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Contents

6.A. Overview of Strategies
Appendix 6a. Crosswalk of Patient Experience Domains and Survey Measures
Appendix 6b. How Health Plans Can Drive Improvements at the Medical Group Level
References

6.A. Overview of Strategies

The steps you take to assess patient experience with care in your organization and explore what is driving those experiences will enable the quality improvement team to identify opportunities to improve and establish goals. As discussed in Section 4 of this Guide, the next step in the quality improvement process is to identify possible strategies. Your team may have several ideas for improvement strategies based on its evaluations of care delivery processes and input from stakeholders. To supplement and help to organize those ideas, this section presents selected strategies for improving the experiences of patients and enrollees as measured by the CAHPS surveys.

The strategies are intended to address the various topics covered by CAHPS surveys of ambulatory care, with an emphasis on the three core survey domains of access to health care, communication, coordination of care, and customer service. Table 6-1 lists sixteen strategies you could consider and the survey topics they address. Appendix 6a provides a crosswalk of these topics and the measures derived from different CAHPS surveys (all of which are variations on the CAHPS Health Plan Survey or the CAHPS Clinician & Group Survey).

These strategies represent a range of possible solutions. Some are easy and inexpensive to implement, while others are more logistically complex and require a significant investment of money, time, and other resources. If your team wants to pursue a more intensive strategy, it can help to "start small" by breaking down the strategy into smaller components and tackling one component at a time. Also, some strategies may allow you to see results right away, while others may require time to make a measurable difference; your team will need to work with the organization's leaders to decide which approach would be best.

Finally, it is important to note that these strategies are directed at different audiences. Some strategies are aimed at physician practices and medical groups because they address aspects of care that happen in the doctor's office, such as access to care (e.g., scheduling appointments and receiving timely care and information), communication between providers and patients, interactions with office staff, shared decision making, and self-management support. Other strategies address experiences within the domain of health plans, such as member services, information to manage health care and costs, and health promotion and education. For some strategies, both health plans and provider groups have a role to play, even if one is more "responsible" than the other for an aspect of patient experience. Health plans, for example, can equip providers with the skills, tools, and information systems they can use to improve their communication with patients. Health plans can also play a very important role in motivating medical groups, practices, and individual physicians to improve patient experience. Appendix 6b discusses three ways in which health plans can harness reporting and purchasing strategies to focus attention on the experience of care.

Table 6-1. Improvement Strategies Organized by Topic

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Appendix 6a. Crosswalk of Patient Experience Domains and Survey Measures

The tables below list composite measures derived from the standard items in each survey, i.e., the items included by every user of that specific survey. Many other topics, including some of the domains in the left column, are covered by supplemental items that users can choose to add to their surveys. The tables do not include the global rating measures.

Table 6-2. Domains and Composite Measures in Current Versions of the CAHPS Clinician & Group Survey (as of Winter 2017)

*In 2016, CMS accepted results for two versions of the ACO Survey: ACO-9 and ACO-12.
**Health Status/Functional Status is not included as a composite measure for the purposes of this table because the questions are not asking about the patient's experience with care.

Table 6-3. Domains and Measures in Current Versions of the CAHPS Health Plan Survey (as of Winter 2017)

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Appendix 6b. How Health Plans Can Drive Improvements at the Medical Group Level

Many of the measures in the CAHPS ambulatory surveys address issues outside of the direct control of health plans, because the locus of the care or service lies at the medical group or practice level. However, health plans can exert some influence on medical groups and individual physicians, encouraging and motivating them to improve the patient's experience in the doctor's office. The degree of influence a plan can exert depends in part on the structure of its relationship with its provider network. Health plans that own physician practices and/or employ physicians, and those that have an exclusive relationship with their contracted providers, tend to have more influence than those that account for only a small share of a medical group's patients.

