Cooperative uses grant to evaluate quality plan

Joint venture will involve academic researchers

The University of Washington (UW) School of Public Health and Community Medicine in Seattle has received a two-year, $656,000 grant from the Robert Wood Johnson Foundation to evaluate the impact of Group Health Cooperative’s recent innovations to improve access and quality of care for its members.

Group Health is a Seattle-based, nonprofit integrated health care system including one hospital, a number of outpatient clinics, physicians, and health plans that coordinates care and coverage for nearly 540,000 people in Washington and Idaho.

The study will review what Group Health calls its Access Initiative, a six-point plan to improve quality and access that has been rolled out over the past several years. The plan includes:

  • offering patients same-day appointments to primary physicians;
  • allowing patients direct access to most specialists, eliminating the need to go through primary care doctors to make appointments for specialty care;
  • providing patients access to their own medical histories, appointment schedules, immunization records, and other health care information over a secure member web site;
  • encouraging patient-physician e-mail communication via a secure web portal called MyGroupHealth;
  • providing physicians and other providers with a $40 million clinical information system that offers up-to-the-minute patient health information, such as lab, X-ray, and pharmaceutical data;
  • providing physicians with new incentives based on measures of productivity, cost, and quality.

"Our findings will be relevant to all people interested in issues of quality and access, regardless of what model of health care they represent," said Eric B. Larson, MD, MPH, director of Group Health’s Center for Health Studies (CHS) and a co-investigator of the study, upon the announcement of the grant. "This is a seminal observation opportunity."

The CHS conducts research related to prevention, diagnosis, and treatment of major health problems.

David Grembowski, PhD, professor of health services in the UW School of Public Health and Community Medicine, is the principal investigator. He and his colleagues will use Group Health’s automated databases, member and physician satisfaction surveys, patient visit surveys, and in-depth interviews with care providers. Based on the data, they will determine how the access initiative is affecting factors such as cost, utilization of services, quality of care, member enrollment, and patient and provider satisfaction.

"We have a structured set of questions we will be asking," Grembowski explains. "First of all, we will look at what we call the take-up’ of the initiative: Are they making same-day appointments? Are visits to specialists increasing? The second thing we want to look at is, did access actually increase? In other words, if you put this package out there in a group health system, is there actually an increase in access? Also, we want to see if satisfaction with care has increased as well. The final question we want to look at is, if we do find access has increased, is the quality of care better?"

Other UW researchers contributing to study will be Douglas A. Conrad, PhD, and Diane P. Martin, PhD. Other CHS researchers on the project are Paul Fishman, PhD, and James Ralston, MD, MPH.

Full-range access

The leadership of the Group Health Initiative "is attempting to increase consumer access to the full range of preventive, palliative, and health services," Fishman explains. "This includes everything from primary care and prevention to palliation/hospice. And it’s not simply to make sure the senior patients have access to their cardiologist, but that the patient has same-day access."

This part of the initiative has been in place the longest — since 2001, in fact. "To do it, they had to get rid of the backlog, so there was a short-term crunch," Grembowski notes. "But once you got over that, it was just dealing with the same-day appointments. The caveat is, you may not have the appointment with your personal primary care provider, but Group Health physicians work in clusters of three or four, so the appointment is kept within the cluster."

"I was not convinced as a consumer that this would be a big deal," Fishman adds. "But it really makes a difference — to be sitting there at midnight needing to see a doctor, sending an e-mail and having an appointment the next day."

The extensive electronic contact is significant, Grembowski adds. "Patients also have access to their electronic medical records over the web, and they can also do prescription refills.

"They can not only schedule office appointments online, but also obtain visit summaries. And if you are seeing a physician for a specific medical problem, the system will automatically send health care information about that condition to your e-mail address," he notes.

"The web-based initiative is, quite frankly, amazing," Fishman says. "Currently, about 30% to 40% of our patients are registered."

Financial incentives are another unique aspect of the initiative. For example, Grembowski adds, physicians get financial credit for responding to patients’ e-mail messages.

"It’s part of their compensation. Historically, Group Health physicians have been paid on a salary that was 100% guaranteed. Now, it’s 80% guaranteed, and they can earn from 80% to 120% based on productivity, quality of care, and accuracy of coding," he says.

Peer review imprimatur

The reason the Group Health has sought such a study, says Fishman, is quite straightforward: "We are trying to get this initiative to have the imprimatur of peer review," he asserts. "We want this work to be subject to that standard, and then to make sure the heath plan is responsive. When we say, Here’s what we’ve learned,’ we want them to be responsive to this."

The two-year grant ends November 2006. By that time, the researchers hope to gain understanding in several key areas: for example, whether physicians are responsive to alternative means of compensation and whether consumers are responsive to alternative venues of care, Fishman says.

"The literature shows that when the gatekeeper is eliminated, there aren’t significant levels of change in care or in how people choose care. We have the opportunity to study these issues in ways others don’t. Typically, these studies have only looked at physician care, but we can track how people move through the entire system." For health care quality professionals, he adds, the study should shed additional light on the relationship between health outcomes and quality measures.

"We will see whether there are relationships between all theses factors; we have a chance to do things others don’t," Fishman concludes.