Trust and good data keys to physician change

Physicians respond to one-on-one learning

As medical groups strive to improve care, they invariably face their most difficult question: How can you change physician behavior?

There is no simple answer. But trust and loyalty, combined with data on evidence-based medical practices, form the foundation for change, says Jeffrey Lenow, MD, JD, medical director of JeffCare, a physician hospital organization for Thomas Jefferson University Hospital in Philadelphia.

In fact, Lenow says he was so committed to the goal of physicians accepting him as their peer, he put his career on hold while completing a residency in family medicine. An obstetrician, Lenow had spent 13 years as a medical director of various organizations. "You have to establish trust and credibility. You’re only as good as your credentials in the eyes of your peers.

"You have to show that you know what you’re doing; you have to be one of the group," he says. "That’s why I still practice in the academic setting. I think it’s important to the people with whom I have to share performance and management data to be able to say, I’m one of you.’"

Loyalty among physicians may come from standing up for them on an issue they care deeply about. Physicians should be involved in creating the internal "report cards" and even deciding what data elements will be measured.

After all, the feedback is designed to help physicians improve care for their patients. "Merely providing high-quality data is a potent motivator among many physicians," says Tom McAfee, MD, chief medical officer for Brown & Toland Medical Group in San Francisco.

Starting with physician input

What data should you give physicians? And how should you present the information?

In an effective feedback system, the physicians themselves largely determine that, says Lenow, who is chairman of the disease management committee for Jefferson Health System. "We involve our physicians as much as we can on our committees in which we design disease management and study evidence-based practice," he says. "If we get their buy-in early, they become partners in the cause. They become standard-bearers."

At Brown & Toland, primary care physicians receive quarterly score cards showing what percentage of their patients have received certain types of care, such as mammograms for women 52 to 69 and cervical cancer screening. (See sample score card, inserted in this issue.) They also receive a list of patients who haven’t been screened and letters they can sign to send to those patients asking them to come in for care.

In the beginning of the feedback program, the screening percentages and lists included all patients assigned to the physician. But some of those patients signed up with a primary care physician and never came for a single office visit.

"There may be a whole lot of reasons why people don’t come in to see their physicians," says Sharon Katz, RN, ND, corporate director of quality and care management with Brown & Toland Physician Services Organization. For example, a patient may sign up with Brown & Toland as part of a secondary insurance plan, while seeing a primary care physician with another practice.

So now, Brown & Toland physicians learn how many of their active patients they’ve screened. The Brown & Toland physician services organization tries to contact the other patients to encourage them to come for an office visit and receive necessary screening.

Physicians also have a chance to correct the information on the score cards and accompanying lists, notes McAfee. "If, in fact, our records are wrong, we allow the doctor to send us some kind of proof," he says. "Then they can improve their score."

The medical group voluntarily publishes some of its overall Health Plan Employer Data and Information Set (HEDIS) measures, which are indicators required for health plan accreditation by the National Committee for Quality Assurance (NCQA) in Washington, DC. Those HEDIS measures have improved for the past three years the medical group has reported data to physicians.

Financial incentives don’t work

Financial incentives aren’t a key motivator for changing physician behavior, says Lenow. And if they have a punitive aspect, they won’t work, he says. "Physicians are so worn out by the promise of financial incentives; I don’t think they’re thinking about it that much."

In fact, the incentive is inherent in providing good care, says Lenow. Physicians see their patient outcomes improve, while the medical group receives cost savings from early diagnosis and chronic illnesses that are better managed.

Physicians also may qualify for outside recognition, such as the Provider Recognition Program sponsored by the NCQA and the American Diabetes Association in Alexandria, VA, indicating that the physician met quality goals for diabetic patients.

Brown & Toland’s Managed Care Quality Incentive Program previously produced a financial incentive for physicians. But that has been canceled for this year, and McAfee doesn’t expect its absence to change the physicians’ attitude toward quality improvement.

Katz notes that previous feedback on patients receiving diabetic retinal exams wasn’t included in the financial incentive, yet that indicator improved significantly.

"Physicians, when all is said and done, want to do a good job," she says. "When they see their score compared to other physicians, it is a motivator. Also, when they see people who haven’t had preventive health screening and they have a tool that can help encourage that, I think they’re big supporters."