By Jeffrey Levin-Scherz and Thomas H. Lee, Partners Community HealthCare, Inc.
If you doubt that public reporting can drive improvements in quality without dividing payers and providers, watch carefully what happens in Massachusetts this year. This month, Massachusetts Health Quality Partners (MHQP) released a comprehensive report on the effectiveness of care provided by physician groups. (Effectiveness of care means the reliability with which patients receive tests and treatments known to improve outcomes.) Then in March, MHQP will for the first time publish data about patient experiences with care for about 150 medical groups. Previously, such data had been released at the network level only.
What will the impact be? Surveys suggest that, as yet, patients do not aggressively seek out or act on such information.[1] But MHQP's public release is already having a considerable effect on the provider community. Along with other state physician organizations, Partners Community HealthCare, Inc., has been digesting data from MHQP for a few years. Today, we put more energy into using the data to learn how to perform better than complaining about the methodology. While public reporting may never make physicians happy, MHQP's collaborative process of collecting and disseminating information about medical groups has the potential to serve as a national model.
The table summarizes the key things that we believe MHQP is doing right and that others should strongly consider emulating. MHQP pools data from multiple payers, yielding large sample sizes for statistical analysis. MHQP involves physicians at every step of the way, including the plans for data collection and the design of public release. It typically gives physicians a year to get used to receiving quality data—and to improve their performance—before releasing information publicly. Once the public release process begins, the data provided to the public become progressively more detailed with each cycle. Thus far, data on small groups and solo practitioners have not been published but are given to providers to assist them in local quality improvement efforts.
MHQP's aim is to leverage collaboration among health plans, providers, and other key players. Through MHQP, the state's five major health plans have pooled claims data to assess effectiveness of care based on 15 Health Plan Employer Data and Information Set (HEDIS) measures. In addition, the health plans shared the expense of fielding 150,000 mail surveys that asked patients about their perceptions of the care delivered by primary care physicians. This effort, funded in part by The Commonwealth Fund and the Robert Wood Johnson Foundation, yielded more than 50,000 completed surveys. Each of the plans ended up with more robust data than any one plan could have collected on its own, and they were obtained at a lower cost.
There's no doubt that MHQP might have been able to publicly report data earlier if it did not include hospitals and physicians in the design and development of the performance measures. But the inclusive nature of the process means that providers cannot easily dismiss these data when they hit the newspapers and the Internet.
The data themselves bring generally encouraging news about health care in Massachusetts—our state is at the 90th percentile nationally for two-thirds of the 15 measures of effectiveness of care. However, our patients have the right to expect even greater reliability. Massachusetts physician groups perform exceptionally well for measures that have been targeted with quality bonuses or pay-for-performance (P4P) contracts over the last decade, such as rates of breast and cervical cancer screening, diabetes monitoring, and pediatric asthma controller use. Groups perform less well for measures that have not been highlighted in bonus or P4P programs, including mental health care and adult asthma controller use.
Variability in the effectiveness of care is driven by medical group and individual physician performance; it is minimally influenced by payer or network affiliation and not at all by a patient's health plan. Thus, MHQP's release of performance data at a physician group level offers patients information that is substantially more actionable than that available to them in previous years.
In addition, the public release of information encourages self-reflection among physicians and provides medical groups with a powerful incentive to engage in local quality improvement efforts.[2] Aggregated data from health plans representing half of Massachusetts' residents also facilitate acceptance among providers, who are less likely to disregard such information as statistically unreliable or unrepresentative. In our own organization, we are pouring over this data and working hard to improve our scores through the use of systems, such as electronic medical records with decision support.
There are always opportunities to improve reporting of data on quality and patient experience. MHQP is exploring the potential to account for severity of underlying illness and socioeconomic group. Although specialists deliver much of the medical care in Massachusetts, the current MHQP data release focuses on the performance of groups of primary care physicians. MHQP has announced that it will focus some of its future attention on measuring and reporting on effectiveness of care and patient experience for physicians in high-volume specialties.
While many elements of effectiveness of care depend upon systems that are best measured at the group level, many elements of patient experience are better measured at the level of the individual physician. What's more, consumers receive direct care from an individual physician, not a group. Nonetheless, MHQP has thus far resisted pressure to report data at the individual physician level because of its limited statistical validity. We hope that they continue to value fairness and validity of the data in the face of market demands for more information.
Looking forward, MHQP not only must replicate its data gathering and public release process but also should measure its impact by reviewing improvement in Massachusetts compared with states that do not engage in public reporting and assessing providers' level of engagement in establishing systems to improve their results.
Physician groups aspire to high scores to validate their own belief that they are high performers, but adding economic value to a high score is important, too. Physician groups can benefit somewhat from an increased volume of well-informed patients who have scoured the MHQP Web site and made prudent choices, but many physician groups do not have the capacity to care for substantially more patients without higher reimbursements. Health plans and employers should, in the future, offer financial rewards to groups of physicians that score well on reliable, valid measures of effectiveness of care and patient satisfaction.
Jeffrey Levin-Scherz, M.D., M.B.A., chief medical officer of Partners Community HealthCare, Inc., can be reached at [email protected] and Thomas H. Lee, M.D., M.S., chief executive officer of Partners Community HealthCare, Inc., at [email protected].
References
[1] T. H. Lee and K. Zapert (2005) Do High-Deductible Health Plans Threaten Quality of Care? New England Journal of Medicine 353, 1202–1204.
[2] J. H. Hibbard et al. (2005) Hospital Performance Reports: Impact on Quality, Market Share, and Reputation. Health Affairs 24, 150–1160.