An abstract is available at:
An analysis of the organizational and market factors that affect primary care physicians' performance on patient surveys found that physicians who work in larger groups, particularly integrated medical groups, performed better on several measures of patients' experiences. Doctors practicing in markets that have a high concentration of low-income patients performed worse on measures of access to care and care coordination—perhaps because they face systemic constraints.
Increasingly, pay-for-performance programs and public reporting initiatives take into account physicians' performance on measures of patients' health care experiences. That's why it is important to understand the extent to which physician performance is shaped by the activities and characteristics of the medical groups in which physicians practice, as well as by market factors beyond their control—such as availability of doctors in a given area.
- Most California medical groups that monitor individual physician performance using the CAHPS Clinician & Group Survey are using one or more interventions to help improve this area of performance, with individual skills training used most commonly and financial incentives for individual physicians used least.
- Physicians in larger medical groups, particularly those who are part of integrated medical practices, performed more favorably on all patient experience measures than those in smaller, less-integrated practice settings.
- Physicians belonging to medical groups whose financial incentives place greater emphasis on productivity and efficiency showed worse performance on all patient experience measures, with significantly lower performance on some.
- Physicians in medical groups located in areas with greater "area-level deprivation" (a measure of the percentage of residents living at or below 200 percent of the federal poverty level) performed worse than physicians in groups located in more affluent areas on measures of access to care and care coordination.
Addressing the Problem
The results suggest that financial incentives emphasizing productivity and efficiency might negatively affect patients’ care experiences—for example, by encouraging doctors to see more patients per day, resulting in longer waiting times and rushed, less personalized visits. In the context of statewide pay-for-performance and public reporting that includes patient experience measures, it appears that large medical groups, particularly integrated medical practices, may invest more effectively in systems or strategies that facilitate more favorable patient care experiences; these include better care coordination, access to care, and clinician–patient communication. Policies are needed to ensure that pay-for-performance programs do not punish physicians who work in markets with high concentrations of vulnerable populations and therefore face constraints when attempting to improve the quality of care they deliver.
About the Study
The authors examined data from the 2006 and 2007 CAHPS Clinician & Group surveys for 2,009 adult primary care providers belonging to 34 diverse medical groups in California. Survey questions related to physician communication, access to care, care coordination, and office staff interactions. The authors also asked medical group directors about the type and magnitude of financial incentives available for physicians and the medical group’s efforts to improve patient experiences. Finally, they used Primary Care Services Area data to characterize the market environment of the physician practices.
The Bottom Line
Medical group and market factors influence how individual physicians perform on measures of patient experience. Further research is needed to explore whether improvement activities and greater resource allocation could address the performance deficits seen among physicians in medical groups serving large numbers of disadvantaged patients.