# Presentation: 930360

## CAHPS and Quality Improvement

- Susan Edgman-Levitan, PA
- Executive Director
- John D. Stoeckle Center for Primary Care Innovation
- Massachusetts General Hospital
- Boston, MA
- Co-PI, YALE CAHPS Team

## CAHPS III Quality Improvement Demonstrations

- Purpose of evaluations:
- To improve the patient’s experience of care
- To develop and test an improvement framework and set of interventions that will effectively improve CAHPS scores for various CAHPS survey instruments

## RAND QI Demonstrations

- University of California- LA(UCLA)
- HealthPlus of Michigan

## HealthPlus of Michigan 

- HealthPlus Background:
- commercial, Medicaid, and Medicare Advantage HMO, commercial PPO, and Third Party Administrator (TPA) services to over 200,000 members
- contracts with over 900 PCPs in the state of Michigan
- All three HMO products have been recognized by NCQA as "Excellent" in each of the last 10 years.

**Notes:**
HealthPlus of Michigan is an independent, not-for-profit company that offers health care coverage services in mid and southeast Michigan.  It offers commercial, Medicaid, and Medicare Advantage HMO, commercial PPO, and Third Party Administrator (TPA) services to over 200,000 members. The majority of members (approximately 140,000) are served through one of HealthPlus' HMO products.
The HMO products are based on a model in which most care is directed by a primary care physician (PCP).    As of March 2008, HealthPlus had approximately 72,000 commercial HMO members and contracts with over 900 PCPs in the state of Michigan. HealthPlus' Medicare Advantage and Medicaid HMO physician networks are primarily subsets within the commercial HMO group, limited mostly by the smaller geography for those products and a lower rate of PCP participation.  All commercial HMO PCPs are part of HealthPlus' PPO preferred physician network.  All three HMO products have been recognized by NCQA as "Excellent" in each of the last 10 years. 
HealthPlus generally contracts with PCPs through physician group organizations, such as Physician-Hospital Organizations (PHOs), Physician Organizations (POs), and Independent Physician Associations (IPAs).  Currently, HealthPlus also contracts with approximately 40 PCPs outside of these physician organization structures for its HMO commercial product only. 

## HealthPlus of Michigan

- Use of CAHPS Clinician/Group survey:
- fielded the CAHPS C-G survey to evaluate care provided by primary care providers (PCPs) to its commercial HMO members annually since 2005.
- Results are reported to physicians and to consumers at the individual physician level annually.

**Notes:**
Fielding Patient Experience Survey(s):
HealthPlus has fielded the CAHPS C-G survey to evaluate care provided by primary care providers (PCPs) to its commercial HMO members for the past three years (2005, 2006, and 2007), and plans to continue doing so.  
HealthPlus administers the adult C-G CAHPS survey once per year (each fall).  
Since 2005, HealthPlus has also fielded 16 additional QI items (developed with RAND during CAHPS2 and fielded in the initial survey in the fall of 2005).  The QI items were designed to identify specific actions that are associated with physician-patient interaction and information exchange during the visit.  In the fall of 2006, 5-6 more QI questions were inserted into the survey.
HealthPlus administered the pediatric ACES (Ambulatory Care Experience Survey) survey from Tufts New England Medical Center in 2005 and 2006 to the parents/guardians of pediatric patients, in keeping with the same survey fielding cycle as the CAHPS C-G surveys (ie, fall).  In 2007, HealthPlus shifted completely to the new CAHPS C-G Child survey instrument. 
Reporting Patient Experience Data:
HealthPlus has reported data to individual physicians once per year (each spring/early fall) starting in 2006.  Reports are distributed to physicians in hard-copy format via regular mail.  The template of these individual physician feedback reports was developed with RAND during CAHPS2, and has undergone some minor revisions in subsequent reporting cycles based on experience/feedback received.  
HealthPlus has not yet reported data to physicians from the CAHPS C-G Child survey, pending the resolution of analytic, formatting, and survey-transition issues (i.e., trying to retain continuity during transition from ACES to CAHPS survey).  
Since December 2007, HealthPlus has reported CAHPS C-G data to consumers at the individual physician level on its website which is available to the public.
Individual, group, and PHO-level data are also reported to and reviewed by HealthPlus staff and Senior Management on a regular, on-going basis.  

