Everyone talks about quality, few pay for it

But pressure from payers and plans may mean more doctors encounter incentives based on standards other than productivity.

By Myrle Croasdale, amednews staff. Feb. 18, 2002.

Like most medical groups, Prevea Health Services of Green Bay, Wis., uses productivity as the main segment of its physician incentive pay formula. But the clinic is wondering whether that's the best way to get the best work out of its 135 physicians.

So it's considering results from patient satisfaction surveys as a financial incentive for doctors. Jeff Young, DO, head of Prevea's pediatrics department, said this could help improve care -- and Prevea's market share.

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"You can't just use productivity to [motivate] physicians," Dr. Young said. "Seeing more patients in a day doesn't mean that you're going to be a better doctor. In today's medical market, the patient needs to be treated more like a consumer, and we, unfortunately, have to see ourselves as a commodity. Patients in Green Bay have a great deal of choice. They don't have to come to Prevea."

The question of whether patient satisfaction surveys or some other quality measure should be included in determining how clinics pay doctors is one that is being asked more often, especially in larger groups such as Prevea, part of a system that includes two hospitals and a health plan.

In 1999, 19% of doctor pay incentives were based on quality, 72% on productivity.

Even health plans are getting in on the act. Late last year six California plans said they would pay individual doctors bonuses based on a standard quality-measurement system, which has yet to be created. That followed an announcement a few months earlier from WellPoint Health Networks' Blue Cross of California, which said it would pay doctors bonuses based on patient satisfaction scores.

One reason for the quality focus is that employers are swallowing double-digit health insurance premium increases and feeling like they're not getting that much more for their money. Corporate payers such as the Leapfrog Group are taking an active interest in promoting quality to improve care and prevent what they see as unnecessary health costs. Physician groups are seizing on patient satisfaction as a marketing tool.

But at this point, much of the talk about incentives within groups for patient satisfaction and quality is just that. At Prevea, for example, Dr. Young said many physicians are troubled about adding results from patient surveys to incentives, because they're so subjective. For now, Prevea doctors' incentives are based on productivity, meeting attendance and administrative responsibilities.

Measuring pay

One of the few surveys on the use of patient satisfaction or quality incentives in physician groups came Jan. 22 from the Center for Studying Health System Change.

The Washington-based group found that in 1999 (the most recent data available), 24% of 12,000 physicians nationwide faced incentives based on patient satisfaction surveys, while 19% had incentives based on quality-of-care measures. Meanwhile, 72% had productivity incentives, while 14% had incentives based on comparisons to other doctors on using medical resources. The numbers add up to more than 100% because physicians in the survey often received a variety of incentives.

The HSC study also found that those numbers changed only slightly from 1997.

Warren Jones, MD, president of the American Academy of Family Physicians, said these numbers were unlikely to have changed much since the survey was done. "The only physicians that might be pursuing more quality or patient satisfaction measures would be large groups in university settings, which have the infrastructure to capture that type of data," he said. "My own sense from discussions with physician leaders is that there is not a great deal of interest in the process. If you look at the HSC data, there was virtually no change from 1997 to 1999, and I'm willing to bet if the data were available today, there would be no change."

To change this, there would need to be a big increase in funding linked to quality, which isn't happening, Dr. Jones said.

And in the case of California HMOs' professed commitment to have at least a part of bonuses based on quality -- which plans elsewhere say they do -- doctors are not sure of the insurers' intentions.

Said Peter Warren, spokesman for the California Medical Assn.: "We would like to see a pilot program and make sure it has some real ways to measure improving quality. We hope it's not just a device for health plans to associate themselves with a white-hat issue. There is nothing in the system to give more money to take care of sicker people."

"If plans are smart, they'll come out with a proposed mechanism for quality measures and ask physicians and medical associations for input," said AMA President Richard F. Corlin, MD. "If they do that, they may well come up with a good system," and one that many groups already have in place.

Quality is key

Cheryl Phillips, MD, medical director of the Sutter Medical Group in northern California, said the health plan report cards and quality incentives that she had seen duplicated what Sutter already does.

"Incentives should lie with us, since the health plan is just passing through the dollars," Dr. Phillips said.

Sutter, which has 160 doctors and 50 physician assistants and nurse practitioners, uses a small percentage of its withholding money from capitated plans for physicians' bonuses. Besides utilization measures, Sutter's bonuses are linked to quality measures such as cancer screening and patient satisfaction surveys keyed to each doctor.

Child and adult immunizations are going to be included soon, as well as peer reviews. Dr. Phillips may drop use of Health Plan Employer Data and Information Set standards, because the doctors hit these targets regularly.

The trick to keeping doctors involved is the quality tie. "Utilization management alone is not that useful," she said. "We need to make a clear link to quality to get doctors to change."

Dr. Corlin said objective quality measures had always been a goal of doctors. While big groups may use financial incentives to get doctors to respond to quality measures, small groups have the advantage of peer pressure.

Dr. Corlin's group of six gastroenterologists hired a gastroenterologist from outside the group to review charts. This doctor's findings are now a part of regular office meetings.

"We have someone with no ax to grind and no reason to not be fully objective," Dr. Corlin said. "We use peer pressure within the group. So far, we have adopted some data additions on patients.

"We did find some documentation problems with one physician. We talked among ourselves. The next time charts were reviewed, that problem was gone. We have an intolerance of mediocrity."