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Health Affairs, 22, no. 1 (2003):
181-189
doi: 10.1377/hlthaff.22.1.181 © 2003 by Project HOPE |
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Health Tracking |
MARKETWATCH
How Are Health Plans Supporting Physician Practice? The Physician Perspective
| Abstract |
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IPA-model HMOs are now the dominant organizational structures for delivering "managed care" in the United States. Are they taking advantage of opportunities to support physician practices in ways that arguably could improve care? In this paper we report the findings from a survey of generalist and specialist physicians in nineteen health plans. Not surprisingly, we found that generalists are much more likely than specialists are to be the target of health plans’ efforts to support care delivery. However, our survey data indicate that these opportunities generally are not being fully exploited; also, efforts that plans do make to provide information to support care often are not seen as useful by physicians.
Independent practice association (IPA)–model health maintenance organizations (HMOs), typically with large physician and hospital networks, have become the dominant organizational forms that deliver "managed care."1 The literature suggests that some health plans of this type use the data they, or their intermediaries, collect to provide physicians with information about performance relative to that of peers and benchmarks.2 They also provide educational and practice support for physicians, such as the development and implementation of practice guidelines and disease management programs.3 Efforts such as these could improve the quality of care and, depending on how they are implemented, could be viewed favorably by physicians in health plan networks. They also could be useful to plans in demonstrating "value added" to employers, in the face of rapidly rising premiums.4
How widely are the tools that could support physician practice and care improvement being used by health plans? Are they being implemented effectively? We address these questions from the perspective of physicians who contract with health plans. Physicians have information about the operation of health plans that is not observable to patients or purchasers or, sometimes, to the health plans themselves. For instance, while plans may report that they compile and distribute data that benchmark physician practices, do physicians receive this information or find it useful? There is a large literature on physicians’ perceptions concerning managed care in general, but much less is known about their views concerning managed care tools, particularly those that can be supportive, as opposed to restrictive, and the usefulness of these tools in the context of relationships with specific health plans.5
| Data And Methods |
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 Top Data And Methods Study ResultsDiscussion And Policy...NOTES |
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To learn about physicians’ perspectives on these issues, we administered a mail survey to 11,453 generalist and specialist physicians in twenty-three health plans serving commercial, Medicare, and Medicaid populations. Our survey instrument is grounded in a conceptual framework for physicians’ assessment of health plan quality.6 It also was informed by a 1998 telephone survey of 5,050 physicians by the same research team. This effort was important in developing the survey questions and in confirming that physicians can respond to questions about patients in specific health plans.7 However, it also was clear from the telephone survey that physicians often were not able to distinguish the proximate source of practice management efforts: health plans or intermediary organizations that contracted with plans. Therefore, in our mail survey we asked physicians about practice management efforts for patients in plan X, not whether plan X carried out these efforts directly. This approach is consistent with the view that purchasers and consumers care whether these practice management efforts are directed at patients in a specific health plan, not what organizational structure is used to carry them out. It is the responsibility of the health plan to find the most efficient means to manage care, whether directly or by contract to intermediary organizations.
We solicited participation from commercial, Medicare, and Medicaid purchasers in Seattle, New York City, Miami, Pittsburgh, Philadelphia, and Denver. These purchasers facilitated access to the physician lists for their contracted health plans. Overall, 194–300 physicians per health plan were surveyed, with no financial incentives provided to respondents. An experiment was incorporated into the survey administration to evaluate different modes of follow-up with nonrespondents.8
We report selected survey results for physicians providing care to enrollees in nineteen health plans that we classified as IPA-model HMOs (Exhibit 1
). These plans did not volunteer to be part of our study, but neither are they a random sample. We view them as broadly representative of the large-network plans that are now dominant in the HMO industry; ten are part of national HMO firms, four are regional plans (including Blue Cross/Blue Shield HMO affiliates), and five are local. In eight plans we asked physicians about care management for commercial patients, in eight we asked about Medicaid patients, and in three about Medicare patients.
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A total of 2,982 physicians responded to the survey; 57.1 percent were generalist physicians. More than 90 percent of both generalists and specialists had contracts with more than two plans at the time of the survey; they were asked only about care management strategies employed by the specific (reference) plan. Not surprisingly, generalists were significantly more likely to report higher percentages of their patients enrolled in the reference plan. After retrospectively adjusting for errors in physician lists, we estimate that the overall response rate for eligible physicians was 41–45 percent. For most plans, very few data on non-respondents were available. However, we obtained detailed characteristics about physicians in two plans, including the number of plan patients they served. We found no major differences between respondents and nonrespondents in these two plans.
| Study Results |
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| TopData And MethodsStudy ResultsDiscussion And Policy...NOTES |
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The most common practice-support strategy reported by physicians was clinical guidelines, with 68 percent stating that guidelines were available to them for patients in the reference plan. However, plans also continue to use restrictive managed care tools; the second most common strategy was prior authorization for specialist care (Exhibit 2
).
