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Quality of Care in Physician Groups Do Larger Integrated Systems Deliver Higher Quality Care?

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  1. Quality of Care in Physician GroupsDo Larger Integrated Systems Deliver Higher Quality Care? Ateev Mehrotra MD MPH RAND Pittsburgh & University of Pittsburgh AcademyHealth Annual Research Meeting June 5th 2007

  2. Background • Organization of Physician Groups • Integrated Medical Groups • Individual Physician Associations (IPAs) • Many believe that integrated medical groups provide higher quality care • Centralized decision making • Closer affiliations with physicians • Pooled resources

  3. Previous Evidence • Large medical groups generally more likely to implement QI • Provide health promotion • Smoking cessation • Patient reminders for preventive care McMenamin, Medical Care, 2003 Schmittdiel, Prev Med, 2004 Rittenhouse, Medical Care, 2006

  4. Two Studies • Does P4P impact relationship between organizational structure and use of QI initiatives • Relationship between organizational structure, QI initiatives, and performance on quality measures

  5. Will Increasing Use of P4P Impact the Relationship between Organization and QI Strategies

  6. Study Sample • 100 groups on Massachusetts 2005 publicly released physician group report card • Interviewed leaders of 79 groups between May and September 2005 • Semi-structured phone interviews lasting 30-60 min

  7. Prevalence and Magnitude of P4P in Massachusetts

  8. Use of QI Initiatives

  9. Variables Associated with Increased Use of QI Initiatives

  10. Findings • Even in a setting of widespread use of P4P, larger physician groups that utilize employed physicians are more likely to utilize QI efforts • Limitation that P4P not financially important to most groups

  11. Differences in Quality?

  12. Hypotheses • Integrated medical groups provide higher quality care than other types of physician groups • Higher quality is due to increased use of QI initiatives and EMR

  13. Study Population Examined quality of care delivered by 119 California physician groups to 1.7 million enrollees of PacifiCare

  14. Survey of Physician Groups • 45 minute interview with CEO or Medical Director (6/99 – 7/00) • Interviewees self-identified the type of physician group • Integrated medical group • IPA • Hybrid physician groups - core integrated medical group with associated IPA

  15. Quality Indicators 6 HEDIS quality measures (7/99-6/00) • Mammography • Pap smear • Chlamydia screening • Diabetic eye screening • Asthma controller medication use • Beta-blocker use after MI

  16. Other CovariatesIf There are Quality Differences, Why? • Use of EMR • Use of QI initiatives • Different physicians • % of physicians board certified • Larger size • Volume of patients - # of pts in the group eligible for each quality measure regardless of payor

  17. Unadjusted Quality Scores ** ** ** P < 0.05 difference from IPA ** ** ** ** **

  18. Greater Use of EMR and QI initiatives Among Integrated Medical Groups

  19. Surprisingly, Adjusting for Covariates Did Not Change Relationship Predicted outcomes shown ** P< 0.05 difference from IPA Adjusted for: Use of QI Use of EMR % of board certified Volume of care 10% ** ** ** ** 36% 16% ** ** 12% ** **

  20. Relationship Between Other Variables and Quality Scores • No clear relationship with quality scores: • EMR • QI initiatives • % physicians board certified • Exception • Volume of care

  21. Volume – Quality Relationship Predicted outcomes shown ** P< 0.05 difference from lowest quartile ** ** ** **

  22. Limitations • Cross-sectional study • California physician groups different • Labels do not capture heterogeneity of groups • Limited number of quality measures • Measurement of EMR & QI initiatives limited • Decision support in EMR?

  23. Overall Implications of Both Papers • Findings illustrate importance of organizational setting on quality of care • Need for better understanding of why • Do we need policy interventions that encourage integration?

  24. For More Information Ateev Mehrotra RAND Pittsburgh University of Pittsburgh School of Medicine mehrotra@rand.org

  25. Difference in QualityGroups with and without QI strategy

  26. Difference between groups with EMR and those without EMR

  27. Statistical Methods • Hierarchical multivariate logistic regression to account for the clustering of patients within physician groups • All covariates included in final model