Public reporting on patient experience, which has previously focused on health plans and hospitals5, 6
, is increasingly being applied to ambulatory physician groups and practice sites.7
Patient experience surveys are intended to produce performance results that physicians can use to identify specific targets for quality improvement, that patients can use to compare and select providers, and that payers can use as a basis for setting incentive payments in pay-for-performance programs.2, 8, 11, 22
Despite substantial investment in these efforts and the potential salience of this information to practicing physicians, little is known about how physician groups have responded.
We found that the majority of Massachusetts physician groups are engaged in efforts to improve the patient experience. Physician groups engaged in these efforts were more likely than others to have an integrated medical group organizational model (as opposed to an IPA or mixed model), to employ the majority of their physicians, and to have financial incentives based on patient experience.
However, a substantial number of physician group leaders reported no efforts to improve patient experience, and others focused their efforts exclusively on low-performing physicians or practice sites. These groups had less integrated organizational models, suggesting that improvement efforts may require a managerial infrastructure capable of starting and directing improvement activities. This finding is consistent with national data suggesting that medical groups may be more likely than IPAs to participate in general quality improvement activities.23
In addition, groups not engaged in improvement activities were more likely to lack payment incentives based on patient experience. This association between group-level financial incentives and engagement in patient experience improvement echoes similar findings at the physician level, where performance incentives that emphasize patient experience have been associated with improved performance.24
The most common areas of patient experience targeted by groups’ improvement efforts were access (e.g., waiting times for an appointment), communication with patients (e.g., triage of incoming phone calls), and the customer service (e.g., staff courtesy). Groups were less likely to focus on the performance of physicians and other clinicians or on patient educational activities to enable self-management. Even though continuity of care has been highly associated with patient satisfaction25, 26
, very few groups reported efforts intended to improve the continuity and coordination of care (despite wide performance variation and relatively poorer statewide performance in these domains).9
Though improvements in physician communication skills are thought to be crucial to the provision of patient-centered care, physician groups rarely pursued strategies to train physicians.27
Instead, groups most commonly changed processes for managing interactions between patients and nonclinical staff, trained non-clinicians, and invested in structural capabilities such as EHRs.
It is notable, however, that even when attempting to improve physician communication with patients, groups predominantly pursued this goal by reassigning staff responsibilities and adopting or enhancing EHRs. A reluctance to directly intervene with individual physicians may reflect physicians’ skepticism regarding physician-level patient experience results as well as a sensitivity to low morale among primary care physicians—two explanations that were volunteered by some group leaders.28, 29
Further, groups’ general focus on EHRs as a means of improving patient experience may reflect a previously observed association: in a national sample of physician groups, the use of patient feedback to analyze and improve services has been associated with increased adoption of health information technology.23
The study has limitations. Physician groups’ use of patient experience survey reports was based on self-report by group leaders. Despite our efforts to minimize response bias, leaders may have over-reported their efforts to improve patient experience. Our statewide sample of physician groups was too small to allow meaningful multivariable modeling, so we could not assess the independent effects of organizational variables on groups’ level of engagement with patient experience reports. The observational study design limits our ability to infer causation from associations between groups’ characteristics and activities. Groups that did not respond to our survey may be less likely than respondents to engage in improvement activities.
The study was limited to Massachusetts, and some findings may not generalize to other states. Two national surveys of physician groups have found associations between external incentives to improve patient experience and greater use of processes that may improve quality.20, 30
Because statewide public reporting of patient experience scores may constitute an external incentive, improvement efforts among physician groups in Massachusetts may exceed those in states without public reporting.
We lacked the data necessary to assess whether groups targeted their improvement efforts towards patient experience domains on which they had low performance. The extent to which groups’ reported improvement efforts will improve their scores on patient experience surveys is unknown. Finally, public reporting on patient experience had recently begun at the time of our study, and groups’ responses may evolve over time. Describing this evolution is a planned area of future research.
In a state that has publicly reported patient experience survey results for more than 2 years, we found that many physician groups have engaged in efforts to improve their performance. Groups with more integrated organizational models were especially likely to engage in group-wide improvement efforts, and all groups facing financial incentives based on patient experience reported improvement efforts of some kind. While patient experience surveys assess both provider-level and organization-level aspects of care, groups have predominantly focused their improvement efforts on organizational factors. If policy makers wish to motivate changes in the behavior of individual providers, new incentives that target specific, provider-focused domains of patient experience may be necessary.