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This suggests that the best practice intervention had a significant impact on some of the health care processes in the physician practices. The most impactful interventions were those related to face-to-face educational discussions and patient medical chart documentations rather than those pertaining to medication adherence. Improvements in measuring reporting and recording of data at post-intervention were also observed.
Avoid the most common mistakes and prepare your manuscript for journal editors. The National Healthcare Disparities Report documents that racial and ethnic disparities remain pervasive [ 1 ].
A decade prior, in , the Institute of Medicine released the Crossing the Quality Chasm report that recommends incentives to encourage quality health care and better health outcomes [ 2 ].
To address these concerns, numerous private-sector initiatives to link portion of payments made to physicians and hospitals dependent on improved quality are underway. These initiatives are commonly referred to as pay-for-performance programs P4P [ 2 ]. P4P is broadly defined to include any type of performance-based provider payment arrangement, including those that target performance on cost measures [ 2 ]. The primary goal of P4P is rewarding or improving quality of care; a secondary goal is controlling cost by reducing errors and inappropriate utilizations [ 2 ].
P4P is only one of many proposed strategies that may improve quality and thus positively impact healthcare disparities [ 3 — 6 ]. It is well recognized [ 3 , 4 , 7 — 11 ] that there are both advantages increased payment, improved efficiency, and improved care quality, especially among disparate populations and disadvantages cost of acquiring information technology, multiple programs and guidelines, data collection to P4P programs currently designed and implemented as reported by the American Academy of Family Physicians AAFP [ 8 ].
One challenge associated with P4P is its potential to increase disparities if some groups like medically underserved groups are less able to respond to specific interventions when compared to others [ 12 ]. Another reported challenge is to implement P4P in the small practice setting [ 2 , 4 , 8 ], which experiences substantial barriers like limited staff and fewer resources than larger group practices, thus increasing the difficulty completing quality improvement projects [ 2 , 4 , 8 ].
According to AAFP, there are seven P4P guiding principles that programs should adhere to [ 8 ]: 1 focus on improved quality of care; 2 support the patient relationship; 3 utilize performance measures based on evidence-based clinical guidelines; 4 involve practicing physicians in program design; 5 use reliable, accurate, and scientifically valid data; 6 provide positive incentives; and 7 offer voluntary participation.
Specifically, the program recognizes and rewards primary care physicians PCP for collaborating with Highmark to improve the quality and effectiveness of health care services provided to our members. Highmark has been engaged in both focused disparity-related activities as well as P4P for several years. These efforts have been published elsewhere [ 13 — 15 ]. NHPC was a novel public-private partnership between eight health plans covering approximately 95 million lives.
The Quality Blue Physician P4P program is offered in 49 counties of western and central Pennsylvania with approximately primary care physicians PCP in more than practices, providing services to more than 1,, unique Highmark members.
The practices explore opportunities for clinical-based activities, thereby empowering them to integrate improvement models into daily office activities and promote proactive rather than reactive care.
The Best Practice studies carried out by practices have varied over the years and have included some of the following improvements:. Although P4P strategies are increasingly common, little is known about the impact of applying this payment method to reducing healthcare disparities HCD in general or by geography urban and rural areas , including Pennsylvania [ 16 ].
In this study, we hypothesize that existing P4P programs have the potential to decrease disparities in minority groups. Although all PCP practices that participate in the Quality Blue Physician P4P program are encouraged to conduct a Best Practice study, practices identified as serving sizable minority populations e.
Efforts were made to recruit practices where African American and Hispanic Highmark members with known cardiovascular and diabetes disparities received their primary care. Since previous data analysis had identified disparities in pediatric asthma clinical indicators, efforts were also made to recruit pediatric practices that served minority children. These PCPs were identified through a query report matching all minority patients with known healthcare disparities in diabetes and cardiovascular disease HEDIS indicators with their primary care physician practices who were participating in the Quality Blue Physician P4P program From these PCPs, practices were identified that included a total of at least five eligible minority patients.
The five-patient criterion was used to allow sufficient numbers of minority patients for the statistical evaluation of the pilot and to help identify practices that may be more willing to participate. Figure 1 illustrates how the practices were selected for the pilot study. Of the practices identified from the eligible PCPs, only 29 met the minimum five-patient criterion. In addition, 30 practices were identified by Highmark staff between April and August that were not included in the query report but were recommended as having a larger volume of minority patients with hypertension or pediatric asthma.
Thus a total of 59 practices were available for the pilot. Of those, 50 practices met the eligibility criteria of having previously participated in the best practice option. Of the 50 practices, 25 chose to participate in the pilot, and among those, a total of seven completed the pilot study.
Best practice interventions were decided within each of the seven participating practices. Therefore, each practice participated in different interventions. The clinical Best Practices were measured at the end of each month for six consecutive months.
A random sample of medical charts of minority patients with the identifiable healthcare disparity was selected to audit for evidence of the intervention-specific measurement. The baseline measurement was taken before the start of the intervention and was compared with results at month six to evaluate the effectiveness of the various interventions within each practice.
Interventions are described in the left most column of Table 1. A two-tailed, two-sample test of proportions was performed, which compares the baseline results proportion of patients satisfying the BPPO measure for each BPPO with the final results at month six. The baseline and final samples were treated as independent samples.