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The entire pattern of results in Exhibit 2
suggests a much more aggressive effort by health plans to influence the care provided by generalists than by specialists. However, in general, it appears that plans could do more in support of clinical practice improvement. For example, only 25 percent of physicians said that they received any reports (of the four types in Exhibit 2) for patients in the reference plan; 41 percent received reminders about patients’ ongoing care needs.
With respect to pharmacy management, the results were similar but more striking (Exhibit 3); 22 percent of the physicians reported receiving profiles (cost of prescriptions or compliance with guidelines) or summary reports on pharmacy use (such as drug interaction, efficacy, and dosage levels) for patients in the reference health plan. A relatively small percentage received information to assist in responding to direct-to-consumer drug advertising or were asked their views on pharmacy policies. Again, generalists were significantly more likely to report that they received patient-specific pharmacy information or educational support.
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Overall, 63 percent of physician respondents in our survey treated patients in an in-patient setting who were enrolled in the reference plan during the six months prior to the survey. Less than half of this subset reported that they were required to seek prior authorization for hospitalization of patients in the reference plan (Exhibit 4
), even though prior authorization historically has been a hallmark of HMOs’ aggressive management of hospital use. However, only 15.5 percent reported receiving admission and length-of-stay utilization reports on their hospitalized patients. Only 3.6 percent said that the plan asked them about the quality of hospital care.
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Physicians who reported that clinical guidelines and disease management programs were available generally found them to be useful (Exhibit 5
). The information provided by health plans, such as reminders of patients’ on-going health needs, reports on patient satisfaction, reports on the use of referrals or tests, and reports on immunization and mammography, also was viewed as useful by the majority of physicians who said that they received the information. Generalists rated the usefulness of reminder information significantly higher than did specialists, whereas specialists rated the accuracy of reports on referrals or tests significantly higher than did generalists (Exhibit 5).
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Patient-specific drug information generally was viewed favorably by generalists and specialists with respect to accuracy and usefulness. Such information was rated as more useful than summary reports of patients’ prescription drug use (Exhibit 6
).
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With respect to inpatient care, a health plan’s prior-authorization process (where present) was reported to have delayed a hospital admission in the past six months by 28.2 percent of respondent physicians; 18.7 percent reported that hospital admissions were denied in the past six months. Admitting specialists were significantly more likely than generalists were to report a delay because of prior-authorization requirements. Twenty-five percent of physicians who had admitted a patient in the past six months had requested an extended length-of-stay, and physicians reported that 48.9 percent of those requests were denied (Exhibit 7
). Physicians on average gave high ratings to the accuracy of utilization reports on patient admissions and lengths-of-stay but were less favorable about the usefulness of these reports (Exhibit 8).
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In our survey process we asked some physicians about plans’ efforts relating to their commercial patients, some about Medicare patients, and others about Medicaid patients. We found few significant differences in physicians’ responses across these three groups; these differences were small in magnitude and did not have a clear interpretation.
| Discussion And Policy Implications |
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| TopData And MethodsStudy ResultsDiscussion And Policy...NOTES |
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Generalists versus specialists. First, generalists were more likely to be the target of the plan’s management efforts than specialists were. More than half of generalists reported the availability of guidelines, disease management programs, and reminders of their patients’ ongoing care needs. Generalists were far more likely than specialists were to receive all types of reports.
Usefulness of information feedback. Second, physicians’ ratings of the usefulness of the information-feedback efforts for health plan patients were not impressive, possibly reflecting the fact that one-third to half of physicians who reported receiving these reports questioned their accuracy. In contrast, clinical guidelines and disease management programs, where health plans’ reporting accuracy was not an issue, were viewed as much more useful. The skepticism of contracting physicians about health plan reports appears to be an important limitation on the ability of plans and their intermediaries to use information systems to support physician practice.
Incorporating physicians’ views.
Third, physicians perceived that health plans made little attempt to incorporate their views on the plan’s pharmacy and hospital policies (Exhibit 9). This suggests that health plans may not be investing in the development of longer-term collaborative relationships with their network physicians relating to care management. Large physician network sizes may discourage plans from pursuing these types of collaborative relationships.
