Patient Experience and Physician/Staff Satisfaction in Transforming Medical Homes

ABSTRACT

IMPORTANCE: To assess the association between degree of change in medical home transformation and the satisfaction of patients, physicians, and other staff with the experience.

STUDY DESIGN: Cross-sectional surveys of lead physicians and patients.

METHODS: Lead physicians in the first 108 primary care clinics in Minnesota certified as patient-centered medical homes (PCMHs) were asked about the presence and change over the past 3 years of medical home-related practice systems, as well as the job satisfaction of their physicians and staff. Patients in 54 of these clinics were surveyed using the CG-CAHPS (Clinician-Group Consumer Assessment of Healthcare Providers and Systems) questions about their experience.

KEY RESULTS: The extent of change in systems over time was significantly correlated with reported positive changes in physician (0.29, P = .002) and staff (0.27, P = .005) job satisfaction, but not with the number of systems. System change was negatively correlated with patient reports of access to care (—0.43, P = .001) but unrelated to their experience with physicians and staff.

CONCLUSIONS: These results add to a minimal literature on these important topics by suggesting improved physician and staff satisfaction, while highlighting the importance of the amount of change on both their satisfaction and that of patients. There may be a need to be particularly careful that medical home changes do not cause deterioration in patient access.While there is currently a rush to encourage and facilitate the transformation of primary care practices into patient-centered medical homes (PCMHs), surprisingly little is known about the impact of such a change on the experiences and satisfaction of either patients or healthcare personnel. In 2010, Hoff described the foundation for the PCMH as shaky, primarily because so little was known about whether either patients or physicians find it attractive.¹ In 2012, he published a systematic review of studies through 2010, finding only a few studies of patient or clinician satisfaction; their results presented a mixed picture.² The main positive results were from studies in Group Health Puget Sound, atypical because of salaried physicians and a common budget between health plan and medical group.^3,4 Evaluation of the 36 diverse family practices in the National Demonstration Project was especially troubling, since after 2 years of work on transformation, patients in these practices reported a worse experience with care than at baseline.^5,6 Since then, studies of Canadian or safety-net clinics have found positive results for patient or clinician satisfaction, but not since 2010 has this topic been addressed regarding typical United States practices that are becoming PCMHs.^7-9

This topic is very important, both because the primary care physicians who are increasingly seen as central to healthcare reform are generally discouraged with their work life and because a major goal of that reform is to improve the experience of patients. Shanafelt et al recently reported that burnout is more common among physicians than among other US workers, and physicians in specialties at the front lines seem to be at greatest risk.¹⁰ Linzer et al surveyed physicians in 119 New York and Upper Midwest primary care practices and found that half said their work pace was chaotic, three-fourths felt they had a low degree of control over their work, and a quarter reported being burned out.¹¹ International comparisons of patient satisfaction are complex, but a Commonwealth Fund survey of patients in 6 developed nations found the United States to be in fifth place for the kinds of patient-centered care that, when successful, are associated with satisfaction.¹²

As part of our larger evaluation of 132 primary care practices in Minnesota that had achieved state certification as “healthcare homes,” we had an opportunity to survey clinic leaders and to obtain patient satisfaction data from many of these clinics.¹³ We used those data to address the question of whether the satisfaction of patients, physicians, or clinic staff was associated with the degree of transformation in their clinics. Our hypothesis was that the satisfaction of each of these groups would be improved by the transformation.

Methods

In 2010, Minnesota established standards and a process for certification of primary care practices as medical homes (here called healthcare homes) as well as an associated payment system change for patients covered by state programs, all intended to encourage primary care transformation. As of May 2013, 242 of the 728 primary care practices in Minnesota (33%) had been certified as healthcare homes.

In order for clinics to become certified, they had to demonstrate compliance with standards in 5 areas: access, a patient registry, care coordination, care plans, and quality improvement methods. The certification process involved an application and self-assessment; an on-site visit that included interviews with both staff and patients; and review by a multi-stakeholder advisory committee. The leaders of all 132 clinics that had been certified as of October 2011 agreed to participate in this study. However, this report is limited to those 108 certified clinics that provide care to adults, returned the survey of practice systems noted below, and either completed an additional survey that included satisfaction questions or had standardized patient experience data available.

