Transcript Planning a Collaborative to Survey Patients About Their

Patient Experience Surveys—
Spreading Their Reach
by Robert Krughoff and Paul Kallaur
Consumers’ CHECKBOOK/Center for the Study of Services
Consumer-Purchaser Disclosure Project
July 12, 2007
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Cost of Physician Surveys
• Survey Administration
– C/G CAHPS mail-mode protocol is about $220 per physician
(assuming need for 40 responses and get 36% response rate).
– $110 million to get results on 500,000 physicians annually.
– Requires surveying about 56 million patients.
• Reporting Results
– Quality improvement
– Public reporting
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Key Factors Affecting Costs
• How often survey is done—every three years vs every year cuts
the annual national cost from $110 million to $37 million, the percitizen annual cost to about 12 cents.
• Whether just a subset of specialty types is included—for
example, PCPs, Ob/Gyns, cardiologists, gastroenterologists.
• Number of completed surveys required per physician—for
example, moving from average of 40 completes per physician to 32
completes per physician cuts cost by 20% and still may allow
statistically significant distinctions among physicians in some markets
on some dimensions.
• Protocol options—
– Nonprofit mail rates possibly cuts 20%
– First wave by e-mail might save in future if—plans/groups/docs
can get e-mail addresses, spam standards and blocks can be
accommodated, privacy issues with shared or corporate e-mail
addresses can be addressed
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Alternate Modes of Administration
Don’t Pay Off
• Passive Web survey on plan website
– Plans trying this have gotten tiny response
– Concerns about bias
– Worth continuing to test and find ways to promote, but not
currently promising
• Hand-outs of questionnaires or survey invitations in
physicians’ offices
– Has been used by specialty boards, but not where scores counted
– Distribution can be cheaper to the study sponsor than mail, but
may impose hidden costs on the practice, and on the sponsor to get
practices to participate and to audit
– Might be difficult for a plan or other sponsor to implement (and
audit) on a large scale—especially if physicians are resistant
– Mode/physician interaction effects observed in tests raise questions
about manipulation by physicians. Will results be credible?
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Key Question: Who Pays for the Survey
– The user(s) of the information—
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Consumers (through information publishers)
Employers
Plans
Medical groups
Government payers
Government health agencies
Specialty boards
Malpractice insurers
Multi-stakeholder consortiums
– Physicians, practices, or medical groups being
evaluated—for intrinsic self-improvement motives, to earn
recognition/rewards for doing survey or performing well (in PVRP,
P4P, recognition program, certification programs), or because
purchasers or governments simply require it
– Either way, consumers/the public pays indirectly
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Implementation Models for CAHPS
Clinician & Group Survey
• Regional collaboratives
– BQI markets
– Aligning Forces markets
• Accreditation/certification
– American Board of Medical Specialties
• Independent efforts
– Health plans
– Medical groups
• National health plan consortium
– CSS initiative
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Collaborative Model: Health Plan Driven
• Major health plans contract to contribute to survey costs
(formula that takes into account number of docs on which they want data,
number of members who’ll benefit from data, a basic pay-to-play element)
• Plans provide survey sampling frame of physicians’ patients (pooled
across plans) from claims data
• Contributing plans get rights to resulting data for their use for
provider directories, P4P, recognition programs, etc.
• Medical specialty boards get data on docs who are up for
maintenance of certification and boards or docs contribute to survey costs
• Medical groups and hospitals can buy rights to data from
collaborative (medical groups might be invited or required by plans to
participate in initial survey costs)
• Information publishers (WebMD, Consumer Reports, CHECKBOOK,
Revolution Health, Healthgrades, etc.) will be able to purchase rights to
survey results for publication directly to consumers
• Other users such as malpractice insurers will be able to purchase survey
results
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Collaborative Model: Physician Driven
• Physicians or medical groups volunteer and pay for survey
• Physicians/groups own the data and decide to whom to
release it (option 1: must agree to make public before collection;
option 2: decide after seeing their data)
• Plans collaborate to provide survey sample (or medical
groups/physicians provide survey sample if plans can’t, and plans
selectively audit)
• Various parties collaborate to create incentives for
voluntary participation—plans and other payers (P4P, PVRP,
recognition programs, etc. using Bridges to Excellence, NCQA
Medical Home, and similar approaches), specialty boards for maint. of
certif., information publishers, malpractice insurers, etc.)
• Collaborative role same as in previous model for
independent survey implementation, reporting standards,
etc.
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To Move Toward Goal of Widespread
Surveys of Patients About Physicians
• CSS/CHECKBOOK and consumer/purchaser leaders need to—
– Try to arrange for plans that collaborate on patient surveys to be scored higher by
plan evaluation tools like NBCH’s eValuate, NCQA’s Quality Plus, and Leapfrog’s
scorecards.
– Work with Bridges to Excellence, NCQA’s Medical Home effort, Medicare
measurement programs (including PVRP), and other programs to ensure that P4P
programs and network designs reward physicians who participate and score well in
patient surveys.
– Work with specialty board leadership on integrating patient survey results into
Maintenance of Certification and quality improvement programs.
– Work with malpractice insurers and their associations to assess the usefulness of a
physician’s patient survey results as an underwriting element.
