Quality of Care in Physician Groups
Do Larger Integrated Systems Deliver Higher
Quality Care?
Ateev Mehrotra MD MPH
RAND Pittsburgh & University of Pittsburgh
AcademyHealth Annual Research Meeting
June 5th 2007
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
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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
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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
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Will Increasing Use of P4P Impact the Relationship
between Organization and QI Strategies
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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
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Prevalence and Magnitude of
P4P in Massachusetts
Groups with P4P incentives
in health plan contracts
Overall revenue tied to P4P
89%
2.2%
(0.3 – 8.0)
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Use of QI Initiatives
HbA1c Measurement
Mammogram Screening
Asthma Controller Medication Use
Adequacy of Well Child Visits
Chlamydia Screening
Hyperlipidemia Screening
LDL control
Hypertension Control
0
20
40
60
80
100
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Variables Associated with Increased Use
of QI Initiatives
Odds Ratio
(95% CI)
P
Value
Pay-for-performance
incentive
1.6
(1.1-2.5)
0.04
Physician Group employs
majority of physicians
(vs. employs minority)
Larger group (>median of
39 physicians vs. <median)
3.9
(1.7-8.8)
0.002
2.6
(1.1-6.2)
0.03
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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
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Differences in Quality?
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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
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Study Population
Examined quality of care delivered by
119 California physician groups to 1.7
million enrollees of PacifiCare
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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
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Quality Indicators
6 HEDIS quality measures (7/99-6/00)
1. Mammography
2. Pap smear
3. Chlamydia screening
4. Diabetic eye screening
5. Asthma controller medication use
6. Beta-blocker use after MI
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Other Covariates
If There are Quality Differences, Why?
1. Use of EMR
2. Use of QI initiatives
3. Different physicians

% of physicians board certified
4. Larger size

Volume of patients - # of pts in the group
eligible for each quality measure regardless of
payor
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Unadjusted Quality Scores
100%
90%
Medical Group
80%
Hybrid
**
IPA
70%
60%
50%
**
**
**
**
40%
** P < 0.05
difference
from IPA
**
**
30%
20%
10%
0%
Mammogram Pap Smears
Chlamydia
Diabetic Eye
Screening
Asthmatic
Medication
Use
Post-AMI
Beta Blocker
Use
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Greater Use of EMR and QI initiatives
Among Integrated Medical Groups
Integrated
Medical
Groups
Hybrids
IPAs
EMR
37%
18%
2%
Remind eligible women
of missed mammogram
74%
51%
28%
Asthma disease
management program
63%
62%
41%
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Surprisingly, Adjusting for Covariates Did
Not Change Relationship
Predicted
outcomes
shown
100%
Medical Group
Hybrid
IPA
90%
80%
70%
60%
10%
**
**
**
**
36%
16%
50%
12%
40%
30%
** P< 0.05
difference
from IPA
**
**
Adjusted for:
Use of QI
Use of EMR
% of board
certified
Volume of
care
**
**
20%
10%
0%
Mammogram Pap Smears
Chlamydia
Diabetic Eye
Screening
Asthmatic
Medication
Use
Post-AMI
Beta Blocker
Use
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Relationship Between Other Variables and
Quality Scores
• No clear relationship with quality scores:
– EMR
– QI initiatives
– % physicians board certified
• Exception
– Volume of care
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Volume – Quality Relationship
Predicted
outcomes
shown
100%
Highest Quartile
90%
80%
70%
**
Lowest Quartile
** P< 0.05
difference
from
lowest
quartile
**
60%
50%
40%
**
30%
**
20%
10%
0%
Mammogram
Pap Smears
Chlamydia
Diabetic Eye
Screening
Asthmatic
Medication Use
Post-AMI Beta
Blocker Use
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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?
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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?
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For More Information
Ateev Mehrotra
RAND Pittsburgh
University of Pittsburgh School of Medicine
mehrotra@rand.org
Difference in Quality
Groups with and without QI strategy
Measure
QI Strategy
Univariate
Multivariate
10% **
6%
Mammograms
Patient reminder program
Pap smears
Collect data
9%
5%
Beta blocker after AMI
Collect data
-1%
-2%
Diabetes disease management
program
8% *
1%
Feedback to doctors on screening
rates
-3%
-3%
Guidelines for diabetic eye screening
used
-1%
0%
Patient reminder program
5%
1%
Asthma disease management
program
1%
0%
5% **
6% **
Diabetic Eye
Screening
Asthma Med
Use
Feedback program to doctors on
asthma medication use
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Difference between groups with EMR and those
without EMR
Univariate
Multivariate
Mammogram
8% *
-1%
Pap Smears
-4%
-17%**
Chlamydia
8%**
5%
Diabetic Eye Screening
7%
0%
Asthmatic Medication Use
1%
1%
Post-AMI Beta Blocker Use
12% *
6% *
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Statistical Methods
• Hierarchical multivariate logistic
•
regression to account for the
clustering of patients within physician
groups
All covariates included in final model
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