program. Approximately 12,000 surveys were distributed by email to patients with commercial and Medicare coverage who had a virtual visit (phone or video) with a primary care provider in California; 1,500 email responses are reflected in the research findings.
Key Findings
- Equal satisfaction between virtual and in-person care: No significant differences were found in ratings of patient visits between telehealth and the regular PAS survey responses (which measure in-person care).
- Telehealth was popular: A total of 87% of survey respondents recommend telehealth; of survey respondents, 73% want to continue using telehealth in the future.
- Video visits were favored over audio-only: Ratings of visits and communications were nearly identical in video and telephonic visits, but patients who reported that they would likely recommend telehealth and engage in repeat telehealth visits significantly favored video appointments.
- Provider communication was good: Most patients said the provider with whom they met via telehealth methods explained information in a way that was easy to understand (92%), listened carefully (92%), spent enough time with them (91%) and had relevant patient medical history on hand during the visit (88%).
- Most patients received medical tests: Half of survey respondents had tests ordered by their provider. Most followed up to have the tests conducted (84%), and most patients were able to access their test results (88%). Patients were most likely to get the tests ordered on their behalf while being seen for COVID-19 concerns, whereas patients being seen for chronic health care or other health issues were least likely to have tests ordered for them. Patients who did not receive ordered tests (16%) scored their health care provider lower on communication scores.
Despite these promising findings, PBGH research has been, to date, limited to commercial populations in the state of California. Further research on patient experience and clinical outcomes should be conducted nationwide with more diverse populations, including Medicaid beneficiaries, racial and ethnic minorities and those with limited English proficiency. PBGH will have preliminary results from a survey with a sample of patients with Medi-Cal coverage in Spring 2021 and seeks to expand this measurement nationwide.
Implications
The findings of the PBGH Telehealth Survey are instructive for provider organizations, solution providers and health plans. The survey findings suggest the following four steps can make a meaningful difference in ensuring that patients have a positive experience with telehealth:
- Continue to offer telehealth. Patients enjoy telehealth and want to continue using virtual care in the future.
- Offer video visits. Satisfaction with telephonic and video care was high, but users of video visits were more likely to recommend telehealth and want to continue using telehealth.
- Provide instructions for video visits. Patient satisfaction is highest when clear instructions are provided to the patient in advance of a video visit.
- Offer both virtual and in-person care options. Patients indicated the need for in-person options to evaluate certain physical concerns, such as broken bones or rashes. Patients feel they can determine if an in-person appointment versus virtual care is appropriate for their unique health issues.
Read the full report.
Is Shorter Better When it Comes to Collecting Patient Feedback?
October 15th, 2020
Patient experience is an important quality indictor, both for provider organizations and patients. The benefits to patients include better disease management, quality of life, treatment adherence, outcomes and preventive care. Provider organizations that provide a better patient experience also benefit through lower medical malpractice risk, higher employee satisfaction and better patient loyalty.
PBGH’s pioneering work to measure medical group performance on patient experience set the precedent for the development of the Agency for Healthcare Research & Quality (AHRQ)’s Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS) tool. The CG-CAHPS is the gold-standard survey instrument used to measure patient experience at the provider organization level nation-wide. The survey includes 22 questions (and nine demographic questions) that elicit patient feedback on five domains of care: timely care, provider communication, care coordination, office staff and rating of care.
Provider organizations that use the CG-CAHPS survey to gather patient feedback have expressed concern that the survey is too long, leading to survey fatigue and less-than-desired response rates. Increasing response rates would yield multiple benefits, such as more patient feedback, reduce the time it takes to collect feedback, lower survey costs and reduced administrative burden.
PBGH’s Patient Assessment Survey (PAS) program tested an ultrashort version of the CG-CAHPS. Instead of asking patients to fill out the standard CG-CAHPS instrument (including 30 questions on five domains of care), each patient received a survey by email that included no more than 10 questions on just one to two domains of care. The ultrashort test survey was sent to approximately 10,000 Health Maintenance Organization (HMO) patients across California.
Three main research questions were investigated:
- Would patients be more likely to respond to a shorter survey, and would it make a difference if we told them it was short in the invitation?
- Would asking patients for feedback on just one or two aspects of their experience (instead of the 5 topics covered in the standard survey) lead to different patient feedback?
- Would different types of patients respond to a shorter survey?
Key Findings
Results of the study were surprising. The researchers had anticipated that a survey invitation telling the patient the survey was short would entice patients to open the survey, and that having a small number of questions on the survey itself would lead to drastically more people taking and finishing the survey. However, results of the survey showed:
- Respondents were only slightly (1%) more likely to engage in the survey process if they were told the survey was short in advance
- Once patients started the survey, they were likely to finish it irrespective of the survey length (99% completion rate for the ultrashort survey, vs. 91% for the standard survey)
- Patients gave similar feedback on their care between the ultrashort and the standard survey
- Respondents to the email survey were younger and more educated than respondents to the mailed survey
The findings are instructive for provider organizations and health plans using the CG-CAHPS instrument to assess the quality of care delivery and are looking for methods to encourage greater patient engagement.
The survey findings suggest the following five steps can make a meaningful difference:
- Focus on engaging patients. Telling patients a survey is short in the invitation might not lead to higher engagement – experiment with a variety of invitation language, length and visual formats to see what resonates most with users and entices them to engage with your surveys; when you find a method that increases your response rate use it as widely as possible.
- Use email to reach patients. Most CG-CAHPS surveys are sent by mail. Emailing patients the survey can increase response rates by approximately 9%, while lowering costs (the outgoing sample can be reduced by 25%). A mixed-mode approach with email, mail and telephone follow-up will get the best response rates. Email will also help you reach younger and more educated populations.
- If you plan to collect patient feedback on one or two topics only, keep surveys short. Surveys with 12 questions or less can increase your completion rates by 8%, compared to the regular-length CG-CAHPS survey (28 questions). However, consider how much information you are trying to gather. If you are asking patient for feedback on all five standard domains of care, you will likely need to field the full CG-CAHPS instrument. If you are only interested in the topic of access, then your response rates will likely increase if you only include the survey questions specific to that.
- Place important questions earlier. If certain questions are essential to your project, consider placing those at the beginning of the survey to reduce the risk of patients getting distracted and not completing the survey.
- Explore sending surveys by text message. Response rates to surveys sent to patients by email, mail and telephone are going down every year. With 80% of people owning a smartphone, text messaging could be a promising way to reach patients, and at a lower cost. Explore the legal implications of texting patients and consider sending patients a link to an online survey by text messaging; if response rates increase then consider moving more of your surveys to text message.
Read the full report here