– Work with AQA leadership and CMS/AHRQ to move the collaborative patient
survey approach forward on the agenda of BQIPs and Value Exchange pilots—and
possibly to make collaborative patient surveys the initial organizing catalyst for
coalitions in some communities.
– Recruit community coalitions to move forward the collaborative patient survey
approach in their communities.
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We First Published Consumer Survey Ratings of
Physicians in 1980 and Hope Progress Will Be
Faster in the Next 27 Years
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Appendix
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Collaborative Model: Health Plan Driven
(more details)
• Sampling at beginning, and analysis and scoring at back end,
are done by collaborative
• Survey fielding is done by contractor or contractors
competitively chosen by committee of plans, specialty boards,
and other collaborative participants
• Plans pay for survey only every three years
• Physicians or medical groups who want to be surveyed more
often can pay for those surveys—with plans providing sampling frame
and collaborative independently sampling, fielding, and analyzing results
• Physicians not affiliated with participating plans (or with too
little sample in those plans) can arrange for surveys by providing sampling
frame through medical groups, if so affiliated, or directly—so
collaborative can sample, field, and analyze results (collaborative with
help of affiliated plans will attempt selectively to audit sampling frame for
completeness)
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Collaborative Model: Health Plan Driven
(more details)
• Work with community coalitions (BQIPs, Value Exchanges,
etc.) where possible—and seek to provide an initial organizing
principle for coalitions where they do not already exist
• Welcome participation from government agencies and
purchasers, including Medicare, and possibly provide a vehicle for
incorporation of patient experience surveys into PVRP
• Use C/G CAHPS survey questionnaires and protocols
developed by AHRQ as approved by NQF
• Allow plans or others who have license to use survey
results to have flexibility in reporting but not to change
underlying scores calculated by collaborative (for example, by
changing case-mix adjustment method)
• Require all reports of results to adhere to well-accepted
reporting principles (for example, AQA’s principles for public and
provider reporting)
• Allow individual physicians an opportunity to see their
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results before public release
What CHECKBOOK/CSS Will Be
Doing in Coming Months
• Continue to revise the description of the collaborative
models based on feedback from advisory committee and
others, including seeking to share costs and capture some survey
responses more efficiently
• Seek several communities that are interested in being sites
for pilot surveys for the collaborative—both models
• Recruit health plans, specialty boards, medical groups,
foundations, and others to participate in, and contribute to, the
pilot projects
• Hope to launch pilot projects this fall
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Advisory Committee to CHECKBOOK/CSS Collaborative
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Reed Tuckson, MD, Senior Vice President for
Consumer Health and Medical Care Advancement,
UnitedHealthcare
Dick Salmon, MD, PhD, Vice President and National
Medical Executive, CIGNA
Paul Thompson, Director, National Cost & Quality
Transparency Initiatives, CIGNA
Chuck Cutler, MD, M.S., National Medical Director,
Aetna
Thomas James, MD, Chief Medical Officer, Humana,
Kentucky
Arnold Milstein, MD, Medical Director of Pacific
Business Group on Health and the National Health
Care Thought Leader at William M. Mercer Co.
Andy Webber, President and CEO, National Business
Coalition on Health
Francois DeBrantes, National Coordinator, Bridges to
Excellence
Debra Ness, CEO, National Partnership for Women
and Families
Joyce Dubow, Associate Director, AARP Public
Policy Institute
Jim Guest, President and CEO, Consumer
Reports/Consumers Union
Melinda Karp, Director of Programs, Massachusetts
Health Quality Partners
Cary Sennett, MD, Senior Vice President for
Research, American Board of Internal Medicine
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F. Daniel Duffy, MD, Executive Vice President,
American Board of Internal Medicine
Steve Miller, MD, MPH, President, American Board
of Medical Specialties
Amy Mosser, Vice President, American Board of
Medical Specialties
Carmella Bocchino, Executive Vice President,
Americas Health Insurance Plans
Charles Darby, CAHPS Project Officer, U.S. Agency
for Healthcare Research and Quality
Bernard Rosof, MD, Co-chair, AMA Physician
Consortium for Performance Improvement and Senior
Vice President, North Shore-Long Island Jewish
Health System
David Stumpf, MD, Medical Director,
UnitedHealthcare Clinical Operations
Gregory Pawlson, MD, MPH, Executive Vice
President, National Committee for Quality Assurance
Carol Cronin, consumer information consultant
Michael Barr, MD, Vice President, Practice Advocacy
and Improvement, American College of Physicians
Paul V. Miles, MD, Vice President and Director of
Quality Improvement, American Board of Pediatrics
Peter Hayes, Health Benefits Strategist, Hannaford
Bros.
Lee Tiedrich, Partner, Covington & Burling, LLP
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Benefits of Multi-User Collaboration
• CHECKBOOK/CSS has been working to build a
collaborative of plans, specialty boards, and others (see
advisory committee list at end of presentation)
• Docs’ scores don’t seem to depend much on plan or
group—so one score per doc may be able to be used by all
• Avoid duplicative cost of survey set-up and fielding
• Get adequate sample sizes per doc
• Minimize survey respondent burden
• Produce consistent results/scores—simplifying for
consumers and providers
• Insulate against possible physician resistance
• Be a better candidate for public/government support
• Individual organizations can still distinguish themselves by
how they use the survey results
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