Access Initiative Impacts on Primary Care Provider Productivity
Douglas A. Conrad, PhD* Paul Fishman, PhD** University of Washington, Department of Health Services*, and Group Health Cooperative, Center for Health Studies**
Timeline of Group Health Cooperative Access Initiative and Initiative Components
Access Initiative
97 00 01 02 03 04 05 06 07
MyGroupHealth & Secure Messaging Adv Access to PC PC Redesign Direct Access to Specialists Physician Payment Reform
EpicCare Phase I EpicCare Phase II
Apr 2002 Pre-Initiative
Aug 2003 Full-Implementation
Rollout
Productivity Hypotheses
Postulated Principally Positive Effects of Access Initiative on Productivity However, Anticipated Some Short-Run Decrements in PCP Productivity, Potentially in Adjusting to: • New Systems • New Incentives • New Clinical Management Routines
Overview of Study Design
• Productivity Analysis Embedded within Overall Evaluation of the Initiative Intervention • Analysis Period: 1998 – 2005 • Unit of Observation: PCP in any of 32 Quarters, at least .25 FTE, practicing within the Integrated Group Practice (IGP) in Western Washington – 147 unique physicians (49%, or 72, of eligible PCPs present in all 32 quarters)
Study Design (continued)
Dependent Variables in Productivity Analyses included: (at PCP-Quarter level) • Mean Work RVUs per FTE • Mean Visits per FTE • Mean Work RVUs per Visit (“Intensity”) Also, examined the “Dual” of Productivity: • System Cost of Care per PCP empanelled Enrollee
Independent Variables in Productivity Analyses (General Estimating Equation Models)
• • • • • • Initiative Time Primary Care Clinic (“fixed effects”) Interactions: Initiative Time*Clinic PCP Years in the IGP PCP Gender Case Mix (Expected Resource Intensity) of Individual PCP’s “Panel” (prospective)
Description of Study Sample (PCPs and Enrolled Panel)
• • • • • • • 70% of PCPs were Male 41% of PCP-Quarters had 1.0 FTE Mean Panel Size: 1455 (SD = 557) 84% in Commercial Market Segment Mean Age of Panel Enrollees: 43 years 51% of Panel Enrollees are Women Mean Per Member Per Quarter Cost: $744 (SD = $407)
Primary Care Productivity Patterns over Initiative Time
Relative to Pre-Initiative Levels: • RVU/FTE Rose during Rollout, Rose Further during Full Implementation • RVU/Visit Intensity Rose Modestly during Rollout, More Dramatically Post-Initiative • Costs per Panel Member Rose during Rollout, Declined below Pre-Initiative Levels during Full Implementation
Visits per FTE Productivity over Initiative Time (adjusted)
1280 1260 1240 1220 1200 1180 1160 1140 1120 Visits per FTE Post-Full Implementation Pre-Initiative During Rollout
RVU per Visit Levels over Initiative Time (adjusted)
1.2 1.15 1.1 1.05 1 0.95 RVU per Visit Pre-Initiative During Rollout Post-Full Implementation
RVU per FTE Productivity over Initiative Time (adjusted)
2700 2600 2500 2400 During Rollout 2300 2200 2100 2000 RVU per FTE Post-Full Implementation Pre-Initiative
Cost per Panel Member (PMPQ) over Initiative Time (adjusted)
5.4 5.35 5.3 5.25 5.2 5.15 5.1 5.05 5 Log ($) Cost Per Member per Quarter
Pre-Initiative During Rollout Post Full Implementation
Note: Raw Post-Full Costs ~ $650/qtr versus ~ $800/qtr during Rollout
Implications
• Comprehensive Access Initiative Was Associated with Increased PCP Productivity and Reduced PMPQ Cost for Primary Care Providers • System Adjustments Appeared to Mitigate Potential Decrements • Enhanced Productivity Occurred in Parallel with declining, then flat FTE, respectively, during Rollout, Post-Full Implementation