## HealthPlus of Michigan

- Demonstration focus:
- Physician-Patient and Office Staff-Patient Communication

## HealthPlus of Michigan

- Target audience:
- adult PCPs and their office staff.
- Participation in all interventions is voluntary.
- Incentives: increased reimbursement (pay-for-performance), public reporting of CAHPS C-G performance, and free software and technical assistance to assist with communication (Medfusion).

## HealthPlus of Michigan

- Interventions:
***Medfusion:*** A computer software intervention that supports communication with patients through a secure web portal. (First pilot launch Spring 2008)
***Physician-Level Pay-for-Performance:***  launched in February 2006. 2008 is the first year that payment will be made based on CAHPS scores.  P4P program:  a) clinical, b) patient experience (CAHPS), c) access, d) IT (electronic prescribing this year); CAHPS counts for 20%.  (First payout Fall 2007)
***Transparency:*** HealthPlus posts adult CAHPS C-G scores at the individual physician level on a public website. (Individual physician scores first posted December 2007).
***Physician training:***  In-person workshops facilitated by outside experts will be offered to a sub-set of PCPs.  (Not yet started; still in planning phase at this time.)

**Notes:**
HealthPlus is currently engaged in 7 interventions primarily intended to improve physician-patient and office staff-patient communication.  For physicians in this demonstration, HealthPlus is focused on PCPs.  Some individual interventions also have other improvement goals, such as improved efficiency, and consumer empowerment for healthcare decision-making, but improved communication is the central goal of all interventions.  A description of each intervention is provided below.  Interventions were not launched simultaneously; therefore an unique start date is listed in parentheses after each one.
1. Medfusion: A computer software intervention that supports communication with patients through a secure web portal.  HealthPlus is sponsoring a 6-month pilot program with 10 volunteer PCP practices affiliated with several, different PHOs.  It will likely be followed by another 6-month pilot with 5 more PCP practices. Pilots start times will be staggered to accommodate individual practices.  (First pilot launch Spring 2008)
2. Physician-Level Pay-for-Performance:  HealthPlus’ P4P program was launched in February 2006. The first payout was made in Fall 2007 (lump sum based on 2 yr rolling averages, 2005-06).  2008 is the first year that payment will be made based on CAHPS scores.  In 2008, there are 4 parts to the P4P program:  a) clinical, b) patient experience (CAHPS), c) access, d) IT (electronic prescribing this year; Medfusion might qualify in subsequent years). CAHPS counts for 20%.  (First payout Fall 2007)
3.  Transparency: HealthPlus posts adult CAHPS C-G scores at the individual physician level on a public website.  It is in the process of re-designing this website (re-launch scheduled for Spring 2008).  This intervention is intended to provide consumers with information for decision-making, and also to encourage physicians to want to improve their scores.  This intervention will be dynamic, with new information posted to the website periodically, and data refreshed to keep it as current as possible. (Individual physician scores first posted December 2007).
4.  Physician training:  In-person workshops facilitated by outside experts will be offered to a sub-set of PCPs.  (Not yet started; still in planning phase at this time.)
5.  Learning Networks:  Telephone learning networks will be offered to physicians and their office staff in between the in-person training sessions, facilitated by outside experts.  (Not yet started; still in planning phase at this time.)
6.  Educational materials/performance reports for physicians:  This intervention includes individual feedback reports as well as other educational materials for physicians.  In CAHPS 2, RAND and HealthPlus co-designed a template to share CAHPS C-G survey data with individual physicians.  This template has been used for two years (2006 and 2007).  Along with the report, HealthPlus has sent a summary of interviews RAND conducted with high performing physicians in CAHPS2; this document also outlines best practices as determined in the literature.  HealthPlus will continue to design other educational materials to share with physicians. (First report 2006). 
7.  Patient Education:  Quarterly newsletters have been sent to HealthPlus members for many years.  As part of the intervention focused on communication, HealthPlus has been promoting the “AskMe3” questions in recent newsletters, and it recently released its “Cost/Quality Booklet” (Feb 2008) which encourages consumers to approach health care choices much as it does other decisions (e.g. planning a trip, buying a car), and provides guidance for doing so. HealthPlus will continue to develop resources for consumers.  (On-going; started prior to CAHPS3).

