Access Intervention in an Integrated, Prepaid Group Practice: Effects on Primary Care Physician Productivity

This paper presents one part of the evaluation of Group Health Cooperative's (GHC) Access Initiative, an organizational innovation designed to improve access to improve quality (Ralston et al. in press). The Initiative's broad goal is to transform GHC from the standard health management organization (HMO) model, with managed care controls restricting enrollee access and choice, to a more patient-centered model, in which enrollees receive care when and how they want it from their choice of primary or specialty provider. We specifically examine the effect of this patient-centered intervention on primary care physician (PCP) productivity. The Initiative comprises the following seven, system-wide reforms rolled out during 2002–2003: Advanced access to primary care (appointments with a patient's PCP at the preferred time of the patient). Direct access to most specialties without primary care gatekeeping. Changes in physician compensation. Primary care system redesign to control costs. Patient-provider secure messaging through the MyGroupHealth enrollee website including physician financial incentives for secure messaging patients. Internet access for enrollees to their electronic medical records (EMRs) through MyGroupHealth. Health promotion information on the MyGroupHealth secure website. GHC's Access Initiative is “ahead of the curve” in improving quality of care in concordance with national recommendations. In two prominent reports the Institute of Medicine (IOM) (2001) and RAND Community Quality Index Study (McGlynn et al. 2003) conclude that the U.S. health care delivery system is plagued by low-quality care and in need of fundamental change. The IOM argues that poorly designed delivery systems are a major cause of the problem, and that quality can be improved by changing systems to assure that health care is safe, effective, patient-centered, timely, efficient, and equitable. Complementing these objectives, the IOM also recommends changes in three areas: (1) new care processes guided by “simple rules” to serve patient needs (e.g., “patients should receive care whenever they need it and in many forms, not just face-to-face visits”); (2) better information technology to support care processes; and (3) alignment of provider payment with quality improvement (IOM 2001). Three of the IOM aims (patient-centeredness, timeliness, and efficiency) are central to the Access Initiative, and the Initiative includes all three IOM change areas (simple rules, information systems, and physician payment). Our principal objective in this paper is to estimate and interpret effects of the Access Initiative on several dimensions of PCP productivity. While patient centered, the Initiative is also designed to enhance physician incentives and organizational structures and processes to support improved access and quality of care. Indeed, increased physician productivity is essential in realizing the Initiative's primary goal of improving access for patients, while maintaining financial viability. A secondary objective of the paper is to assess the relationship between certain physician and enrollee characteristics and PCP productivity, while controlling for clinic attributes and time. This study is one of a small number addressing PCP productivity within an HMO (Lewandowski et al. 2006), and also one of the few using an extended time series (Hurdle and Pope 1989; Pope 1990), thereby allowing us to trace the evolution of primary care productivity. Three of the Initiative's seven components directly address physician productivity: Primary Care Redesign: Faced with declining enrollment, relative provider inefficiency when compared with similar group practices, and excessive overhead costs, GHC sought to reposition the group practice in October 2002 to be market competitive by restructuring primary care (Ralston et al. in press). Changes in Physician Compensation: To support Advanced and Direct Access and Primary Care Redesign, the primary physician compensation method changed from 100 percent of guaranteed salary to a variable compensation system in April 2003. Primary physicians receive 80 percent guaranteed base salary plus additional variable compensation up to 120 percent of the guaranteed base, determined primarily by individual physician productivity (number and intensity of patient encounters). Patient–Physician Secure Messaging through MyGroupHealth: In January 2002, GHC introduced web-based secure messaging between patients and providers. The website, MyGroupHealth, was introduced in 2000 and by April of 2002 allowed all enrollees to exchange electronic messages with their PCPs. Patient access to the EMR over MyGroupHealth is provided through a direct link to Group Health's clinical information system (CIS), EpicCare.™ Physician order entry and integrated systematic documentation in the CIS was rolled out at Group Health between October 2003 and December 2005. New Contributions: This study makes several unique contributions to the evidence base on PCP productivity: We control for enrollee case mix in productivity analyses, thus eliminating an important potential confounder in previous medical productivity studies. This study examines case-mix-adjusted panel size, thus examining productivity beyond measures of service production per physician full-time equivalent (FTE). Case-mix-adjusted, annual cost per member per quarter (PMPQ) in the provider's panel is also measured, allowing one to assess PCP clinical efficiency in caring for a defined population. To the extent that improved health of the physician's panel is related to lower annual care costs per enrollee, this PMPQ metric comes closer to capturing production of health—the ultimate “product” of physician services. The time series of productivity experience (8 years) is the longest of extant studies of medical productivity. We focus on the intervention's joint effect on productivity, rather than attempting to parse the impact of each of the seven Initiative components. The Access Initiative was conceived as an integrated package. Our evaluation design takes advantage of the phasing of key aspects of the Initiative to identify changes in productivity that are plausibly attributable to the Access Initiative, but we do not attempt to link discrete intervention components to changes in primary care productivity.