How Plans Influence Physician Practice Patterns

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How Plans Influence Physician Practice Patterns
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Plan for Today

• How Plans Influence Practice Patterns
• Team Meeting

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(Framework )
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Influencing Practice Patterns

• Selective contracting
• Use of gatekeepers
• Financial incentives
• Utilization review
• Profiling
• Clinical guidelines or protocols

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The Goals

• Reduce unexplained variation in treatment
  patterns
• Improve quality
• Underuse, overuse, misuse
• Lower costs

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What Do Managed Care Plans Do to Affect Care?

• Remler et al.
• Inquiry 34(3) Fall 1997

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Financial Incentives

• Capitation
• Risk/bonus pools for referrals and hospital
• Penalties/bonuses for achieving performance
  measures
• Immunization rates
• Mammography rates
• Patient satisfaction
• Productivity

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Average share of physicians patients who are
covered under different financial arrangements
(1995)
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Primary care physicians in managed care in
California (1996)

• Financial incentives
• Use of referrals (14)
• Use of hospital (19)
• Patient satisfaction (21)
• Productivity (18)
• Median earnings from bonus 7 of net practice
  income

Grumbach et al. Primary Care Physicians
Experience of Financial Incentives in Managed
Care Systems, JAMA 339(21)1516-1521, November,
19, 1998.
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Primary care physicians in California (1996)

• 58 of physicians with bonuses based individual
  and group performance
• 15 of physicians with bonuses based on
  individual performance only

Grumbach et al. Primary Care Physicians
Experience of Financial Incentives in Managed
Care Systems, JAMA 339(21)1516-1521, November,
19, 1998.
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Utilization Review

• What percentage of the patients you see have
  health plans that review
• Your clinical decisions about the appropriate
  site of care, including inpatient, outpatient and
  emergency room care?
• The content of your diagnosis or treatment
  decisions to assess appropriateness?
• The length of hospital stays of your patients?

Remler et al.
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Average share of physicians patients who are
subject to managed care techniques (1995)
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Utilization review denials Percent of patients
for whom recommended care denied coverage
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For what percentage of all the patients you see

• Are you provided with profiles of your clinical
  activity to identify outliers in the use of
  services, diagnoses, and/or treatments?
• Are there condition-specific protocols or
  guidelines for physicians to use in making
  diagnoses or prescribing treatments?

Remler et al.
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Average share of physicians patients who are
subject to managed care techniques (1995)
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Physician profiles
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Issues in Profiling

• Sufficient patient volume
• So that differences not just due to random
  variation
• Case-mix differences
• Information system requirements

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Physician Adherence to Protocols

• Perceived legitimacy
• Expert consensus
• Based on scientific evidence
• Involvement of local physicians
• Perceived purpose
• Quality
• Cost

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Physician Adherence to Protocols(cont.)

• General dissemination not effective
• Announcements
• Conferences
• Requires active strategies, in combination
• Participative workshops
• Outreach visits (academic detailing)
• Patient involvement
• Reminders or audit with feedback

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HMO Market Structure and Performance 1985-1995

• Wholey, Christianson,
• Engberg and Bryce
• Health Affairs 16(6) Nov/Dec 1997

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Hospital Days and Ambulatory Visits for
Non-Medicare Enrollees