A statistically significant result is indicated if the p value is less than or equal to 0. Due to the exploratory nature of this pilot, no adjustments were made to account for multiple comparisons. It is possible that some of the subjects were measured at both baseline and month six; in this scenario, the independent two-sample test of proportions will likely yield a conservative p value. Additionally, most of the outcomes are measures of documentation rate of the practice which would be unaffected by the particular patient being documented.
As such, even if patients did overlap in the samples, the resulting pre- and post-documentation rates of the practice would be independent of each other.
Practices were identified if it met or exceeded the target proportion. Targets were specified separately by each practice. Of the 50 eligible intervention practices that met the requirements for this study, only 25 chose to participate with seven completing the P4P program. As shown in Table 1 , two of the seven practices were hospital owned and multi-specialty, and the remaining five were independently owned.
Four practices were located in urban Pennsylvania while two were in rural areas; one was located in a suburban area. Most practices offered only weekday hours. Only one practice reported not having an electronic medical record EMRs system. Table 2 shows a description of the patient population of the participating practices. Three geographic regions were represented across practices: Southwestern, Northwestern, and Central Pennsylvania.
Approximately one in five patients in practices 1, 3, and 4 were black patients. For practices 6 and 7, one in three patients was Hispanic. As shown in Table 3 , most of the differences in the proportion of patients satisfying the BPPO measure between the baseline, which was measured before the start of the intervention, and month six were statistically significant.
For example, in practice 1, only three of the 19 patients had their BMI measured and documented before the start of the intervention. At the end of the intervention, all 19 of the patients selected in month six had their BMI measured and documented. The most impactful interventions were those related to education, discussions, and patient medical documentations rather than those pertaining to medication adherence.
We found significant improvements in blood pressure measurement and documentation from While there was no formal comparison group, the magnitude of these findings suggests that P4P had a significant impact on some of the physician practices. This study supports the findings of others reporting the use of P4P as a proposed strategy that may improve quality and thus positively impact healthcare disparities [ 1 — 6 ].
Similar to findings reported by Coleman 14 , improvements were observed in diabetes for our patients that tested their HbA1c from However, these changes were not statistically significant. One proposed strategy presented by Coleman is to include a patient social support [ 17 ] component in the P4P approach. This may be a reasonable starting point for examining this link as minorities report lack of social support as a barrier to their health care behaviors cues to action , including compliance [ 17 ].
Because in our study the most impactful interventions were those related face-to-face educational discussions and patient medical chart documentations rather than those pertaining to medications, we propose that strategies for examining this particular link also includes an education, discussion, and patient medical documentation component.
Whether these components should be tested alone or in combination needs further research. There are five notable strengths to this study. First, this study included feedback from a disparate population that could benefit from improved health care quality. Thirdly, this study provided an opportunity for one health insurer and several local practices serving minority patients to work together and identify potential strategies aimed at rewarding or improving quality of care.
Another strength of the pilot is the absence of selection bias. Because the P4P incentive was based solely on completing the intervention and not on the results, there was no pre-selection of patients within each practice. Lastly, all doctors and staff were required to complete a cultural competency course as a prerequisite for the participating in the pilot study.
Completion of the course was optional but encouraged for nurses, physician assistants, and other staff at the practices.
For example, our P4P program focused on improving quality of care as defined by the selected biological and behavioral endpoints at baseline and monthly assessments over a six-month period.
Our program utilized performance measures based on evidence-based clinical guidelines. The pilot physician and nurse participants were given access to a complimentary E-learning Quality Interactions Continuing Medical Education CME course and other cultural competency educational resources and the tools to implement the healthcare disparities activities.
These resources remained available to network providers post-intervention. Based on the opinion of and feedback from these intervention pilot practices, this P4P program can be easily adopted by other health plans provided they have an engagement strategy in place to support the spread of evidence-based guidelines, process, and quality improvement activities and a commitment to eliminating healthcare disparities.
Results of this study may also help to inform next steps for public health initiatives aiming to improve patient medical chart documentations. Reported strategies include the following [ 18 ]: 1 to focus on how proper documentation can improve quality, having impact is important.
This may help to encourage and provide added reasons for physicians to improve their medical documentation; 2 to provide training opportunities for the practices. Medical documentation is mostly the responsibility of a physician and medical staff, and thus across-the-board trainings become increasingly important.
This may help provide consistency in documentations across staff members; and 3 to improve existing coding structures used by a practice. Review of coding structures should be revisited on an ongoing basis. It is well documented that targeted interventions yield better outcomes when compared to non-targeted approaches. Three limitations must be noted. First, this was a one-time assessment of seven of 50 potential practices in Highmark service areas. Thus, the patients who participated in this study might not have been representative of all practices, including those serving outside the Highmark service area.
However, many of these health professionals had experience working within and outside Highmark and stated that they had no reason to believe that the P4P approach used would not work in other practices serving minority patients. We did not assess whether their minority patients were any different compared to other minority patients. This was outside the scope of this study.
Second, of 25 practices that committed to participation, only seven completed the pilot study. A major programming change in the Quality Blue P4P program requirements and scoring was implemented in The focus of the Quality Blue P4P component shifted to support meaningful use and patient-centered medical home activities.
We do not believe that this reason is associated with any of our measured outcomes. As such, the low completion rate does not pose a statistical concern of biased results.
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