We collected descriptive information about these clinics from a survey completed by the manager of each clinic; it was constructed to identify their size, the number of clinics in their medical group, and patient population. We also administered a survey (and have reported the results previously) that measured the presence of practice systems for medical homes.¹³ This is the research version of the original PPC-PCMH (Physician-Practice Connection — Patient-Centered Medical Homes) survey used by the National Committee for Quality Assurance to recognize practices as medical homes.¹⁴ Known as the PPC-Research Survey (or PPC-RS), this instrument is completed by the medical leader of each clinic to document the presence and function of medical home—related systems present at the time of completion as well as those that were present 3 years earlier. It is scored on a scale of 0% to 100%, where 100% means that all measured systems are present and working well. Scores were calculated for each clinic for what was then the present time (2010-2011) and the point 3 years prior, and for the change between those points in time. The results from this instrument have been reported previously for the subset of clinics that serve adults and we have used them to assess the degree of transformation and the change in the past 3 years.¹³

1. Job satisfaction among physicians in our clinic has increased as a result of changes we made to become a medical home

2. Job satisfaction among nonphysician staff in our clinic has increased as a result of changes we made to become a medical home

Our measurement of physician and staff job satisfaction was dependent on separate assessments by the physician leader and clinic manager on a survey on which 108 of the 120 adult clinics had responses from both leaders (90.0%). The specific questions asked with a 5-point answer scale, from Strongly Agree (1) to Strongly Disagree (5), were:

Answers to these questions (on a 1-5 scale) were averaged between the 2 leader respondents for each clinic.

Measurement of patient experience depended on standardized use of the CG-CAHPS (Clinician and Groups version of the Consumer Assessment of Healthcare Providers and Systems) survey developed by MN Community Measurement, a nonprofit organization established and supported by all the health plans in Minnesota to develop and report publicly on standardized measures of quality. CG-CAHPS is a well-established public domain survey created and maintained under contract to the Agency for Healthcare Research and Quality; it is increasingly used nationally as the standard way to assess patient experience.15 The data about patient experience used in this study were collected from those clinics that volunteered to participate in this survey in 2010, knowing that in the next year it would be required for all clinics in Minnesota.

Four domains of satisfaction were reported by MN Community

Measurement. The individual questions within sections 1, 2, and 3

1. Access to care—a composite of 5 questions about the frequency of getting urgent and routine appointments as soon as needed, of having phone calls returned during office hours and after hours as soon as needed, and of being seen by the provider within 15 minutes of appointment time.

2. Provider communication—a composite of 6 questions about the frequency of the provider listening carefully, giving understandable information, being aware of one’s medical history, showing respect, spending enough time, and providing test results.

3. Office staff—a composite of 2 questions about the frequency of office staff being helpful and showing courtesy and respect.

4. Provider rating—a single question rating the provider on a 1-to-10 scale from worst to best.

had response choices of Never, Sometimes, Usually, and Always:

Each question is scored as the percentage of respondents indicating the highest satisfaction choice, and the composites represent an average of these percentages across the constituent items. The overall provider rating represents the percentage of respondents choosing either a 9 or 10. An average of 327 responses were obtained per clinic, representing 35% of the surveys distributed.

- Physician and staff satisfaction data were available for 108 clinics

- Patient experience data were available for 54 clinics

The analysis used Spearman correlations to test the relationship between each satisfaction measure and the PPC score for systems in the present (at the time of the survey) as well as the absolute amount of change in the prior 3 years. Spearman rank correlations are more powerful than parametric statistics (eg, Pearson correlations, linear regression) when the data are ordinal and non-normal. Due to varying sample sizes, the satisfaction analyses were conducted with 2 subsets of the original 132 clinics depending on the availability of data for each question:

Results

Table 1 provides comparative descriptive information about the clinics included in these analyses, both the 108 with data on staff and physician job satisfaction and the subset of 54 with patient experience data. Those with patient satisfaction data are clearly different, with nearly all of these clinics being part of large medical groups in the Minneapolis-St. Paul metropolitan area that have smaller proportion of patients who have Medicare or Medicaid insurance.

