Online Program

Does form follow function?: Provider group structure as a driver of HEDIS quality of care measures in a large urban Medicaid health plan

Sunday, November 3, 2013

S. Rae Starr, MPhil, MOrgBehav, HealthCare Outcomes & Analysis, L.A. Care Health Plan, Los Angeles, CA
Quality of healthcare relies on how well doctors perform. Delivery of care is affected by the manner in which providers organize themselves to deliver care. Provider groups serve various functions in the process of connecting doctors to patients.

The practical side of those functions is rarely patient-oriented, but affects the delivery of care. Independent practice associations (IPAs) and medical groups offer different mixes of services to doctors and clinics: centralized contracting; centralized billing; collecting claims and encounter data for submission to payers; reviewing and authorizing services; sharing risks; attracting doctors with specialized skills; contracting for specialist access; etc.

The human side of those functions comes back into focus, as reforms in healthcare increasingly emphasize measuring, reporting, and rewarding high-quality service to patients. Exploring what drives quality, remains a long-term focus of administrators given a double challenge: serving more patients without seeing declines in quality. Does provider group structure have an impact on the quality of the clinical care that patients receive?

(1) Study design: Data for this study come from HEDIS quality-of-care measures from 2011 broken out by provider group. Provider group structure is analyzed in 4 categories: independent physician associations (IPAs); traditional medical groups; fully-integrated staff model settings; and county-operated clinics.

(2) Setting: The study examines the clinical quality of care provided to patients in a large and diverse urban Medicaid health plan in Los Angeles County, California, served in a geographically large county through an unusually complex provider network designed to reach members where they live. That Medicaid population disproportionately includes mothers and children, but increasingly includes adults living with disabilities.

(3) Findings: The presentation compares performance on HEDIS quality of care measures among the different provider group structures, to assess which structures serve Medicaid members best on measures relating to well-care visits, immunizations, and care specific to chronic diseases such as asthma or diabetes.

(4) Analysis: The analysis explores differences between different provider group structures to determine strengths, weaknesses and tradeoffs in effectively organizing doctors' services to improve performance on standard measures of clinical quality. The analysis breaks out the findings across demographics to determine which populations fare better or worse under different provider group structures.

(5) Implications: Differences in performance provide a reasonable basis for incentive programs to improve quality. The briefing explores best practices and generalizable lessons on provider group organization, toward improving how doctors organize themselves to deliver quality health care to patients.

Learning Areas:

Biostatistics, economics
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Program planning

Learning Objectives:
Describe the functions that provider groups serve in connecting patients to doctors, and how those functions impact services to patients. Describe which provider group structures deliver the best or worst performance on measures of clinical quality. Analyze whether provider group structure is an underlying factor in disparities in clinical quality between demographic groups in the Medicaid population. Identify which structural features of high-performing provider groups are associated with better performance on HEDIS measures. Explain how findings on provider group structure can be made actionable to improve quality of care.

Keyword(s): HEDIS, Quality Improvement

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Served seven years as Senior Biostatistician at the largest public health plan in the United States serving Medicaid and CHIP populations in an ethnically diverse urban county in the southwest United States. Designed and managed patient satisfaction surveys (2006-2012), adding components with tie-ins to HEDIS performance. Consulted on provider satisfaction surveys, and on the analyses of performance in a complex provider network.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.