Enhancing Patient Experience in an Era of 'Pay for Experience'

A national effort to improve the quality of healthcare and lower costs is under way. Supported by a growing body of literature demonstrating that health systems emphasizing the role of primary care can achieve superior outcomes at lower costs,¹ the Patient Protection and Affordable Care Act of 2010—or simply the Affordable Care Act (ACA)—makes a concerted effort to revitalize the foundation of primary care by reforming reimbursement for providers delivering highvalue, patient-centered care and rewarding innovative models of healthcare delivery. The accountable care organization (ACO) and the patient-centered medical home (PCMH) have emerged as inter related models for health system reform, with the common objective of improving the quality and coordination of healthcare and slowing the growth of spending. While the provider-led ACO model focuses on managing the complete continuum of care, overseeing quality of care, and controlling costs, the PCMH model emphasizes comprehensive, patient-centered care as well as payment reform via enhanced reimbursement to primary care providers for high performance.²

Increasingly recognized as a core element of quality healthcare delivery in the United States and other countries,³ patient-centered care experiences are gaining prominence. An extensive body of literature supports the notion that patient experience is associated with improved health outcomes and better medication adherence.^4-7 Studies of the PCMH have demonstrated the potential for this model to improve patient experience.^8-10 For the accountable care system to succeed in providing high-value care, primary care plays a vital role. Additionally, new recognition of patient experience has grown as health plans and health systems have begun to link measures of patient satisfaction to provider payment,⁷ helping providers and healthcare systems to understand patient perceptions of care delivery and establishing the concept of “pay for experience” in clinical care. At the heart of primary care is the patient-provider relationship, and as “pay for experience” broadens its reach, upholding mechanisms necessary to revitalize patient-provider communication will be necessary to maintain a strong foundation of primary care.⁹

As ACOs expand and practices consider transformation to PCMH models of care, policy makers and leaders of healthcare organizations must consider several key elements in order to improve and sustain patient experience. First, health systems must preserve job “do-ability” in primary care. Second, organizations need to capitalize on patient experience survey data to drive care process improvement across the entire continuum of patient care. Third, these organizations must leverage health information systems to enhance virtual patient communication and disease management.

Physician supply in primary care has been associated with improved health outcomes and reduced mortality.¹¹ However, the severe shortage in the primary care workforce, coupled with a wave of retiring baby boomers and the ACA’s provision of insurance coverage to 32 million new Americans, puts primary care in exceeding demand.¹² Already, there is insufficient time in primary care to provide evidence-based care in the management of chronic disease¹³ and the average primary care physician’s panel size of 2300¹⁴ is too large to offer optimal care, even assuming team-based care.¹⁵ Physician burnout, startlingly prevalent¹⁶ and known to be associated with decreased patient satisfaction and decreased expression of empathy,^17,18 may escalate as providers find themselves held accountable to “pay for experience” while simultaneously adjusting to new payment models and anticipating new quality metric expectations.¹⁹ Encouragingly, one demonstration of the PCMH had a positive impact on primary care providers’ self-reported burnout⁸ while also improving patient experience and quality, though longitudinal evidence is needed. Increasing the supply of primary care providers to prevent potential compromises in health outcomes and provider burnout (factors sure to impact patient experience), emphasizing teambased care delivery, and reforming payment policies for primary care physicians and specialists²⁰ are all essential first steps toward optimizing patient experience.

Patient surveys have been routinely used among innovative physician organizations as a means to assess patient experience. As the Centers for Medicare & Medicaid Services begins to roll out incentives for quality metrics and clinical practice improvement activity,²¹ organizations may find increasing value in using patient experience surveys to inform outcomes and care delivery. One recent study demonstrated variability in organizations’ use of data gathered from these surveys: over half applied the information toward group wide practice improvement, while less than half targeted low-performing physicians (and a small number of practices did nothing)^.22 As organizations consider transforming to a PCMH model of care, examining the perspectives of patients will be essential to ensuring improvements in patient experience. Applying these data across the continuum of patient care—from primary care office visits to specialists, throughout hospitalizations, and encompassing ancillary services—will be a key step toward achieving patient-centered care, recognizing that patient satisfaction is a complex construct reflected in a range of patients’ whole-care experiences (eg, accessing care, staff interaction, provider communication and follow-up, among others).²³

