Massachusetts pioneers making quality a public priority for safety net patients

This post was produced for the USC Health Data Accountability Project, a joint initiative of the USC Center for Health Journalism and the Gehr Family Center for Health Systems Science.

On a Saturday morning in 2007, Dr. Lester Hartman plopped a thick manila envelope on his desk at home. The return address read “Massachusetts Health Quality Partners (MHQP),” then a new nonprofit formed to collect quality data on physician practices across the state and report results to the public.

Hartman was leery. He, like many physicians at the time, doubted the validity of patient satisfaction scores.

“They were subjective, not scientific, and not representative of my patients,” Hartman recalled thinking.

But even if the scores weren’t all that useful, Hartman was sure that his medium size pediatric practice in a small suburb west of Boston would could come out on top. So Hartman expected to feel pride as he compared Westwood-Mansfield Pediatrics to similar-sized physician groups across the state. Instead, as Hartman flipped through the pages, he felt his blood pressure rise. 

“This isn’t right,” Hartman remembered muttering. Within a few minutes he was yelling, “This is crazy.”

To prove MHQP wrong, Hartman created his own patient survey, using the same questions, and sent it out to patients. Within a month, his anger shrank to humility. In a few categories, scores tallied from his own survey were even worse than those from MHQP. 

After “swallowing some humble pie,” Hartman responded with zeal. He sent front office staffers to a customer service training course to boost their scores. He shot video after video (50 and counting) to help patients become better “self-managers” of their care and give the practice a stronger rating. (His video on ”How to perform a rapid strep test” at home has more than 90,000 YouTube views.) Hartman added tabs in the patient record to help physicians remember special traits about each child or family member. The practice’s “knowledge of patient” score climbed.

“Doctors are competitive,” Hartman said with a laugh. “I like being number one.” Westwood-Mansfield is now at or near the top of MHQP ratings for similarly sized pediatric practices.

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But Hartman can only claim to be near the top for the 50-percent of his patients insured by private health plans. MHQP has not surveyed the more than one in four Massachusetts residents covered by MassHealth, the state’s Medicaid program. That’s about to change. Earlier this summer, MHQP completed a pilot survey, the first of an up to five-year contract with the state of Massachusetts, worth $4.4 million.

The initial survey focused on primary care. MHQP sent patients roughly three-dozen questions including: “Could you get an appointment for an urgent need right away?” “Did your provider explain things in a way you could understand?” and “Did your provider help you set health care goals? In the second and third years, MHQP plans to add questions about behavioral health and long-term services.

Why now?

This effort to measure patient experience is part of a major shift from ”fee for service,” or billing for each procedure, to an Accountable Care Organization (ACO) model for 850,000 Massachusetts residents covered by Medicaid, nearly half the MassHealth population. ACOs receive reimbursements based on the value of the experience (Do patients get better or stay out of hospitals and nursing homes?) rather than the number of procedures under a traditional fee-for-service model. Seventeen ACOs will be paid on a set budget per patient, with adjustments for age and severity of illness, but will have broad flexibility about how Medicaid dollars are spent. The organizations will have to demonstrate that they are not skimping on care and that their patients are healthy.

“Patient experience is an essential factor in understanding the quality of care from the patient’s perspective,”’ said MassHealth spokeswoman Sharon Torgerson. “This information is important for the member, provider and health system as part of the evolution of patient-centered, outcomes-based care. 

Patients and providers may use the MHQP survey to compare the satisfaction levels of Medicaid and commercially insured patients. But creating an apples-to-apples comparison may be difficult, something MHQP knows from experience. 

The organization conducted a previous pilot survey of adult MassHealth patients in 2008 and decided it could not contrast the experience of MassHealth and privately insured patients.  

“There were just too many differences in the racial and ethnic composition of the populations, the language and the health status,” said MHQP president and CEO Barbra Rabson. 

Those differences may not be as stark today. The percentage of Massachusetts residents covered by MassHealth has increased 65 percent since 2008, while enrollment in employer-sponsored coverage has dropped, which may mean the populations are more alike. Rabson says MHQP already adjusts patient satisfaction scores according to age, gender, education, race, language, chronic conditions region and health plan — but may need to make additional adjustments for clinics or physician groups that treat a large number of MassHealth patients.

Rabson says the fact that Medicaid patients tend to have more health problems and more trouble maintaining good health is all the more reason to measure the quality of their care.

“If I have more complex medical problems, it’s really important that I have health care goals,” Rabson said. “If patients are sicker, patient experience measures are even more important for their health.” 

Health Care for All (HCFA), the state’s largest health care consumer group, says it looks forward to the results of the survey.

“Doctors have told us that they treat Medicaid patients the same as their other patients — this will be a good way to tell if that’s true,” said HCFA policy director Brian Rosman.

Collecting a representative sample of MassHealth patients may be more difficult than for commercial patients. They may have less time to return a survey and may not be fluent in English. There will be a Spanish version, but Rosman says the survey should be available in Portuguese and other languages to capture a broad range of patient perceptions. 

Rosman also urges MHQP to promote the survey results and make them easily accessible, especially on mobile phones. The MHQP website gets very little traffic, 30 to 60 hits a day, which is a common problem for health care quality measurement tools. The organization is launching a new site in September and is looking into ways to make the quality scores more accessible and mobile-friendly. 

Some consumers say they’d be more interested if they could review survey results for individual doctors rather than physician practices, which is what the site offers now. Some physicians argue that most problems in health care are system failures, not the result of a few bad clinicians. 

Payments tied to patient scores

Rabson says MHQP’s survey is becoming more and more valuable for clinicians “because there’s money on the table for patient experience.” 

Starting in 2019, the MHQP scores will be one of several quality measures Massachusetts will use to adjust payments to the MassHealth ACOs. ”Performance on these measures and their impact on payment will be based on a combination of meeting pre-established thresholds, excellent performance, and demonstrating improvement over time,” Torgerson said.

MassHealth officials say this will be the first time a Medicaid program has tied provider payments to patient experience.

The change is admittedly “a little scary,” said Jim Hunt, president and CEO of the Massachusetts League of Community Health Centers. “We know what our in-house scores say, every health center has them, but measuring us in the context of an ACO is a big unknown.”

Hunt says health centers tend to get the brunt of patient frustration when a patient is dropped from or forgets to renew with Medicaid — or if they have another problem with the vast state program. So health centers, says Hunt, are spending a lot of time and money on customer service skills for front desk staff.

But Hunt and others say uniform patient experience feedback about Medicaid is long overdue. 

“We’re thrilled that MassHealth will now be included,” said Lindsay Gainer, senior executive director for innovation at North Shore Medical Center and the North Shore Physicians Group, where about half of the patients served are covered by Medicaid.

Gainer said the MHQP results have already have pushed the hospital to improve behavioral health and its rating by adding social workers and coaches.

“When the data is out there for the public to see, everyone takes notice,” Gainer said.

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(Photo by Adam Berry/Getty Images)