Until ten years ago, relatively little systematic information was available on physician practices in the United States, particularly in regard to their use of evidence-based care management processes (CMPs) to meet the needs of patients with chronic illness (asthma, congestive heart failure, depression and diabetes). With major support from the Robert Wood Johnson Foundation (RWJF) and some additional support from the California HealthCare Foundation (CHCF), the first National Study of Physician Organizations (NSPO1) was launched. While restricted to medical groups and independent practice associations (IPAs) of twenty or more physicians, it established an important 2000-2001 baseline of information on the use of evidence-based CMPs and the factors most strongly associated with such use (Casalino, et al., 2003). These findings were drawn on by both policy-makers and providers alike in the design of new pay-for-performance and related initiatives. This study resulted in 16 articles appearing in leading peer-reviewed journals and presented at a number of conferences.
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Building on the success of this first initiative, RWJF, with some funding from CHCF and the Commonwealth Fund (CMWF), provided support for the second National Study of Physician Organizations (NSPO2), conducted in 2006-2007. This study also produced a number of publications. NSPO2 documented that while the use of recommended CMPs by physician organizations increased from use in 2000-2001, implementation still fell short of expectations and most practices fell far short using processes fundamental to being a Patient-Centered Medical Home (PCMH) (Rittenhouse, et al., 2010a). By making use of both the baseline NSPO1 survey and the second round 2006-2007 survey (NSPO2), we were able to identify the factors most likely to result in increased use of recommended CMPs. These included involvement in quality improvement initiatives, being externally evaluated through public reporting, and maintaining or enhancing the practices’ financial viability (Shortell, et al., 2009).
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While the first two surveys involved larger practices of 20 or more physicians, the third survey (the National Study of Small and Medium-sized Physician Practices, NSSMPP), funded solely by the RWJF, focused on small and medium sized practices (1-19 doctors) - the majority of United States physicians currently practice in these smaller practices. NSSMPP included a national sample of small physician practices and more targeted oversamples of practices located in the 17 communities of the RWJF’s Aligning Forces for Quality Program (AF4Q); 1,949 practices responded, with an overall response rate of 64 %. In this work, we grouped the CMP processes and related characteristics into an index capturing dimensions of the Patient Centered Medical Home (PCMH). The findings indicated that practices of 13-19 physicians used nearly twice as many PCMH components as 1-2 physician practices. Use was also strongly associated with ownership by larger organizations (mostly hospitals); with external incentives for public reporting and pay-per-performance-based quality improvement processes; and with shared risk for hospital costs (Rittenhouse, et al., 2010b). We also found that, by and large, specialist physicians do not believe that they are serving as primary care physicians for their patients (Casalino, et al., 2010).
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For a listing of the above citations, please see our website: http://nspo.berkeley.edu/Publications.htm.