## HealthPlus of Michigan

- Interventions:
- 5. ***Patient Education:***  Quarterly newsletters to patients promote the “AskMe3” questions and the “Cost/Quality Booklet” (Feb 2008) (On-going; started prior to CAHPS3).
***6. Learning Networks:***  Telephone learning networks will be offered to physicians and their office staff in between the in-person training sessions, facilitated by outside experts.  (Not yet started; still in planning phase at this time.)
***7. Educational materials/performance reports for physicians:***  Individual feedback reports as well as other educational materials for physicians, e.g., a summary of interviews RAND conducted with high performing physicians, best practices as determined in the literature. (First report 2006).

## HealthPlus of Michigan

**Key Research Questions:**
- how do the 7 individual interventions, and the combination of them, impact physician-patient and office staff-patient communication.

## UCLA Faculty Practice Group (FPG)

- Background:
- A provider organization whose members participate in the various Departmental compensation plans of the UCLA’s David Geffen School of Medicine.
- FPG faculty and UCLA Medical Group affiliates provide clinical services in multiple hospitals and more than 70 ambulatory clinic settings in the UCLA Health System.
- The FPG provides financial, technical, quality, and support services to its physician members, including approximately 1,200 clinical faculty and approximately 200 clinical affiliates.
- The FPG serves 220,000 unique patients annually.

**Notes:**
UCLA Faculty Practice Group (FPG) Basics:
Authorized in 2005 to support physician faculty members, especially in clinical service delivery, the UCLA Faculty Practice Group (FPG) is a provider organization whose members participate in the various Departmental compensation plans of the UCLA’s David Geffen School of Medicine. FPG faculty and UCLA Medical Group affiliates provide clinical services in multiple hospitals and more than 70 ambulatory clinic settings in the UCLA Health System.  The FPG and the UCLA Hospitals (The Ronald Reagan UCLA Medical Center, the UCLA Mattel Children’s Hospital, the Lynda, the Stewart Resnick Neuro-Psychiatric Hospital, and the Santa Monica UCLA Orthopedic Hospital) together make up the UCLA Health System.
The FPG provides financial, technical, quality, and support services to its physician members, including approximately 1,200 clinical faculty and approximately 200 clinical affiliates.  On behalf of the clinical faculty, the FPG negotiates contracts with payors for professional services, provides complete billing services for professional fees (inpatient and outpatient), supports human resources and health information technology functions, collects and shares performance and quality information with members, provides training and quality-improvement support, and a host of other services.  As of June 2008, the FPG contracts with approximately 50 unique health plans.  
The UCLA Medical Group is the contracting entity for the UCLA FPG.  This includes HMO, PPO, and other types of service contracts.  The FPG is the organizational home for the UCLA Medical Group and its activities.  UCLA Medical Group activities in support of its HMO contracts include utilization review, quality management, credentialing, and affiliate contracting.  UCLA Medical Group currently has approximately 50,000 members.  
In all, the FPG serves about 220,000 unique patients annually.  
UCLA FPG physicians provide clinical care – primary, secondary and tertiary care – in a complete array of primary and specialty care services that are organized in the following Departments within UCLA’s School of Medicine:    
Anesthesia
Family Medicine
Medicine
Neurology
Obstetrics and Gynecology
Oncology
Ophthalmology
Orthopedics
Pathology
Pediatrics
Psychiatry
Radiation Oncology
Radiology
Surgery
Urology
In addition, the UCLA FPG is the Departmental home for a community primary care network called the Community Physician Network (CPN),  whose physician providers include both UCLA Faculty and Clinical Affiliates. 

