SELECTING A PRIMARY CARE PROVIDER

Making Choosing a Physician Easier

Selection of a personal physician is an activity that touches every member of a health plan. This plan paid attention to the details that can make this difficult choice a little easier.

While most members selected a primary care provider (PCP) as part of the open enrollment process, some new members became eligible without having selected a physician. Without a PCP to provide a referral, these members would be limited to nonreferral services such as urgent and emergent care. The plan provided new members with materials explaining the importance of choosing a PCP.

The plan noted that established members also changed PCPs. Changing needs, relocation, PCP retirement or personal preference were commonly cited reasons. PCP selection and change consistently ranked in the top five categories of requests received by the customer service department.

Prior to 1995, the plan required members to contact the doctors of their choice to ask if they would be accepted as patients. Members frequently complained about this process, and member satisfaction survey results validated the problem. As early as 1992, less than half of members rated the process of choosing a doctor as "very good" or "excellent."

The plan decided that the process for choosing a PCP could be improved. It convened a task force to address this and related activities.

The plan targeted all commercial members for this activity. As part of a statewide consortium of health plans, in 1994 the plan worked with NCQA to develop a satisfaction survey. It used a contracted vendor to conduct this survey on a random sample of members; 858 members were sampled in 1994. The plan focused on one measure from the survey:

"Rate the process for choosing a primary care doctor, including information about the doctors available and how to choose or change a primary care doctor."

CHANGING MEASURES The initial activity reported baseline measurements from a telephone survey. By 1995, the plan had adopted a mail-in survey. It focused on a question regarding the "ease of choosing a personal physician." The change in methodology would have produced a decrease in scores if service had remained the same, because satisfaction scores from mail surveys are generally lower than scores from telephone surveys. In 1996, changing specifications made the plan decide to forego a survey. HEDIS 3.0 methodology, including a somewhat different survey, was in use by 1997 and 1998.

The plan set a goal for each year of reducing by 10 percent the difference between a perfect score and the previous year's mark. In 1997, it cited a benchmark taken from NCQA's Quality Compass. The best score reported for the question under study was 69.7 percent.

The task force addressing the issue included representatives from provider services, quality improvement, customer service, product development, and communications as well as the medical director and the associate counsel.

Members of the task force used anecdotal information to identify barriers. They reached a consensus based on personal experience and reports of member and employer complaints.

The plan identified the following barriers to satisfaction:

• Information regarding the doctor's willingness to accept new members was often outdated
• Members needed to call multiple offices to find one that would accept them. This led to an inappropriate opportunity for doctors to screen out high-risk patients
• Members selected PCPs at open enrollment, later to find out that they were not accepting new patients. The turnaround time to select a new PCP could leave a member in limbo if an immediate health need were to arise

The plan decided to implement a new process for members to select PCPs. The new process called for the plan to query the PCPs three times a year. Each PCP was asked to sign a form verifying their "patient acceptance status for the next four months. As a result, the provider directory was updated and printed three times a year.

TIMING AND OPEN ENROLLMENT The plan was now able to provide current directories listing physicians who would accept new patients. The printing schedule for the directory had been timed so that the material distributed during large fall open enrollments was good through January, the effective date for most new members.

With accurate and timely information in the provider directory, the plan dropped the requirement for members to call the PCP's office prior to selecting the provider.

The first remeasurement was based on 1995 data and showed a very good or excellent satisfaction rating of 48 percent with "ease of choosing a personal doctor." The sample surveyed included 1,250 members, 51.7 percent of whom responded.

As its understanding of the process grew, the task force identified new barriers to satisfaction:

• A surge in call volume for selecting a PCP occurred every December, in anticipation of a January effective date. This surge clogged phone lines and delayed service
• The only way to choose a PCP was to call the health plan

The plan printed names of new practitioners in bold face in the provider directory. It enhanced the directory to include a tear-out, postage-paid card. This card gave members the option of selecting or changing their PCPs via the mail. (A copy is included in QP Tool .)

The plan developed a brochure for existing and prospective members. It simply and clearly outlined detailed information about the plan, including how to choose a primary care physician.

The second remeasurement was conducted using 1997 data. The rate of excellent/very good responses to the question, "Ease of choosing a personal physician" had risen to 55.4 percent, a statistically significant increase.

Additional barriers to satisfaction surfaced:

• Member preference for direct access to an OB/GYN for preventive health services
• The need for a PCP change process whenever PCPs relocate, retire or die
• Members need more information about PCPs to make an informed selection

The plan added language to the provider directory explaining PCP referral for routine gynecologic exams. It added options for members whose doctors had left the plan. This included auto-assignment to another practitioner, or choosing from a list of other doctors accepting new patients and affiliated with the same hospital.

TECHNOLOGY SOLUTIONS Technology solutions, such as an updated and interactive Web site, require significant investment of time and resources. While it's important to pursue online interventions, other initiatives can be pursued simultaneously. This can allow for significant improvements in service in both the near and more distant future.

The plan placed the provider directory on its Web site, to allow members instant access to this information.

Remeasurement number three, using 1998 data, showed a very good or excellent satisfaction rating of 57.9 percent with "ease of choosing a personal doctor." While not a significant increase over the previous year, it demonstrated an upward trend, and continued statistically significant improvement from baseline.

The plan has continued all of its interventions. In 1998, it instituted open access to OB/GYN practitioners, and it modified its provider directory to reflect this change. It has noted a reduction in member services call volume as a result of this activity. This has freed up staff to handle other, more pressing, member issues.

While the question under study was discontinued in HEDIS in 1999, the plan kept this question, and once again determined its performance. A score of 57 percent convinced the plan to retire this measure, based on its five-year record of maintained improvement.