The frequencies and variance for the 8 variables of interest for this analysis are shown in Table 2. On average, leader ratings of staff or physician satisfaction related to medical home changes were neutral but with wide variance, while patient experience with access was much lower than their experience with staff or providers. Practice systems were reported to have more than doubled over the previous 3 years, but with wide variation among the clinics in both current level and extent of change during that time.

In Table 3, each measure of satisfaction is tested for correlation with the current PPC score (ie, degree of correlation to the ideal medical home) or the change in PPC score (ie, transformation) over the previous 3 years. These data show that there is no relationship between the current PPC score and experience or satisfaction of either patients or clinic personnel. However, the extent of change over the past 3 years is strongly associated with higher job satisfaction by both physician and physician personnel (as reported by clinic leaders). Change is also strongly negatively associated with patient experience with access.

We also tested the associations between clinic characteristics and satisfaction using Spearman-rank correlations, and demonstrated that metro area practices had higher patient access satisfaction scores (r = .31, P = .02) and practices largely limited to primary care physicians had higher physician and staff satisfaction (r = .20 and .23, P = .04 and .02). A regression analysis confirmed that these associations with clinic characteristics did not change the satisfaction relationships with PPC. Controlling for location (urban vs suburban) and physician composition differences, a standard deviation increase in PPC change (6 percentage points for job satisfaction measures and 18 percentage points for patient satisfaction measures) is associated with an increase of 0.15 in physician job satisfaction (P = .029) and an increase of 0.12 in staff job satisfaction (P = .028), but a 1.8 decrease in percent patient satisfaction with access (P = .005).

Discussion

These data suggest that our hypothesis about an inverse relationship between transformation and patient experience is only true for access problems in clinics where there has been more change in clinic systems. This may represent access deterioration as an unintended consequence of change. Patients of clinics that have undergone little change, regardless of the current level of transformation, do not state this dissatisfaction. On the other hand, neither the extent to which clinics have medical home systems nor the degree to which they have changed to create them appears to be related to patient satisfaction with personal interactions with either staff or physicians. In contrast, the more change that has occurred, the more staff and physicians in these clinics are reported by their leaders to be satisfied.

When compared with previous reports of patient experience in relation to medical home transformation, this study and the clinics analyzed demonstrate differences. Most important may be that the conflicting studies reported from Group Health and from the National Demonstration Project were able to compare change in measured satisfaction over time in medical home versus comparison clinics, while we measured satisfaction at a single point in time for clinics achieving certification as medical homes. However, we were able to relate that single measure to the degree to which clinics reported making change in their systems.

The literature is otherwise mixed about PCMH relationships to satisfaction. At Group Health, after adjusting for differences between a PCMH clinic and 2 comparison clinics at baseline, there were statistically significant increases at 12 months that had mostly decreased at 24 months in patient satisfaction with the quality of doctor-patient interactions, shared decision making, coordination of care, and access, but no change for helpfulness of office staff.^3,4 The National Demonstration Project compared patient satisfaction in facilitated versus self-directed medical practices, and had a similar measure to ours of the number of model components in place as a way to measure change.⁵ Over 26 months, there were no significant improvements in any of 8 domains of patient-rated outcomes. There were borderline significant decreases in coordination, comprehensiveness, and access in both groups of clinics. Those practices increased their proportion of model components by an average of 24%, with a borderline significant relationship (P = .11) to patient- reported outcomes.