Health information technology (HIT) offers the opportunity to improve patient experience via enhanced patient engagement. Capitalizing on electronic health record (EHR) capabilities to streamline management of chronic diseases and transitions in care make innovative approaches to “virtual” care an important step forward in enhancing patient-centered care in the medical home.²⁴ For example, EHRs can activate patient engagement by generating real-time after-visit care plans. Patients and providers have both expressed interest in secure e-mail exchange,^25-28 and studies of technology to facilitate safer care transitions have been met with patient enthusiasm.²⁹ Information exchange is vital to patient-centered communication,30 and further research on the role that personal health records may play in this process is warranted. Virtual care allows providers and patients to exchange information remotely and asynchronously, such as via a patient Web portal or through tele-health. Compensation for complex care management outside of a primary care office visit is a promising example of recent legislation with the potential to incentivize providers and improve patient experience.³¹ Even so, dedicated efforts aimed at narrowing the “digital divide” will be imperative if we are to realize the full potential for HIT to enrich the experiences of all patients.³²

Robust evidence has established the many downstream effects of positive patient experience. Strengthening the primary care workforce, incorporating patient perspectives into care-process development, and committing to innovative applications in HIT build a foundation upon which the experiences of patients in primary care can thrive. To sustain and enhance patient experience in an era of transformation in care delivery and reimbursement reform where “pay for experience” plays a key role, a combined macro policy-level and micro practice-level approach has the potential to realize continuous, comprehensive, and coordinated primary care as organizations strive to expand access and promote patient-centered care.Author Affiliations: Leonie Heyworth, MD, MPH, is from Harvard Vanguard Medical Associates, Newton, MA. Steven R. Simon, MD, MPH, is from the Department of Veterans Affairs Medical Center, Boston, MA.1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

2. Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaen C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011;30(3):439-445.

3. Selby JV, Beal AC, Frank L. The patient-centered outcomes research institute (PCORI) national priorities for research and initial research agenda. JAMA. 2012;307(15):1583-1584.

4. Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: Linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008;23(11):1784-1790.

5. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.

6. Greenfield S, Kaplan S, Ware JE, Jr. Expanding patient involvement in care. effects on patient outcomes. Ann Intern Med. 1985;102(4):520-528.

7. Greenfield S, Kaplan SH, Ware JE,Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3(5):448-457.

8. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843.

9. Heyworth L, Bitton A, Lipsitz SR, et al. Patient-centered medical home transformation with payment reform: patient experience outcomes. Am J Manag Care. 2014;20(1):782-785.

10. Kern LM, Dhopeshwarkar RV, Edwards A, Kaushal R. Patient experience over time in patient-centered medical homes. Am J Manag Care. 2013;19(5):403-410.

11. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the united states. Int J Health Serv. 2007;37(1):111-126.

12. Schwartz MD. Healthcare reform and the primary care workforce bottleneck. J Gen Intern Med. 2012;27(4):469-472.

13. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214.

14. Alexander GC, Kurlander J, Wynia MK. Physicians in retainer (“concierge”) practice: a national survey of physician, patient, and practice characteristics. J Gen Intern Med. 2005;20(12):1079-1083.

15. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Ann Fam Med. 2012;10(5):396-400.

16. Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med. 2000;15(7):441-450.

17. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.

18. Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559-564.

19. Wilensky GR. Improving value in medicare with an SGR fix. N Engl J Med. 2014;370(1):1-3.

20. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953-957.

21. SGR repeal and Medicare Provider Payment Modernization Act of 2014. http:// energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/ BILLS-113hr4015ih.pdf. Updated February 6, 2014. Accessed February 24, 2014.

22. Friedberg MW, SteelFisher GK, Karp M, Schneider EC. Physician groups’ use of data from patient experience surveys. J Gen Intern Med. 2011;26(5):498-504.

23. Edgman-Levitan S, Cleary PD. What information do consumers want and need? Health Aff (Millwood). 1996;15(4):42-56.

24. Bates DW, Bitton A. The future of health information technology in the patient- centered medical home. Health Aff (Millwood). 2010;29(4):614-621.

25. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157(7):461-470.

26. Heyworth L, Clark J, Marcello TB, et al. Aligning medication reconciliation and secure messaging: qualitative study of primary care providers’ perspectives. J Med Internet Res. 2013;15(12):e264.

27. Woods SS, Schwartz E, Tuepker A, et al. Patient experiences with full electronic access to health records and clinical notes through the my HealtheVet personal health record pilot: qualitative study. J Med Internet Res. 2013;15(3):e65.

28. Simon SR, Evans JS, Benjamin A, Delano D, Bates DW. Patients’ attitudes toward electronic health information exchange: qualitative study. J Med Internet Res. 2009;11(3):e30.

29. Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-162.

30. Lee RG, Garvin T. Moving from information transfer to information exchange in health and healthcare. Soc Sci Med. 2003;56(3):449-464.

31. Centers for Medicare & Medicaid Services. CMS finalizes physician payment rates for 2014. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/ 2013-Press-Releases-Items/2013-11-27-2.html. Updated November 27, 2013. Accessed February 24, 2014.

32. Yamin CK, Emani S, Williams DH, et al. The digital divide in adoption and use of a personal health record. Arch Intern Med. 2011;171(6):568-574.

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