This section outlines a few ways in which health plans can encourage medical groups and physician practices to take steps to improve patient experience:

• Public Reporting on Provider Performance
• Private Feedback on Provider Performance
• Value-Based Payments

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6b.1. Public Reporting on Provider Performance

Public reporting on provider performance can help patients make more informed choices about which health systems, hospitals, medical groups, and individual physicians best meet their needs. In addition, making such information publicly available encourages providers to engage in quality improvement activities in areas where their performance lags.^1-5

Working independently and in collaboration with other stakeholders (e.g., large employers, local purchasing coalitions, government purchasers), health plans have been active in developing public "report cards" on provider performance—primarily on the web but sometimes in print. These reports provide comparative information on the performance of hospitals and medical groups on various measures of quality, including but not limited to CAHPS survey measures. By making these reports available, health plans encourage their members to pay attention to the quality of their providers and to select high-performing medical practices and physicians.⁶ As part of these programs, health plans can also publicly recognize high-performing providers in their network.

The following examples describe health plan efforts to work with other stakeholders to develop and publicly report on patient experience with providers:

• The Wisconsin Collaborative for Healthcare Quality (WCHQ), a multi-stakeholder, voluntary consortium of Wisconsin health plans, health systems, medical groups, and hospitals, has been publicly reporting provider performance on quality measures since 2004. WCHQ's online on clinics and medical groups shows scores for six composite measures from the CAHPS Clinician & Group Survey: "Getting Timely Appointments, Care, and Information," "How Well Providers Communicate," "Helpful, Courteous, and Respectful Office Staff," "Follow Up on Test Results," "Overall Provider Rating," and "Willingness to Recommend." For large medical groups, the results are broken down by specialty.⁷
• Massachusetts Health Quality Partners (MHQP) is a coalition of health plans, physicians, hospitals, purchasers, patient and public representatives, academics, and government agencies that has worked to improve the quality of health care services in Massachusetts. Among other activities, MHQP collects and publicly reports on the performance of over 500 physician practices on various quality metrics, including patient experience measures from , which is based on the CAHPS Clinician & Group Survey.

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6b.2. Private Feedback on Provider Performance

As a substitute or complement to public performance reports, health plans can also feed useful information to health care providers—including administrative leaders and staff—through private reports that evaluate their performance on various aspects of quality, including patient experience. In some cases, health plans share private reports first, and then introduce public reports after providers become more comfortable with the assessment of quality and the methodology being used. Private reports often contain more detailed information than that available in public reports, thus helping providers to pinpoint more precisely those aspects of the patient experience that are in need of improvement. For example, private reports may include results for individual survey items as well as summaries of patients' complaints and feedback, thus providing insights into common problems that need to be addressed.⁸

Private reports also typically offer more detailed comparisons of individual provider and/or group performance to that of peers and other benchmarks, such as local, regional or national norms and "best-in-class" performance. This comparative data not only encourages a sense of competition among providers to improve, but also may stimulate conversations among doctors and other clinicians about ways to improve performance on patient experience and other quality measures.

Examples of health plan initiatives to compile and disseminate private reports to network providers that include CAHPS or other patient experience survey measures include the following:

• In 2005, HealthPlus of Michigan (an independent health plan) began privately reporting detailed performance data from the CAHPS Clinician & Group Survey to PCPs that direct primary care for enrollees in the plan's commercial HMO product. In combination with information on best practices, this feedback helped to stimulate steady improvement in both CG-CAHPS and CAHPS Health Plan Survey scores over a 7-year period through 2012.⁹
• In addition to public reporting, Massachusetts Health Quality Partners distributes private reports to all medical practices that participate in the statewide Patient Experience Survey.
• In the public sector, the Centers for Medicare & Medicaid Services (CMS) provides each group practice participating in the CAHPS for PQRS Survey with survey results in an individualized, detailed report. These reports describe the content of the survey and include the group practice's scores on both the summary measures and individual questions in the survey, comparison scores and, where applicable, trend data showing how a practice's results from the previous reporting period compare to results from the current one. CMS provides a similar feedback report to convey results from the CAHPS Survey for ACOs to those organizations participating in the Medicare Shared Savings and Pioneer Programs.

