Access Initiative Impacts on Access Initiative Impacts on Primary Care Provider Primary Care Provider

ProductivityProductivity

Douglas A. Conrad, PhD*Douglas A. Conrad, PhD*

Paul Fishman, PhD**Paul Fishman, PhD**

University of Washington, Department of University of Washington, Department of Health ServicesHealth Services**, and Group Health , and Group Health

Cooperative, Center for Health StudiesCooperative, Center for Health Studies****

Access InitiativeAccess Initiative

Pre-Initiative

01 02 03 04

Adv Access to PC

Physician Payment Reform

00

Direct Access to Specialists

EpicCare Phase I

97 06 0705

Full-ImplementationRollout

EpicCare Phase II

MyGroupHealth & Secure Messaging

PC Redesign

Apr 2002 Aug 2003

Timeline of Group Health Cooperative Access Initiative and Initiative Components

Productivity HypothesesProductivity Hypotheses

Postulated Principally Positive Effects of Access Initiative on Productivity

However, Anticipated Some Short-Run Decrements in PCP Productivity, Potentially in Adjusting to:

• New Systems• New Incentives• New Clinical Management Routines

Overview of Study DesignOverview of Study Design

• Productivity Analysis Embedded within Overall Evaluation of the Initiative Intervention

• Analysis Period: 1998 – 2005 • Unit of Observation: PCP in any of 32 Quarters,

at least .25 FTE, practicing within the Integrated Group Practice (IGP) in Western Washington– 147 unique physicians (49%, or 72, of eligible

PCPs present in all 32 quarters)

Study Design (continued)Study Design (continued)

Dependent Variables in Productivity Analyses included: (at PCP-Quarter level)

• Mean Work RVUs per FTE

• Mean Visits per FTE

• Mean Work RVUs per Visit (“Intensity”)

Also, examined the “Dual” of Productivity:

• System Cost of Care per PCP empanelled Enrollee

Independent Variables in Independent Variables in Productivity Analyses (General Productivity Analyses (General Estimating Equation Models)Estimating Equation Models)

• Initiative Time

• Primary Care Clinic (“fixed effects”)

• Interactions: Initiative Time*Clinic

• PCP Years in the IGP

• PCP Gender

• Case Mix (Expected Resource Intensity) of Individual PCP’s “Panel” (prospective)

Description of Study Sample (PCPs Description of Study Sample (PCPs and Enrolled Panel)and Enrolled Panel)

• 70% of PCPs were Male• 41% of PCP-Quarters had 1.0 FTE• Mean Panel Size: 1455 (SD = 557)• 84% in Commercial Market Segment• Mean Age of Panel Enrollees: 43 years• 51% of Panel Enrollees are Women• Mean Per Member Per Quarter Cost: $744

(SD = $407)

Primary Care Productivity Patterns Primary Care Productivity Patterns over Initiative Time over Initiative Time

Relative to Pre-Initiative Levels:• RVU/FTE Rose during Rollout, Rose Further during

Full Implementation • RVU/Visit Intensity Rose Modestly during Rollout,

More Dramatically Post-Initiative• Costs per Panel Member Rose during Rollout,

Declined below Pre-Initiative Levels during Full Implementation

Visits per FTE Productivity over Visits per FTE Productivity over Initiative Time (adjusted)Initiative Time (adjusted)

1120

1140

1160

1180

1200

1220

1240

1260

1280

Visits perFTE

Pre-Initiative

During Rollout

Post-FullImplementation

RVU per Visit Levels over Initiative RVU per Visit Levels over Initiative Time (adjusted)Time (adjusted)

0.95

1

1.05

1.1

1.15

1.2

RVU perVisit

Pre-Initiative

During Rollout

Post-FullImplementation

RVU per FTE Productivity over RVU per FTE Productivity over Initiative Time (adjusted)Initiative Time (adjusted)

2000

2100

2200

2300

2400

2500

2600

2700

RVU per FTE

Pre-Initiative

During Rollout

Post-FullImplementation

Cost per Panel Member (PMPQ) Cost per Panel Member (PMPQ) over Initiative Time (adjusted)over Initiative Time (adjusted)

55.05

5.15.15

5.25.25

5.35.35

5.4

Log ($)Cost PerMember

perQuarter

Pre-Initiative

During Rollout

Post FullImplementation

Note: Raw Post-Full Costs ~ $650/qtr versus ~ $800/qtr during Rollout

ImplicationsImplications

• Comprehensive Access Initiative Was Associated with Increased PCP Productivity and Reduced PMPQ Cost for Primary Care Providers

• System Adjustments Appeared to Mitigate Potential Decrements

• Enhanced Productivity Occurred in Parallel with declining, then flat FTE, respectively, during Rollout, Post-Full Implementation