Physicians and Care Management: More Acceptance than You Think

Issue Brief No. 60, January 2003 — By Marie C. Reed, Kelly Devers, and Bruce Landon

Whether physicians accepted care management tools — practice guidelines, patient satisfaction surveys, and practice profiling — carried significant implications for ongoing efforts to improve health care quality and control costs. According to a study by the Center for Studying Health System Change (HSC), a majority of physicians affected by these tools believed the overall effect on the quality and efficiency of their practice was positive. Physicians who were subject to related financial incentives were more likely to view care management techniques favorably when those incentives were risk-adjusted to account for the higher service needs of patients with health problems.

Understanding Care Management Tools

Research had demonstrated considerable room for improving the quality of American health care, and controlling the cost of care remained a pressing concern. Health plans, hospitals, and physician group practices across the country had attempted to address both issues through several care management approaches:

Practice guidelines helped physicians and other clinicians make treatment decisions for patients with specific clinical conditions. Patient satisfaction surveys gave physicians feedback on important aspects of interpersonal communication and service quality. Practice profiling compared an individual physician's treatment patterns and use of medical resources against those of other physicians, sometimes incorporating patient satisfaction results and measures of guideline compliance.

Many physicians had been skeptical of these approaches. Some saw them primarily as cost-cutting instruments. Each tool had technical limitations that affected its usefulness, and some could even reward undesirable physician behavior — if profiling penalized referrals to specialists, for instance, physicians might improve their scores by avoiding severely ill patients. Some physicians also viewed these tools as encroaching on their professional autonomy. Rather than trusting doctors to make sound decisions, health plans and other organizations had used these tools to evaluate individual physician performance and inform employment and compensation decisions.

Despite these concerns, and despite the loosening of managed care restrictions, the proportion of physicians whose medical practice was affected by these tools grew between 1997 and 2001. By 2001, more than half of all patient care physicians said guidelines had a moderate or greater effect on their behavior. More than 60 percent had been affected by patient satisfaction survey results. And more than a third reported that practice profiles had influenced how they practiced medicine.

Physicians Report Positive Effects

More than half of all physicians who were affected by each care management tool reported that its overall impact on the quality and efficiency of their practice had been positive. Two-thirds of those affected by practice guidelines rated the overall effect as positive. Patient satisfaction surveys received the most favorable assessment, with 77 percent giving a positive rating. Among those affected by profiling, 51 percent reported a positive effect. Physicians who indicated that a care management tool had little or no effect on their practice were not surveyed about its impact on quality and efficiency.

The fact that most physicians affected by care management tools viewed them positively was a welcome finding, since earlier evidence had suggested that physicians' negative attitudes toward these tools were a barrier to their adoption and effective use.

Managed Care Has Limited Effects, but Recently Trained Physicians More Positive

Physicians in practices that drew more revenue from managed care were somewhat more likely to report that care management tools had affected their practice. However, the extent of managed care involvement in a practice showed only a limited connection to whether physicians viewed those tools favorably. There was no clear relationship between practice involvement in managed care and physicians' assessments of practice guidelines. Doctors in practices with a relatively large proportion of managed care revenue were actually less likely to view patient satisfaction surveys positively, while the apparent lower assessment for practice profiling was not statistically significant.

Compared with earlier reports, these findings suggested that managed care plans and other organizations had made progress in addressing some of physicians' concerns about care management tools.

Since more recently trained physicians tended to be in practices with greater reliance on managed care, it was not surprising that they were also more likely to report that their practice had been affected by care management tools. They also tended to view these tools more favorably. Physicians who had completed their training within the past five years were considerably more likely to report that guidelines had a positive effect, and somewhat more likely to have positive assessments of patient satisfaction surveys, compared with physicians who had trained earlier.

The relatively favorable assessments of guidelines and patient satisfaction surveys among newer physicians may have reflected their training in and familiarity with evidence-based medicine, as well as a desire for guidance in an increasingly complex medical environment. These physicians may also have been more attuned to the potential benefits of care management tools and less sensitive to their potential impact on clinical autonomy than colleagues who began practicing earlier.

