1. The Influence of Primary Care Practice Climate on Medical Services Costs and Quality of Care Roblin DW 1, Howard DH 2, Becker ER 2, Adams EK 2, Greenfield S 3 1 Kaiser Permanente Georgia, 2 Rollins School of Public Health at Emory University, 3 University of California, Irvine Project Funding Agency for Healthcare Research and Quality Garfield Memorial Fund of Kaiser Permanente AcademyHealth Annual Research Meeting, 2005 Boston, MA

2. 6/28/20052 Background “Crossing the Quality Chasm” (2001) recommends teamwork and collaboration among clinical staff as a way to improve quality and safety of care Evidence is accumulating that teamwork among clinical staff, both in the hospital and office settings, are associated with higher patient satisfaction and quality and safety of patient care

3. 6/28/20053 Background Are better patient outcomes resulting from higher levels of teamwork and collaboration among clinical staff associated with medical service delivery costs? –Potential to be cost-saving: Reduce redundant or unnecessary services –Potential to be cost-generating: Provide necessary but historically underused services

4. 6/28/20054 Study Objectives Estimate the association of practice climate with medical services costs in the adult medicine practice of an MCO Estimate the association between medical services costs and quality of care provided to adults with diabetes

5. 6/28/20055 Setting 16 adult medicine teams of Kaiser Permanente Georgia in 2000 and 2002 –Team characteristics: 3-5 practitioners (35% PA/NP, 65% MD) 7-12 support staff Empanelled members –Overall: 166,209 in 2000, 167,664 in 2002 –Diabetes: 10,472 in 2000, 12,710 in 2002

6. 6/28/20056 Data and Measures Written survey of HCT practitioners and support staff in 2000 and 2002 –2000: 80% response rate (N= 183 respondents) –2002: 91% response rate (N= 227 respondents) Practice Climate –Average of 7 subscales –Scale scores range from 0 to 100 –Respondent-level reliability: 0.78-0.87 (Cronbach’s alpha) –One measure per team: Equally weighted average of the practitioner mean score and the staff mean score

7. 6/28/20057 Data and Measures Computerized administrative data Medical services costs –Costs in 2000 and 2002 divided by eligibility months –Overall and by subcategory (e.g. acute, pharmacy) Diabetes quality of care –Outcomes in subsequent year: 2001 and 2003 –HbA1c tested and <8% –LDL tested and <100 mg/dl –Systolic BP < 130 mmHg, diastolic BP <80 mm Hg: 2003 only

8. 6/28/20058 Design and Analysis Cross-sectional design Medical services costs –Hierarchical linear regression models 2 Separate cross-sections: 2000 and 2002 costs Principal independent variable: Practice climate in 2000, 2002 Covariates: member age, gender, comorbidities Diabetes quality of care –Hierarchical logistic regression models Combined cross-sections: 2001 and 2003 outcomes Principal independent variable: Team average costs standardized to the KPG mean costs in 2000, 2002 Covariates: member age, gender, comorbidities

9. 6/28/20059 Results Members empanelled to primary care teams with more favorable practice climate (collaboration and teamwork) had significantly higher primary care and ancillary services costs than members empanelled to teams with less favorable practice climate. –Both for all members and for adults with diabetes –In both the 2000 and 2002 cross-sections –No significant association between practice climate and acute care costs (inpatient and emergency services)

10. 6/28/200510 Results

11. 6/28/200511 Results Adults with diabetes empanelled to primary care teams with higher primary care and ancillary services costs (per adult with diabetes) were significantly more likely to have: –HbA1c tested and a result < 8% –LDL tested and a result < 100 mg/dl –SBP < 130 mm Hg than adults with diabetes empanelled to teams with lower costs.

12. 6/28/200512 Results

13. 6/28/200513 Results The difference in average primary care and outpatient ancillary services costs between teams at the 75th and 25th percentiles of practice climate is $30 PMPM. For this difference in cost, a team at the 75th percentile achieved for every 100 empanelled adults with diabetes: –7 more with HbA1c tested and <8% –4 more with LDL tested and <100 mg/dl –4 more with SBP < 130 mm Hg

14. 6/28/200514 Summary Variation in perceptions of teamwork, collaboration, task delegation, and patient orientation among primary HCTs was associated with variation in primary care and outpatient ancillary services costs. –More favorable perceptions  higher costs Variation in primary care and outpatient ancillary services costs was associated with variation in outcomes of care among adults with diabetes. –Higher costs  better outcomes

15. 6/28/200515 Implications for Policy and Practice In the short-term (1-2 years), an MCO that invests in improving primary care teamwork can anticipate improved quality of care (and patient satisfaction). But, an MCO should not anticipate reduced costs –Treatments to improve care of the chronically ill are not necessarily cost-saving in the short-term* –Ho: More visits, monitoring  increased costs Cost savings from improved practice climate may be realized long-term through reduced morbidity and averted acute care use. * Fireman, Bartlett and Selby, Health Affairs, 2004