SELECTING A PRIMARY CARE PROVIDER

More Choices; More Ways to Choose

This plan operated in a highly competitive market. One way this competition manifested itself was in the prevalence of demanding consumers, whose membership in a health plan might be very transient. Like many plans, it had become sensitive to criticisms that managed care interfered with patients' ability to choose their own physicians. Market research cited by the plan linked choice of physicians with member satisfaction. Particularly important? The numbers of primary care practitioners with open panels, and the ease of changing PCPs.

With numerous medical groups and IPAs serving its culturally diverse population, the plan had a real need to offer a wide selection of practitioners, including those serving unique cultural needs. It also needed to offer flexibility for its members to change practitioners as they felt necessary.

The plan had participated in a statewide effort to collect audited HEDIS data using common third-party vendors. As part of this effort, it received data from the HEDIS membership satisfaction survey. These data not only provided information about the plan's baseline performance in a number of specific areas, but also gave it benchmarking information against other plans in its market.

With the goal of balancing the highest quality medical care with maximum choice of available physicians, the plan embarked on an activity to improve its ratings on "ease of choosing a physician."

The plan sought to target its commercial members. It used HEDIS 3.0 methodology to survey the specified random sample of its membership, age 18 and older.

It chose as its performance measure the percentage of its members answering "very good" or "excellent" to the question:

"Thinking about your own health care ... over the last 12 months, how would you rate … ease of choosing a personal care physician?"

Baseline measurement, using 1996 data, showed that only 37.6 percent of members responded "very good" or "excellent" to this question. The plan found the best statewide performer reported that 88 percent of its members had answered "good," "very good," or "excellent" to this question. The plan set a goal of 50 percent of its members answering "very good" or "excellent."

SATISFACTION SCALES AND PRECISION This plan elected to use a score based on the percentage of the two highest responses on a five-point scale. Other plans reported numbers based on the three highest responses from the five-point scale. (Prior to HEDIS member satisfaction surveys, there had been examples of plans using scores based on the combined responses to the top four choices of a five-point scale!) The more categories included, the higher the apparent satisfaction score. While high scores may be enviable marketing tools, they are imprecise in measuring the output of quality improvement efforts. This plan chose to use a more precise measure, even if it resulted in a lower overall score.

The plan organized a work group to manage this activity. It included representatives from quality management, utilization management, sales and marketing, and provider relations.

This work group reviewed the baseline data against the plan's then-current policies for selecting a PCP. It found that changing a PCP could take up to 46 days. Anecdotally, they noted women commonly were requesting additional choices for female PCPs. Some identified barriers to satisfaction in choosing a personal physician:

• Preference of female members to receive services directly from an OB/GYN rather than from a PCP or through a referral
• Younger members who move frequently, and seek greater flexibility in making changes in practitioners
• An auto-assignment of a PCP to a member rarely proved satisfactory
• The plan's PCP change policy could be viewed as restrictive
• Inadequate density of PCPs within the service area

During the baseline year, the plan had already addressed some of these barriers. It implemented a program allowing annual well woman exams without a referral. It added 815 new PCPs to its network, and updated and distributed a new, expanded practitioner directory. It modified its PCP change policies to allow a change to become effective on the first day of the month following the request. It needed to sustain and strengthen these efforts.

The plan continued to expand its PCP base by another 20 percent. A member newsletter featured an article stressing the importance of choosing a PCP, the new policy on changing PCPs, and a phone number for members to call to make changes.

The plan began to roll out an Internet tool that helped members select a PCP. Members could view practitioners by type and by zip code. Information such as board certification and medical school attended were made available with this Web site.

ONLINE MEMBER RESOURCES Initially, the plan found that its Web site was rarely used. Comparatively few people were online in 1997. This has changed greatly since then. Organizations need to be aware of rapid changes in the sophistication of online offerings, while staying prepared for a low rate of "early adopters" of new technology. Coordinating the availability of resources for new members with the open enrollment time frame allows more of a plan's membership to benefit from the latest in technology.

The plan eliminated auto-assignment of a PCP. Instead, it notified the member in writing of the need to select a PCP.

It also revised its policy about changing PCPs. It now allowed members to change PCPs as frequently as they desired, with the changes effective immediately.

It expanded open access to OB/GYN services. It allowed members to seek care from any OB/GYN in its network. OB/GYNs could refer members for routine tests or specialty care without requiring a return to the PCP.

The first remeasurement was based on data from 1997, and showed that the number of members satisfied with the ease of choosing a personal physician had improved to 41 percent. This small increase did not meet the plan's goal, nor was it statistically significant (z-score = -1.1204, p = .2625).

The plan intensified its interventions targeted at members. It ran member newsletter articles, developed new enrollment materials and a plan benefits brochure. It highlighted its online resource for choosing a PCP, and its open access program for OB/GYN services.

It continued to expand its network of PCPs, in 1998 by approximately 12 percent. The plan's medical director met with medical groups to ensure compliance with changed policies for choosing a PCP. These meetings provided an opportunity to discuss such issues as closed panels.

The plan distributed PCP change forms directly to its practitioners. This allowed members to select a new PCP at the point of service, with no prior notification to the plan.

The plan's demographic data indicated the need for additional Spanish-speaking practitioners. It contracted with a Hispanic physician group to help meet this need.

The second remeasurement used survey data from 1998. It showed a 56.5 percent rate of satisfaction with choosing a personal physician.

This represented a statistically significant improvement over the previous year (z-score = 3.8025, p = .0001). The plan had met its goal for performance improvement. It concluded that its actions had a favorable impact and should be continued and improved upon.

Having met its initial goal, the plan set a new performance goal 0f 65 percent. It performed a new barrier analysis using a fishbone diagram.

The plan attacked many of the new barriers with strong interventions. It revised some employers' open enrollment forms to allow space for PCP selection. It met with account benefit managers to discuss the importance of PCP selection. A new package helped members choose a PCP. The package featured:

• A letter explaining the importance of choosing a PCP
• A pre-filled PCP change form with between three and 10 physician alternatives
• References to additional resources (Web site, printed directory, customer service numbers)
• A business reply envelope

The plan shifted attention to medical groups with closed panels. Directed mailings and discussions with the plan's medical director caused many practitioners to change their panel status. Some had simply forgotten that they had closed their panels and now found the capacity to reopen. In all, 18% of closed panels were reopened.

Subsequent remeasurement in 1999 showed improvement to a rate of 63 percent. By understanding the nature of its membership and provider network, this plan successfully designed multiple interventions. It learned that it could make a difference in member satisfaction. Every staff member involved with the activity learned firsthand how committed the organization was to improving member satisfaction.