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Purpose: Recent reports have emphasized the importance of delivery systems in improving health care quality. However, few prior studies have assessed differences in primary care quality between physician groups that differ in size and organizational configuration. We examined whether larger physician group size and affiliation with networks of multiple groups are associated with higher quality of care., Methods: We conducted a cross-sectional observational analysis of 132 physician groups (including 4,358 physicians) who delivered primary care services in Massachusetts in 2002. We compared physician groups on performance scores for 12 Health Plan Employer Data and Information Set (HEDIS) measures reflecting processes of adult primary care., Results: Network-affiliated physician groups had higher performance scores than non-affiliated groups for 10 of the 12 HEDIS measures (p < 0.05). There was no consistent relationship between group size and performance scores. Multivariable models including group size, network affiliation, and health plan showed that network-affiliated groups had higher performance scores than non-affiliated groups on 8 of the 12 HEDIS measures (p < 0.05), and larger group size was not associated with higher performance scores. Adjusted differences in the performance scores of network-affiliated and non-affiliated groups ranged from 2% to 15%. For 4 HEDIS measures related to diabetes care, performance score differences between network-affiliated and non-affiliated groups were most apparent among the smallest groups., Conclusions: Physician group affiliation with networks of multiple groups was associated with higher quality, and for measures of diabetes care the quality advantage of network-affiliation was most evident among smaller physician groups.

Outreach to physicians, CQI net Harvard Pilgrim top NCQA honors. Most health care professionals agree that data collected by the NCQA are regarded as some of the most objective and comprehensive measurements of health plan performance. The 2004 report includes two "top 10" lists of the nation's top performing health plans in terms of clinical quality and member satisfaction. Harvard Pilgrim Health Care is the first health plan to achieve both of those accomplishments.

Background: Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record., Methods: We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care., Results: Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 - 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 - 0.75)., Conclusions: Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation.

Objective: To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO)., Design: Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts)., Setting: Primary care practices in Massachusetts., Participants: General internists and family practitioners in Massachusetts., Measurements: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality., Results: Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P < or =.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P < or =.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P < or =.01)., Conclusions: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.

The tumultuous fall into receivership of Harvard Pilgrim Health Care, and its subsequent financial rise, has been well documented. One of the principal concerns in situations of financial upheaval is how to ensure that staff and customers maintain a positive attitude toward the troubled health plan. An insider at Harvard Pilgrim provides a glimpse at the steps that were taken to ensure high-quality customer service and to retain valuable staff.

What lessons can be learned from the financial collapse and rehabilitation of Harvard Pilgrim Health Plan? One managed care expert says many of the factors that hurt Harvard Pilgrim can be seen in other plans across the nation.

Background: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data., Objective: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences., Methods: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians., Results: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05)., Conclusions: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

A growing number of physicians are using organized labor to gain economic leverage. Hospital downsizing and autocratic managed-care plans have prompted more doctors to join the ranks of other professionals who carry union cards. While not a sweeping trend, interest in unions is growing--even among private-practice physicians who can't bargain collectively because of antitrust laws.

Objective: This study assesses physician attitudes toward clinical practice guidelines, in an organization where guidelines have long been incorporated into the clinical practice. Attitudes toward institutional guidelines and guidelines in general are explored, and are compared to a published study describing attitudes among a sample of American College of Physician (ACP) members., Design: Descriptive study., Setting: A large, mixed model HMO., Sample: Two hundred and three internists and family practice physicians., Measures: Attitudes toward perceived compliance with clinical practice guidelines were assessed. Summary measures of attitudes and anticipated impact of guidelines were created., Results: Overall, attitudes toward practice guidelines among HMO physicians were very positive. Differences were observed by gender, practice model, years in practice and residency training. HMO physicians on average held more favorable attitudes toward guidelines compared with published results of an ACP survey. While HMO physicians in independent group practices viewed the concept of guidelines less favorably than staff model physicians, they were more likely to view the impact of guidelines positively than were the ACP physicians., Conclusions: Exposure to practice guidelines in the context of clinical practice can lead to positive attitudes about those guidelines. While resentment toward a system which relies on practice supports such as guidelines may remain among some physicians, this need not be inconsistent with an appreciation of the potential value of guidelines for improving clinical quality.

Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.

The main objectives of this study are to analyze the Massachusetts Health Maintenance Organizations (HMOs) in order to determine their standard definition of an emergency, the HMOs instructions for seeking emergency care, and distribution of such instructions for the pediatric population. A 15-question survey concerning pediatric emergency care policies and procedures was asked of each of the 20 HMOs contacted. Quarterly statements of each of the 20 HMOs were obtained from the Division of Insurance as well as the HMO's written materials distributed to the enrollees as member handbooks. Ninety percent of the HMOs had a definition of emergency care for the adult population, whereas 0% had a definition of emergency care specifically for the pediatric population. One hundred percent of the HMOs had instructions for emergency care, but 0% had specific provisions for pediatric emergency care. All 20 HMOs inform their enrollees about emergency policies through a member handbook. The results of this study reveal the lack of a standard definition of an emergency for HMOs. The current definitions of "urgent," "emergency," and "life-threatening emergency" care do not reflect the pediatric population, rather, these definitions are based on the adult population. The lack of specific pediatric guidelines could compromise the health of the children in HMOs.