Two studies in safety-net clinics have shown an association between

PCMH characteristics or perceptions and higher staff and

provider/resident morale and satisfaction.^8,9 One study of a single

safety-net clinic also showed an improvement in patient satisfaction

compared with 2 other clinics.⁹

In the recent systematic review that included a few more observational studies, Jackson et al concluded that there was moderately strong evidence that PCMH interventions are associated with small improvements in patient reports of satisfaction and care coordination. ¹⁶ They also reported a low level of evidence that primary care staff may be more satisfied in PCMH practices. In their systematic review covering roughly the same time period, Hoff et al found inconclusive evidence of change in patient/family experience. Finally, in a study of 393 practices published after these systematic reviews, Martsolf et al concluded that there was “no association between PCMH processes and patient experience.”¹⁷

Even fewer studies have measured the impact of the PCMH on clinician and staff job satisfaction. Reid’s evaluation of physician burn-out among the clinical staff at a Group Health PCMH clinic compared with 2 control clinics showed no differences at baseline and a significant decrease in only the PCMH clinic after making PCMH changes over 24 months.³ Hoff ’s review did not find any other adequate studies of provider experience.²

Our study’s limitations include its cross-sectional design that was limited to clinics achieving medical home certification, its dependence on reports by clinic leaders about the job satisfaction of physicians and other staff, and its limited and self-selected subgroup of clinics with patient satisfaction data. Because the data for clinic characteristics, job satisfaction, and patient satisfaction were not normally distributed, we used Spearman-rank correlations to test the association between clinic characteristics and satisfaction. Subsequently, we conducted a linear regression that suggests that clinic characteristics do not confound the associations between PPC and satisfaction. However, due to the smaller sample size in the MNCM satisfaction measures, there is potential for instability in the regression models.

Also, as Table 1 makes clear, Minnesota primary care clinics are unusual in being larger than many other comparable United States clinics and often aggregated into larger medical groups. Thus it is possible that those differences, or external factors other than transformation, might have affected these findings. However, Minnesota Community Measurement data were also available for patient experience in 44 self-selected Minnesota clinics not certified as healthcare homes, although we have no other data about those clinics. Those clinics had experience scores similar to those of the certified clinics on access, physician communication, and staff helpfulness, but their physician ratings were actually 2.6% higher than the healthcare homes’ ratings. Finally, patient experience data were not available for all of the certified clinics in our study. However, our sample size, data about change over time, and the availability of other published evidence about the transformation process and its other impacts on these clinics provide a unique comprehensive examination of them.¹³

Overall, these findings add evidence to the important topic of the impact of medical home changes on clinicians, staff, and patients. Taken together with the minimal other published work on these topics, we suggest that impact on patient experience is not great, but that rapid and large changes risk deteriorating patient access. On the other hand, those same rapid changes may contribute to improved physician and staff job satisfaction. Since morale among primary care professionals is generally not good, this is an important finding. ¹⁰ Sinsky et al report from case studies of 23 high-performing primary care practices that “a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.”¹⁸

The changes reported in this study suggest that clinics that function like medical homes may indeed be happier places to work, both for physicians and other staff.Acknowledgments: The authors would like to thank Eva Kline-Rogers, MS, RN, NP (University of Michigan, MCORRP), and Cydni A. Smith, BA (University of Michigan School of Public Health); Redah Mahmood, MD; Daniel Montgomery, MS; Rachel Sylvester, BS (MCORRP); and the student data abstractors who helped with this study. We are very grateful for the cooperation of the Minnesota Department of Health throughout this study, and for the way in which the leaders of the certified healthcare homes in Minnesota cooperated with the data collection. We are also grateful to Minnesota Community Measurement for providing us with the patient satisfaction data used in this analysis.

Author Affiliations: HealthPartners Institute for Education and Research, Minneapolis, MN (LIS, LS, ALC, RRW, PLF, JOT); MN Community Measurement, Minneapolis, MN (AMcGS).

Source of Funding: This project was supported by grant number R18HS019161 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to: Leif I. Solberg, MD, HealthPartners Research Foundation, PO Box 1524, MS#21111R, Minneapolis, MN 55440-1524. E-mail: Leif.I.Solberg@HealthPartners.com.1. Hoff T. The shaky foundation of the patient-centered medical home. Am J Manag Care. 2010;16(6):e134-e136.

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15. Agency for Healthcare Research and Quality. Get clinician & group surveys and instructions. https://cahps.ahrq.gov/surveys-guidance/cg/instructions/index.html. September 17, 2014.

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