Impact of Financial Incentives and Risk Adjustment

Physicians with financial incentives linked to profiling were more than twice as likely to indicate that profiling had affected their practice, compared with those without such incentives. Similar but less dramatic results were observed for financial incentives tied to patient satisfaction surveys. Physicians subject to financial incentives were more likely to be aware of a care management tool and may have worked in practices with more capacity and interest in encouraging the use and implementation of these tools.

However, physicians' positive assessments of care management tools did not appear to be strongly linked to the presence of financial incentives. Physicians whose compensation could be affected by rewards or penalties tied to patient satisfaction surveys were no more likely to report positive effects than those without such incentives. And physicians who were financially rewarded based on profiling results were only slightly more accepting of profiling than those without an incentive. One possible explanation for the weak relationship between financial incentives and positive evaluations was that other factors — such as perceived fairness and the evidence base behind the tool — may have carried more weight.

Risk adjustment, which accounts for the greater service needs of patients in poorer health, made a substantial difference in physician acceptance of practice profiling. Nearly two-thirds (64 percent) of physicians with financial incentives tied to risk-adjusted profiling reported a positive effect, compared with just 46 percent of those whose profiling-linked incentives were not risk adjusted. Without risk adjustment, profiling was likely to produce results that were either beyond the physician's control or difficult to improve through positive changes in clinical behavior.

Growing Acceptance Bodes Well

Increasing physician acceptance of care management tools was an encouraging sign for policy makers and industry leaders. Physicians' positive views appeared to result from several factors: the adoption of these tools by a wide range of organizations, including providers as well as health plans; efforts by these organizations to respond to physician concerns; and a growing proportion of doctors who were trained in an environment where managed care and care management were standard practice.

Patient satisfaction surveys, which provided a patient-perspective measure of health care quality, had achieved widespread acceptance among physicians. The surveys could become even more valuable if they also guided patients in selecting a doctor and helped purchasers compare insurers with different physician panels. Achieving this would require standardized surveys that allowed for meaningful comparisons. The federal government's effort to adapt the publicly developed Consumer Assessment of Health Plans Survey (CAHPS) to measure patients' experiences with physician practices was a promising step, as it would enable comparative information about physician practices to be reported to purchasers and patients.

The finding that physicians were substantially more likely to view financially linked profiling positively when it was risk adjusted pointed to an area ripe for further research and development. As a payer, the federal government had been investing in risk-adjusted payments to health plans participating in Medicare and Medicaid. In its broader role of improving care for all Americans, the government could extend this research to the development of risk-adjustment methods at the medical practice or individual physician level, along with the information infrastructure — such as electronic medical records — needed to collect valid and reliable data for sound risk-adjustment mechanisms. Such research and infrastructure development were unlikely to be accomplished effectively by the private market alone and would benefit all payers, provider organizations, and patients.

In a period of renewed concern about rising costs, growing awareness of the gap between best evidence and current practice, and an expanding knowledge base, continued development and use of care management tools held significant value. For these tools to improve the quality of care, physicians needed to perceive them as valid, useful, and fair. Risk adjustment helped make profiling fairer, and similar adjustments could be developed for other care management tools. While this was not a simple task, the evidence that risk-adjusting care management tools dramatically increased the prospects of physician acceptance was encouraging.

Data Source

This Issue Brief presented findings from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care in the continental United States, conducted in 2000-01. The sample was drawn from the American Medical Association and the American Osteopathic Association master files and included active, nonfederal, office- and hospital-based physicians spending at least 20 hours per week in direct patient care. Residents and fellows were excluded. The survey contained information on approximately 12,400 physicians, with a response rate of 59 percent.

Sources and Further Reading

1. Institute of Medicine, Crossing the Quality Chasm, National Academy Press, Washington, D.C. (2001).
2. Kassirer, Jerome P., "The Use and Abuse of Practice Profiles," New England Journal of Medicine, Vol. 330, No. 9 (March 3, 1994).
3. Strunk, Bradley C., and James D. Reschovsky, "Kinder and Gentler: Physicians and Managed Care, 1997-2001," Tracking Report No. 5, Center for Studying Health System Change, Washington, D.C. (November 2002).
4. Cabana, Michael D., et al., "Why Don't Physicians Follow Clinical Practice Guidelines? A Framework for Improvement," Journal of the American Medical Association, Vol. 282, No. 15 (October 20, 1999).
5. HSC Community Tracking Study Physician Survey, 2000-01.