HMOs can use clinical data culled from computerized medical records and provider and patient interviews to examine the impact of premature infant births on the family. The results can help guide health plans in developing a clinical intervention program to address the physical and emotional consequences of low birthweight babies. The Harvard Pilgrim Health Care experience describes the data collection process administrators are taking to design such a clinical intervention.

Joint research ventures between health maintenance organizations (HMOs) and academic medical centers (AMCs) can strengthen both organizations from the research and patient care perspectives, by facilitating the exploration of views and cost-effective approaches to diagnoses and treatment. This article describes a research venture between the Fallon Healthcare System, a health maintenance organization (HMO), and the University of Massachusetts Medical Center, an academic medical center (AMC). This research venture, the Worcester Area Trial for Counseling Hyperlipidemia, was a four-year study in which 1,277 participants were recruited from 45 Fallon Clinic physician panels. The study targeted patients with blood cholesterol levels in the upper 25% of the cholesterol distribution. The different priorities and perspectives of the two institutions with regard to health care and research became more apparent as the study progressed. Eventually study personnel needed to re-examine the study objectives and each other's perspectives to accommodate these differences. This learning process showed that research ventures between HMOs and AMCs can prove mutually beneficial. An HMO can gain experience with large government-funded projects. AMCs can study managed care within a controlled setting. However, the differing priorities and perspectives of these institutions' organizational structures require that considerable attention be paid to their representatives' working relationships and perceptions.

Background: Physicians are increasingly practicing within structured or organized practice settings, even though it is frequently assumed that such organizations are inherently dissatisfying to physicians. In this study, a sensitive measure of physician satisfaction is used to compare physicians working in four types of practice settings: private group practice, solo practice, a closed-panel health maintenance organization (HMO), and a hospital-based practice., Methods: A questionnaire was mailed to all physicians in a four county area in western Massachusetts, from which 1302 practicing physicians were identified. Based on responses to the questionnaire, the physicians were placed into one of the four practice arrangements. Satisfaction was measured by using an index methodology, with six statistically acceptable measures of satisfaction., Results: All physicians surveyed were most satisfied with the personal and lifestyle factors related to their practice, regardless of practice setting. Those in a private group practice were the most satisfied. However, physicians in an HMO setting were more satisfied with medicine as a profession and less dissatisfied with the state's medical practice climate than physicians in the other practice settings. It appears that HMOs provide professional satisfaction by buffering physicians from the external regulatory climate, permitting them to focus more on patient care., Conclusions: Identifying the factors that cause physician satisfaction and dissatisfaction within the various types of practice settings becomes increasingly important as current health care reform efforts continue to promote more structured practice environments. More research is needed to identify the various organizations physicians are involved with so that physicians' professional level of satisfaction can be maximized.

A comprehensive case management system has been developed at Fallon Healthcare System, with overall aims of improving medical, social and financial outcomes for health plan members who need complex patient care management. A definition of case management is offered, goals of case management services are specified, criteria for appropriate referrals are outlined, and the process of implementing services is described. Formal evaluation of the program is being planned.

This article describes a collaborative effort between a major health care purchaser, three area health maintenance organizations, and a state Medicaid agency to develop clinical indicators as the basis for a comparison database. Some of the difficulties in developing a "common yardstick" of quality and value are candidly discussed.

With the information resources available today, groups can better determine whether they possess the ingredients for success with regard to risk contracting, write Molly Zelley, M.P.A., and Christy Bell. For those that do, Medicare risk contracting can be a vehicle for developing comprehensive, cost-effective new approaches for attracting and providing health care to this increasingly significant segment of the population.

As part of a pilot test, Cambridge, MA-based Harvard Community Health Plan has patients in about 150 households using home computers to receive medical advice and general health information. The system should better educate patients, improve quality of care and lower costs, according to its developers.

This strategic plan translates the HCHP vision statement into a working plan for one major clinical condition--asthma in children. It is a working plan for clinicians and managers across specialties and levels. The results of the projects will improve in a measurable way significant clinical practice and outcomes, in keeping with the FY 1993 strategic goals.

The Fallon Clinic Pediatric Department initiated a unique pre-operative teaching program in the HMO ambulatory setting for children undergoing elective surgery. The new program is based upon a pre-surgery appointment scheduled 1 week before elective surgery. At this visit, the patient completes required laboratory and other pre-operative testing and a physical examination is performed by the child's pediatrician.

"Reminders" (timely notices about specific clinical events to physicians or patients) are useful strategies for implementing clinical guidelines. These systems can vary widely in content, design, and purpose. This variability makes it difficult to compare systems or predict a reminder's efficacy in a particular setting. In this article, the authors suggest that too much attention has been paid to proving the efficacy of reminder systems as a general strategy or a comprehensive solution. Rather, the usefulness and effectiveness of reminder systems will be better appreciated when quality management principles are applied to designing, implementing, and maintaining them. Physicians must participate in finding the best solutions for clinical process problems, and reminder systems--when implemented as the "best solution"--must be monitored and improved continually on an ongoing basis to continue to meet physicians' needs.

In developing a plan-wide ethics committee for a health maintenance organization (HMO), one will inevitably be faced with the numerous differences between a HMO and any other health care facility. These differences offer advantages and disadvantages with regard to the formation of an ethics committee and strongly influence the logistics and functions of such a committee. Managed health care is a new arena for an ethics committee, one in which the role of an ethics committee is beginning to unfold.