Can Physicians Diagnose Strengths and Weaknesses in Health Plans?

In a competitive market, maintaining health care quality while containing costs requires that consumers and large purchasers of care have access to data on the cost and quality of care in health plans. Both individual health plans and more neutral bodies, such as the National Committee for Quality Assurance, have attempted to meet this demand for information by presenting plan-specific performance data in a “report card” format. Although the perspective of the consumer figures prominently in such reports, the perspectives of physicians, nurses, and other health professionals who deliver care are notably absent. Practicing health care providers are often the passive subjects of assessments of health plan quality; they may also implicitly express their opinions by, for example, deciding to stay with or leave a plan. However, providers seldom directly and systematically provide their perspective on the quality of the systems in which they practice. Formal assessment of providers' perspectives on quality in health plans may complement consumer surveys and other performance measures. We argue that these perspectives should be included in the assessment of the quality of health plans, and we discuss the association between provider satisfaction and providers' perspectives on quality of care.

Most health plan performance measures are intended to help the market function better by providing data for consumers and purchasers of care. Although many performance measures include information on cost, operating efficiency, quality of care, and consumer satisfaction, comparisons among plans have been difficult because of differences in data collection and analysis. Attempts have been made to standardize performance reporting requirements for health care organizations so that both purchasers and consumers can more directly compare the cost and quality of various managed care plans. The most widely used of these standardized performance measures is the Health Plan Employer and Data Information Set, developed by the National Committee for Quality Assurance. This largely employer-driven initiative has focused on identifying and standardizing core performance measures for the assessment of quality, access, patient satisfaction, membership, utilization, finance, and descriptive information on health plan management [1]. A recent review [2] addressed the strengths and weaknesses of the Health Plan Employer and Data Information Set.

Why should the physician's perspective be added to the measures used to assess health plan quality? With their heterogeneous formats, health plans have the potential to either facilitate or create barriers to the delivery of high-quality care. Physicians, who are at the front line of delivering care, are in a pivotal position for observing and commenting on practices and policies that facilitate or impede the delivery of high-quality care in health plans. Specifically, physicians are likely to encounter such practices and policies, and they may know about patients whose care has been adversely or favorably affected. Although we have chosen to focus on physicians' perceptions of quality, other providers, such as advanced-practice nurses and clinical psychologists, may be able to contribute equally valuable information on the quality of health plans.

Consumer-based surveys may not detect or may underdetect some facilitators of and barriers to quality. Physicians may know about health plan processes that are simply not apparent to patients. For example, health plans may enhance quality by providing lists of children in need of immunizations to physicians; conversely, health plans may impede quality by imposing barriers to referral, a practice that encourages “gatekeeper” physicians to deal with problems that they are not sufficiently skilled to address. Similarly, physicians are knowledgeable about the adequacy of the drugs available in a health plan formulary, but patients probably are not. In addition, because physicians often work with a broad spectrum of patients, they may better understand how well health plans work for chronically ill, acutely ill, or healthy persons. Finally, the patient's perspective alone may not tell the whole story. Patients may attribute blame or credit to physicians for perceived shortcomings or strengths in care that actually arise from health plan policies.

Facilitators of and barriers to quality that physicians encounter may include restraints on the amount of time physicians can spend with individual patients, the covered services and benefit structure of plans, utilization management, the balance and integration of generalists and specialists, continuity of care, patient and physician education, the physician–patient relationship, access to care, and ethical issues.

Thus far, research on the physician's perspective has focused primarily on job satisfaction [3-8]. In his classic text on quality, Donabedian [9] suggests that practitioner satisfaction should be considered in measurement of quality of care. Although some research suggests that the perceived ability to provide high-quality care strongly influences provider job satisfaction [6], other factors that do not necessarily reflect health care quality, such as reimbursement and autonomy, also have an influence [3, 4]. Benefits, work hours, and working conditions may also affect job satisfaction. Conversely, job satisfaction may not reflect certain aspects of health plan quality, such as the facilitators and barriers created by a health plan that affect a physician's ability to provide high-quality care. Those who view physicians as “the problem” may see the assessment of physician satisfaction as irrelevant or self-interested, whereas the manner in which health plans enhance or impede physicians' ability to deliver high-quality care is more likely to be widely regarded as important information.

An alternative to measuring job satisfaction is to directly assess physicians' experience with the barriers to and facilitators of high-quality care in health plans. Other researchers have measured quality of care by eliciting physicians' perceptions. In early studies, for example, Sanazaro and Williamson [10, 11] used physicians' perceptions of their colleagues to evaluate the quality of physician performance. More recently, physicians' perceptions were used to develop a method for assessing hospital quality [12, 13]. These measures, which are based on results of physician surveys, have been shown to be reliable and valid. Thus, although physicians' insights have previously been used as sources of data on quality of care for some aspects of the health care system, this approach has not yet been used to assess quality in health plans.

It may be desirable to distinguish physician job satisfaction from physicians' views of the quality of care in health plans, but these two aspects of physicians' perceptions are intimately linked. Job satisfaction influences how physicians perceive quality of care; at the same time, job satisfaction is affected by the barriers to and facilitators of quality that physicians encounter. Satisfaction with care has also played a central role in evaluating patients' perspectives on their health care [14]. However, patient satisfaction has also been complemented by many measures that reflect other aspects of the patient perspective [15]. These aspects include such patient-oriented health outcome measures as functional status and quality of life and patient reports on access to care [16, 17].

Like other measures of health care quality, assessment of physicians' judgments poses methodologic challenges, including the need to disentangle physicians' judgments of a plan's quality from physician job satisfaction and to discern whether practices that affect quality are attributable to a health plan or to the organization of a physician's practice, independent of the plan. It will be necessary to 1) establish how much contact a physician should have with a plan before the plan is assessed and 2) determine whether differences in structure and function between types of plans (for example, independent practice associations and staff model health maintenance organizations) or differences in financial arrangements between physicians and plans confound comparisons among plans. The survey methods must be inexpensive, yield high response rates, and ensure confidentiality. Finally, if physician-based measures are to be useful to consumers for comparing health plans, it must be shown that these measures truly distinguish among plans.

Physicians are an untapped source of information about the quality of care in health plans. Their views could have several uses. First, they can provide individual consumers and large purchasers of care with an additional tool for comparing health plans, one that is based on the views of “their physicians.” Second, they can provide health plans and their physicians with data that can be used for internal quality improvement. Third, they can provide physicians with information that can help them decide whether or not to join the provider network of a specific health plan. Other segments of the marketplace will probably have additional ideas about which data collected from physicians are helpful; their views should be sought before an instrument measuring physician views of quality is tested on a large scale. Future research should focus on clearly identifying the information about health plans that consumers, purchasers, and regulators of care want to obtain from physicians and other providers.

Dr. Goertz: Institute for Health Services Research, University of Minnesota School of Public Health, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Lurie: Department of Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415.

• Copyright ©2004 by the American College of Physicians