A Colorado HMO ties patient satisfaction to physician incentives

Let patients define quality

Editor's note: Charles Gaughan is manager of research and planning, and Lori Muneta is market research analyst, for TakeCare Colorado, headquartered in Aurora, Colo.

Imagine this: You've already sat 45 minutes in your doctor's waiting room, reading last year's magazines among an assortment of wheezing, sneezing patients. Now you are perched on the edge of an examination table, partially disrobed and shivering, waiting another 15 minutes for the appearance of a physician who will "be with you in just a second." Your blood pressure is nearing a record high, but what can you do if you're sick and can't get an appointment elsewhere for days or weeks?

At TakeCare, one of Colorado's largest health maintenance organizations (HMOs), patients can take heart that their health plan uses a research-based system specifically tying patient satisfaction to a physician incentive system.

HMOs have long been recognized for their ability to monitor costs and utilization. But as membership in managed care plans continues to grow, employers - the primary purchasers - and credentialing organizations are placing an increasing emphasis on measuring quality of care. At TakeCare we asked the people with the most at stake - our customers, the patients. We developed a telephone satisfaction survey more than two years ago to gauge our primary-care physicians' performance in three crucial areas: access to care, physician care, and the office staff and environment.

Our survey targets HMO members who have visited their physician in the past 60 days. The instrument consists of 23 multichotomous and open-ended questions, and takes approximately six minutes to complete. TakeCare interviewers call patients in the evening. Our goal is to complete at least 20 interviews annually for each physician.

Patients don't wait long

Before TakeCare began the survey, many physicians had no idea how long the average patient had to wait for an appointment or sit in their waiting rooms. So far, we are pleased to discover that the scenario described at the beginning of this article isn't played out on a regular basis. Our data show that 77 percent of patients can schedule an appointment within three days. Eighty-three percent wait less than 15 minutes before seeing a physician, and only 6 percent are required to wait more than 45 minutes.

Besides questions on access to care, we asked questions about the physician's delivery of care. Using a five-point rating scale, we asked about the amount of time spent with the doctor; the doctor's bedside manner; how well the doctor explained the diagnosis; the doctor's willingness to listen to patients' concerns; and the doctor's overall competence. Finally, patients are asked if they would recommend their physician to others. Physicians have discovered that a vast majority of patients are very satisfied with their performance. Last year's overall physician rating was 4.57. Only 6 percent of respondents said they wouldn't recommend their physician to others.

These are important measures. Research has shown that patient satisfaction is based more on intangible attributes of health care than on clinical protocol. Physician credentials and technical expertise are important to patients, but not as significant as traits like listening to patients' concerns, clearly explaining a diagnosis, or spending the appropriate amount of time with patients.

Physicians skeptical

When TakeCare began its member survey on physician care, a few physicians questioned the fairness of such an approach. They worried about the subjective nature of the survey and whether patients were qualified to judge the quality of care. There was also some concern about using the results in the bonus program and in physician credentialing (a recertification process all physicians go through every two years).

Ultimately, physicians are interested in ensuring that patients have access to care, and helping them build and maintain healthy lifestyles. With consumers increasingly "shopping around" for medical care, it's even more important to form a strong physician bond, ensuring the long-term health of the patient, and, incidentally, providing a stable patient base for the physician.

One of the timeless challenges of research is to see the findings through to completion - or action. In our case, if HMO members are asked about their experiences, then we must also have systems in place to act on their behalf, improving physicians' health care delivery. This is a great challenge, especially for an HMO with private-practice physicians.

That's why we tie survey results to a positive incentive - the annual physician bonus. Each year, our doctors are given benchmark data, allowing them to compare their performance to their peers. This helps physicians pinpoint specific areas contributing to patient satisfaction. Open-ended responses have also proven very beneficial. The annual survey results contribute up to 20 percent towards a physician's annual bonus. Provider reps visit physicians in the lowest percentile and offer information on how to deliver the levels of service patients expect.

After an initially ambivalent reaction, most of TakeCare's network physicians now fully support the program. Some physicians have even requested additional surveys. Not only do they find the results useful in managing their practices, they also help when negotiating with insurers and networks.

The program has also been a very successful public relations tool for TakeCare. Patients are surprised to hear from their health plan and appreciate the opportunity to discuss their experiences with our employees. On average, less than 5 percent of patients contacted refuse to participate. We doubt the goodwill we create could be duplicated in other ways.

Direct contact

A key to our success has been direct telephone contact using our employees rather than outside researchers. Our specially trained employees know the issues, are focused and ensure quality data. It's also more cost-effective.

In the future we expect our customer information systems to be even more effective. In collaboration with Andersen Consulting of Chicago, TakeCare recently designed an automated survey system using Windows-based software. TakeCare Colorado is a beta test site for this survey software and will be the first health care company in the world to incorporate this technology into its customer service mix.
The new software will provide flexibility and speed in survey design, allowing us to act quickly on results. We plan to use this technology to electronically route critical time-sensitive questions, concerns or suggestions from our callers to our provider services department, improving our response time.

The automated system will also increase productivity. Sampling, call quotas, productivity figures, and list maintenance will be automated, which should bolster our teams' productivity by 25 percent.

Don't forget objectives

Although those of us involved in professional research are excited by this advancing technology, it's important to not lose sight of our basic objectives. At TakeCare we are in the service business. The patient survey helps focus TakeCare employees, management and network physicians on the needs of our common customer, the patient.

One recent study shows that Americans believe their health care should be immediate, effective and convenient, yet affordable. We believe programs like our patient survey help meet these expectations, while positioning TakeCare and other HMOs as the health care delivery systems of choice.

By listening to our customers, TakeCare knows that patients expect to define quality for themselves. We've also found that it's not enough merely to listen - if you are going to ask, you must be prepared to act.