## UCLA Faculty Practice Group (FPG)

- Fielding Patient Experience Surveys:
- Patient Experience Survey (“PES”)
- physician-level patient experience survey using a modified version of the CAHPS C-G survey known as the “patient experience survey” or “PES.” In 2006, allspecialty patients surveyed. UCLA FPG reports PES data at the individual physician, practice, department, and FPG levels.  Chief Administrative Officers and Department Chairs receive practice-level and department-level reports and individual physician-level reports.  Practice managers receive practice-level reports and de-identified MD-level data.

## UCLA Faculty Practice Group (FPG)

- Fielding Patient Experience Surveys:
- Patient Assessment Survey (“PAS”)
- Since 2004, the UCLA Medical Group has participated in California’s “Patient Assessment Survey” or “PAS,” which is organized by the California Cooperative Healthcare Reporting Initiative (CCHRI) in coordination with key payors to gather and share quality and patient satisfaction data.  This program administers annual surveys and reports group-level performance for consumers on the Office of the Health Advocate website (within the California Department of Health Services website). .  FPG reports these data as required to participate in this program.

## UCLA Faculty Practice Group (FPG)

- Use of CAHPS C/G
- Practice-level, point-of-service, **visit-specific** survey
- February 2008, the UCLA FPG developed its own point-of-service, visit-specific survey that ambulatory practices administer directly; results are shared with the FPG. The survey items cover the same, key domains as the PES, and are drawn from the C-G CAHPS survey as well as from the California Quality Collaborative’s (CQC) rapid cycle feedback survey. The goal is for practices to receive reports containing these data on a monthly basis to inform QI activities.

## UCLA Faculty Practice Group (FPG) 

- Demonstration focus:
- Physician-Patient and Office Staff-Patient Communication

## UCLA Faculty Practice Group (FPG)

- Target audience:
- Individual physicians (specialists) and their office staff.
- The target audience of the California-wide P4P program is the FPG as a whole.

## UCLA Faculty Practice Group (FPG)

- Interventions:
- The UCLA Faculty Practice Group has rolled out a series of quality-improvement interventions that address all four key domains of the PES Survey (Access, Provider-Patient Interaction, Helpful Office Staff/ Customer Service, and Coordination of Care).

## UCLA Faculty Practice Group (FPG)

- Interventions:
- Helpful Office Staff: BRITE Training
- Physician training***:  ***A series of workshops/courses for physicians to improve communication with patients.
- Patient Experience Quality-Improvement Collaborative:  A series of interactive problem-solving meetings including speakers, presentations, review of data, policies, and quality improvement strategies and activities.
- Communication of performance scores
- Standardized communication of diagnostic test results

## UCLA Faculty Practice Group (FPG)

- Interventions:
*6.**** ***Ambulatory Reports and Rapid-Cycle Feedback
- 7. Systematic review of complaint data
- 8. Education materials:  A series of educational materials directed at physicians to help them improve communication with patients.
- 9. Departmental alignment and incentives:***  ***A series of activities intended to align incentives internally (e.g., through the Community Practice Network of providers), as well as to respond to external incentives (California-wide P4P program).

## UCLA Faculty Practice Group (FPG)

- Key research questions:
- Whether and how the nine individual interventions, and the combination of them, impact patient experience.

## Yale Demonstration

- Partners Healthcare System/Partners Community Health Inc. & The Stoeckle Center

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Background:
- Implemented in the context of the statewide patient survey initiative sponsored by MHQP.  MHQP conducted a state-wide survey in 2007 in all adult and pediatric primary care, orthopedic, cardiology and obstetrical practices with three or more physicians.  The results of the primary care surveys were publicly reported in the summer of 2008.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Background:
- PCHI:
- PCHI is a management services organization (MSO) that provides the physicians with medical management services, quality improvement programs, data analysis, contracting, information systems and financial expertise.
- PCHI is affiliated with more than 1,000 internists, pediatricians and family practice physicians and over 3,500 specialists who provide care to more than 1.5 million patients.
- 15 Regional Service Organizations(RSO’s)

**Notes:**
The PCHI network is organized into Regional Service Organizations (RSOs). In each RSO the physicians coordinate medical care for their patients, share in financial risk or performance incentives in managed care contracts, and provide representation to PCHI's decision-making bodies. The RSOs vary greatly in size and structure, ranging from a small RSO of 14 physicians in group practice to a physician organization with more than 250 primary care physicians working in an academic medical center.

## Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Background
***BCBSMA Pay for Performance Contractual Obligations(P4P)***
- 2007 – PCHI over sampled at the physician level in primary care (adult and pediatrics), orthopedics, obstetrics/gynecology, and cardiology.
- 2008 – 95% of Practices with Composite Measure scores below the 2007 statewide mean will develop a Performance Improvement Plan(PIP)for one Composite, if any fall below the statewide mean.
- 2009 Practice Targets
- The Practice Target will be to achieve the lower of (1) the 2007 statewide mean; (2) a 5-percentage point improvement over the 2007 baseline, or (3) 90 points in the Targeted Composite Measure.
- Graduated Network Withhold Return is possible with
- 100% return if 80% of PCHI Practices achieve target;
- 75% return if 70% of PCHI Practices achieve target;
- 50% return if 65% of PCHI Practices achieve target; and
- 25% return if 55% of PCHI Practices achieve target.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

***Fielding Patient Experience Survey(s):***
- MHQP 2007 Survey Process
- Patient sample: **commercially insured*** ***patients** with one visit in 2006 (BCBS, Fallon, HPHC, Health New England)
- C/G CAHPS with some questions from the ACES survey instrument
- PCHI paid for over-sampling to obtain physician-level data for primary care, obstetrics, cardiology, and orthopedics.
- MHQP 2009 Survey Process
- MHQP will survey in the same specialties at the practice level and will also offer physician-level sampling again.
- MHQP will use the C/G CAHPS survey in its entirety with the addition of some of the supplemental modules.
- Primary care and specialty practice level data are expected to be publicly reported.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

**Target Audience(s) of the Intervention(s):**
- adult and pediatric PCPs and their office staff.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Interventions:
- Communication plan to educate PCHI/Partners leadership about the design of CAHPS surveys, the importance of patient-centered care, and how to approach this kind of process improvement.
- Dissemination of practice-level and unblinded physician level data to practice leadership
- Dissemination of blinded, physician-level data to all PCP’s.

## Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Interventions:
- Creation and dissemination of brief documents, designed to help practices respond to the MHQP data, at different stages of the improvement process.  Topics such as Planning the Improvement Effort, Initiating the Improvement effort, Evaluating the Improvement effort, Communicating the Improvement effort.
- Creation and dissemination of pre-populated Performance Improvement Plan Proposal to Blue Cross Blue Shield. Composites were selected for each practice for which system-wide resources and intervention strategies can be offered across the system.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Interventions:
- All of the improvement work will be integrated into practice redesign initiatives, whenever possible, and will be used to introduce the practices to the LEAN process improvement method.  Improvement efforts will also be explicitly linked to activities that will improve the quality of work life for the clinical and non-clinical staff in the practices, e.g. the Pediatric Guidebook.

## Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Interventions:
- Educational offerings and internal consulting:
- Educational programs and courses will be offered for three different audiences:
- Clinicians
- Administrators
- Front-line staff
- Internal organizational development and content experts visit with practices.
- Use of *The CAHPS Improvement Guide* as a resource will be promoted across all PCHI practices.

## PHS/Partners Community Healthcare Inc. (PCHI) & The Stoeckle Center

- Key research questions:
- Whether, and how, the individual interventions, and the combination of them, impact physician-patient, office staff-patient communication, and other selected composites.

## Factors That May Contribute to Measurable and Sustained Improvement

- Leadership is committed and engaged
- Strategic goals are aimed at organizational transformation
- Internal communication and action are aligned with strategic goals
- Motivation through external rewards and incentives