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6b.3. Value-Based Payment

Health plan payments to providers can be a critical lever for creating incentives to providers to improve the patient experience. Many health plans have already implemented pay-for-performance (P4P) and other payment programs that financially reward the provision of "high-value" care—i.e., care that is high quality, cost-effective, and person-centered. Such value-based payment programs typically tie payment to performance on a wide array of quality and cost measures, including those that evaluate clinical processes, patient safety, utilization of health care resources, structural elements of care, clinical outcomes (e.g., readmissions, mortality, complications), and costs (e.g., total cost of care, cost per episode). By incorporating Clinician & Group Survey measures into these payment systems, health plans can create meaningful incentives for providers to improve the patient experience.^10,11

For P4P and other value-based payment programs to be successful in stimulating improvement, health plans and providers must come to a mutual agreement on the size and structure of the incentives, and not hesitate to tie a meaningful portion of payments to performance on a manageable number of measures.^12-14

Examples of value-based payment programs that incorporate patient experience measures include the following:

• Blue Cross Blue Shield of Massachusetts (BCBSMA) developed the Alternative Quality Contract (AQC) payment system, which pays providers a population-based, global budget combined with significant financial incentives tied to performance on a broad set of quality measures, including CAHPS measures. By its fourth year of operation, the AQC had led to cost savings of nearly 10% while simultaneously improving quality performance, including patient experience scores. BCBSMA is now using AQC with its new health insurance products so as to create significant incentives for members to choose high-value providers and make high-value care choices, which in turn has encouraged them to participate actively in discussions with health care providers about quality and value.¹⁵
• The (IHA), a multi-stakeholder group in California that includes health plans, administers a statewide P4P program in which participating commercial HMOs use common measures to evaluate the performance of contracted physician groups and pay bonuses tied to that performance. Measures evaluate both clinical processes and patient experience.

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References

1. Fung CH, Lim Y, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008;148:111-23.

2. Lindenauer PK, Remus D, Roman S, et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007;356:486-96.

3. Elliot MN, Cohea CW, Lehrman WG, et al. Accelerating improvement and narrowing gaps: trends in patients' experiences with hospital care reflected in HCAHPS public reporting. Health Serv Res 2015 Apr. [Epub ahead of print]

4. Alexander JA, Maeng D, Casalino LP, et al. Use of care management practices in small- and medium-sized physician groups: do public reporting of physician quality and financial incentives matter? Health Serv Res 2013 48:376-97.

5. Lamb GC, Smith MA, Weeks WB, et al. Publicly reported quality-of-care measures influenced Wisconsin physician groups to improve performance. Health Aff (Millwood) 2013 Mar;32(3):536-43.

6. Martino SC, Kanouse DE, Elliott MN, et al. A field experiment on the impact of physician-level performance data on consumers' choice of physician. Med Care 2012 Nov;50 Suppl:S65-73.

7. The Wisconsin Collaborative for Healthcare Quality Performance and Progress Report is accessible at

8. Gerteis M, Harrison T, James CV, et al. Getting behind the numbers: understanding patients’ assessments of managed care. New York: The Commonwealth Fund; November 2000. Publication 428. Available at: .

9. Unpublished presentation by Clifford Rowley, Director of Member Service and Satisfaction, HealthPlus of Michigan, to the Michigan Patient Experience of Care Initiative, January 16, 2013.

10. Browne K, Roseman D, Shaller D, et al. Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Aff (Millwood) 2010 May;29(5):921.

11. Damberg CL, Sorbero ME, et al. ASPE Research Report: Measuring Success in Health Care Value-Based Purchasing Programs. Summary and Recommendations. Available at .

12. Arcadia. Pay-for-Performance (P4P) Strategies for Health Plans and Provider Networks: Building Collaboration through Technology, Shared Value, and Trust. 2013. Accessible at .

13. Ryan AM, Damberg CL. What can the past of pay-for-performance tell us about the future of Value-Based Purchasing in Medicare? Healthc (Amst) 2013 Jun;(1-2):42-9.

14. Kirschner K, Braspenning J, Jacobs JE, et al. Design choices made by target users for a pay-for-performance program in primary care: an action research approach. BMC Fam Pract 2012 Mar 27;13:25.

15. More information can be found at  and National Quality Strategy Webinar: Using Payment to Improve Health and Health Care Quality.

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