1. 6/28/05 AcademyHealth ARM 1 A Tale of Two Physician Organization Ownership Types Margaret C. Wang RAND/UCLA Post-Doctoral Fellow AcademyHealth Annual Research Meeting

2. 6/28/05 AcademyHealth ARM 2 Background The quality chasm in health care Paradigm shift in chronic care delivery The crucial role of physician organizations (POs)

3. 6/28/05 AcademyHealth ARM 3 PO Ownership Structures Freestanding physician-owned System-affiliated hospital-owned Who owns the equipment and employs the non-physician staff of your PO (including MSO, if any)? Why does it matter?

4. 6/28/05 AcademyHealth ARM 4 Research Questions 1.What is the association between the type of PO ownership structure and: –Clinical IT, scheduling and follow-up capabilities, availability of case managers, and financial resources –External incentives for quality 2.How does ownership structure affect the implementation of the Chronic Care Model?

5. 6/28/05 AcademyHealth ARM 5 The Chronic Care Model (CCM) Source: Wagner et al., 1999

6. 6/28/05 AcademyHealth ARM 6 The Chronic Care Management Index (CCMI) CCM Model ComponentsCCMI Measures Community Linkages:Community Service Agencies Referral Systems Self-Management Support:Assessment of Patient Self-Management Use of Programs to Increase Skills Decision Support:Integration of Guidelines Integration of Specialist Expertise Delivery System Design:Planned Visits Multiple Providers Use of Case Managers Clinical Information Systems:Provision of Written Feedback MDs Use of Internet for Communication

7. 6/28/05 AcademyHealth ARM 7 Data Source National Study of Physician Organizations and the Management of Chronic Illnesses –National census of physician organizations employing 20 or more physicians (2000 – 2001) –Final sample size = 1,104 (70% response rate) –67% medical group and 33% IPAs

8. 6/28/05 AcademyHealth ARM 8 Descriptive Statistics Physician-Owned POs N = 561 Hospital-Owned POs N = 405 PO Type Medical Group (%):5885 IPA (%):4215 Practice Specialty Single Specialty (%):177 Primary Care (%):814 Multispecialty (%):7579 Risk Assumption for Hospital Costs(N = 519)(N = 371) Mean:2217 Geographic Location Pacific (%):2416 Non-Pacific(%):7684

9. 6/28/05 AcademyHealth ARM 9 Organizational Resources Index (Range) Physician-OwnedHospital-Owned Clinical IT Index (0-6)*1.11.7 Group Visit Scheduling Index (0-4)*0.30.7 Multiple Needs Scheduling Index (0-4)*1.01.7 Follow-up Index (0-4)*0.91.5 Case Manager Availability Index (0-4)*1.11.5 Mean values for structural and human resources: Percentage of POs reporting breaking even vs. loss: Physician-OwnedHospital-Owned Reported Loss*3661 Reported Broke Even /Made Profit*6439

10. 6/28/05 AcademyHealth ARM 10 Impact of External Incentives Mean value for Quality Reporting Requirement Index: Physician-OwnedHospital-Owned Quality Report. Require. Index (0-4)*0.61.0 Percentage of PO reporting receiving external incentives for quality: Physician-OwnedHospital-Owned PO Receiving Public Recog. for QI*2228 PO Receiving Better Contracts for QI2225

11. 6/28/05 AcademyHealth ARM 11 Implementation of the CCM Physician-OwnedHospital-Owned (N = 561)(N = 405) Chronic Care Manage. Index* (0-11)3.85.1 Mean and standard deviation for the Chronic Care Management Index (CCMI):

12. 6/28/05 AcademyHealth ARM 12 Stepwise Multivariate Linear Regression: Model 1Model 2Model 3Model 4 Intercept15.0610.7516.2412.42 Hospital Ownership5.683.623.99 2.74 Clinical IT Index1.330.87 Group Visit Scheduling Index2.262.13 Multiple Needs Scheduling Index2.171.73 Follow-up Index1.581.52 Case Manager Availability Index5.805.07 Broke Even or Made Profit2.681.95 Quality Reporting Requirement Index3.162.13 Public Recognition for Quality12.349.03 Better Contracts for Quality7.35.48 Implementation of the CCM Implementation of the CCM

13. 6/28/05 AcademyHealth ARM 13 Sub-sample analyses: Implementation of the CCM Physician-OwnedHospital-Owned (N = 527) (N = 387) Intercept17.197.55 Clinical IT Index1.37 0.54 Group Visit Scheduling Index1.792.36 Multiple Needs Scheduling Index1.641.84 Follow-up Index1.501.60 Case Manager Availability Index5.214.74 Broke Even or Made Profit1.211.31 Quality Reporting Requirement Index2.242.00 Public Recognition for Quality9.367.50 Better Contracts for Quality7.27 2.73

14. 6/28/05 AcademyHealth ARM 14 Conclusions Ownership matters but organizational resources and external incentives are more important for CCM implementation –Receiving public recognition for quality The role of clinical IT among the system-affiliated hospital-owned POs warrants further investigation

15. 6/28/05 AcademyHealth ARM 15 Policy Implications Promoting greater implementation of the Chronic Care Model requires: –Organizational resources Clinical IT, scheduling capabilities, active follow-up, and case manager availability –Incentive mechanisms Requiring quality reporting, providing public recognition for quality, and tying quality improvement with better contracts

16. 6/28/05 AcademyHealth ARM 16 Acknowledgements Dissertation study was funded by Health Research and Education Trust (HRET) Fellowship The NSPO project was funded by the Robert Wood Johnson Foundation (RWJF)