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Concluding comments. In theory, because health plans have an enrolled population of members and a defined network of physicians, they can be held accountable for the health care received by enrollees. There is potential for health plans to influence and improve care delivery by using information, protocols, education, and treatment support directed at quality improvement, or by contracting with intermediary organizations that do so. If done effectively, these strategies also could strengthen plans’ position in negotiations with purchasers. However, our survey data generally indicate that health plans are not effectively exploiting many of these opportunities, at least from the standpoint of physicians. More work clearly is needed to understand why this is the case. One possibility is that plans are providing what purchasers want and expect and therefore feel little pressure to improve. However, our experience in sharing the survey data with health plan medical directors, and with purchasers, suggests that both groups see potential for improvements based on the survey findings. Most health plans intended to use selected survey results to help them relate to network physicians more effectively. Also, most of the purchasers in our study expressed a willingness to collaborate with plans to use the survey findings to improve health plan systems and processes.
This physician survey effort establishes the feasibility of using regularly scheduled, standardized surveys about physicians’ experiences in specific health plans to benchmark health plan performance in areas that arguably should be of concern to purchasers, consumers, and, therefore, health plan accreditation organizations. For public programs like Medicare and Medicaid, which now face severe budget constraints, an important policy question is whether the potential improvements in health plan quality, and ultimately patient care, that can result from surveying physicians about plans are sufficient to justify survey costs.
| Editor's Notes |
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Jon Christianson is the James A. Hamilton Chair in Health Policy and Management, Department of Healthcare Management, Carlson School of Management, at the University of Minnesota in Minneapolis. Doug Wholey is professor and director of the Public Health Administration Program, Department of Health Services Research and Policy, at the university’s School of Public Health. Louise Warrick is a consultant from Tucson, Arizona. Paula Henning is a senior scientist in the Division of Nephrology, Minneapolis Medical Research Foundation.
This research was funded by the Robert Wood Johnson Foundation. The authors appreciate the support of other members of the Physicians Evaluating Health Plans research team: Andrew Bindman, Steven Borowsky, Bruce Center, Margaret King Davis, Michael Finch, David Knutson, Mary Jo O’Brien, Todd Rockwood, and Maureen Smith.
| NOTES |
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| TopData And MethodsStudy ResultsDiscussion And Policy...NOTES |
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- InterStudy, InterStudy Competitive Edge, Part II: HMO Industry Report 11.2 (St. Paul: InterStudy Publications, October 2001); and InterStudy, PPO Directory and Performance Report 2.0 (St. Paul: InterStudy, 2001).
- J.B. Christianson et al., Managed Care and the Treatment of Chronic Illness (Thousand Oaks, Calif.: Sage Publications, 2001).
- J. Sisk, "How Are Health Care Organizations Using Clinical Guidelines?" Health Affairs (Sep/Oct 1998): 91–109; and InterStudy, InterStudy Competitive Edge, version 7.2 (St. Paul: InterStudy, October 1997), 63–72.
- See, for instance, B.C. Strunk, P.B. Ginsburg, and J.R. Gabel, "Tracking Health Care Costs," 26 September 2001, www.healthaffairs.org/WebExclusives/Strunk_Web_Excl_92601.htm (15 October 2002); and "Employers Must Act Now to Rein In Costs of Health Care, Towers Perrin Survey Says," BNA’s Health Care Policy Report (18 March 2002): 419.
- See, for instance, R.A. Bell et al., "Physicians’ Attitudes toward Managed Care: Assessment and Potential Effects on Practice Behaviors," American Journal of Managed Care 3, no. 9 (1997): 1297–1304; [Medline]K.S. Collins, C. Schoen, and D. Sandman, "The Commonwealth Fund Survey of Physician Experiences with Managed Care," March 1997, www.cmwf.org/programs/health_care/physbf.asp (15 October 2002); K. Ellsbury, D. Montano, and K. Kraft, "A Survey of the Attitudes of Physician Specialists toward Capitation-Based Health Plans with Primary Care Gatekeepers," Quality Review Bulletin 16, no. 8 (1990): 294–300; J. Hadley et al., "Perceived Financial Incentives, HMO Market Penetration, and Physicians’ Practice Styles and Satisfaction," Health Services Research 34, no. 1 Pt. 2 (1999): 307–321; and [Medline]Henry J. Kaiser Family Foundation/Harvard School of Public Health, "Survey of Physicians and Nurses," July 1999, www.kff.org/content/1999/1503 (24 October 2001).
- D. Wholey, J.B. Christianson, and L. Warrick, "Evaluating Health Plan Quality I: A Conceptual Model" (Unpublished manuscript, University of Minnesota, 2002). The survey instrument can be downloaded from www.hsr.umn.edu/phps.
- M.A. Smith et al., "To Help or Hinder: Which Is More Important in Explaining a Physician’s Willingness to Recommend a Health Plan?" Medical Care (May 2001): 469–477.
- T. Rockwood et al., "Mixed-Mode of Follow-Up Administration in a Survey of Physicians: Mail versus Telephone" (Unpublished manuscript, University of Minnesota, 2002).
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