Information publishers (WebMD, Consumer Reports, CHECKBOOK

1
Patient Experience SurveysSpreading Their Reach

• by Robert Krughoff and Paul Kallaur
• Consumers CHECKBOOK/Center for the Study of
  Services
• Consumer-Purchaser Disclosure Project
• July 12, 2007

2
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

3
Key Factors Affecting Costs

• How often survey is doneevery three years vs
  every year cuts the annual national cost from
  110 million to 37 million, the per-citizen
  annual cost to about 12 cents.
• Whether just a subset of specialty types is
  includedfor example, PCPs, Ob/Gyns,
  cardiologists, gastroenterologists.
• Number of completed surveys required per
  physicianfor 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
  ifplans/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
• How many plans share in cost for a physician
• What other organizations contribute to cost. For
  example
• Specialty boards have expressed interest in
  contributing because they can use survey results
  in Maintenance of Certification programs
• Malpractice insurers might pay for the data for
  use in underwriting
• Medicare and Medicaid might eventually contribute
  

4
Alternate Modes of Administration Dont 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 scaleespecially
  if physicians are resistant
• Mode/physician interaction effects observed in
  tests raise questions about manipulation by
  physicians. Will results be credible?

5
Key Question Who Pays for the Survey

• The user(s) of the information
• 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
  evaluatedfor 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

6
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

7
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 wholl 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

8
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 cant, and plans selectively audit)
• Various parties collaborate to create incentives
  for voluntary participationplans 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.

9
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 NBCHs eValuate, NCQAs
  Quality Plus, and Leapfrogs scorecards.
• Work with Bridges to Excellence, NCQAs 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
  physicians 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 pilotsand
  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.

10
We First Published Consumer Survey Ratings of
Physicians in 1980 and Hope Progress Will Be
Faster in the Next 27 Years
11
Appendix
12
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
  surveyswith 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 directlyso collaborative can sample, field,
  and analyze results (collaborative with help of
  affiliated plans will attempt selectively to
  audit sampling frame for completeness)

13
Collaborative Model Health Plan Driven (more
details)

• Work with community coalitions (BQIPs, Value
  Exchanges, etc.) where possibleand 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,
  AQAs principles for public and provider
  reporting)
• Allow individual physicians an opportunity to see
  their results before public release

14
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
  collaborativeboth 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

15
Advisory Committee to CHECKBOOK/CSS Collaborative

• 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

• 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

16
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 dont seem to depend much on plan or
  groupso 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/scoressimplifying 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