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

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