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Results of the Medicare Beneficiary and Physician Focus Groups Allison I. Walker In order to design a strategy for quality review and assurance in the Medicare program, the Institute of Medicine (IOM) study committee judged it necessary to learn more about definitions, expectations, and concerns regarding quality of care. To this end, two separate studies were conducted using a focus group methodology. Although initially only one series of focus groups was planned- among Medicare beneficiaries-the activity yielded a wealth of information and generated further interest in this ap- proach. Because of the need to reach more physicians in private practice than the original study design and committee structure permitted, it was decided that a second series of focus groups would be held among practic- ing physicians. This chapter describes the methods and results of the two sets of focus groups. BENEFITS AND LIMITATIONS OF FOCUS GROUPS1 Focus groups are open-ended, but structured, discussions led by a trained moderator. They provide a practical and useful way to identify issues relevant to, and concerns about, a given topic. In contrast to other survey research methods that require the investigators to ask respondents a uniform set of questions, focus groups can be used to collect information in partici- pants' own words about how they view, define, understand, or evaluate the topic under discussion. The focus group methodology was initially devel- oped by sociologists Robert K. Merton and Patricia L. Kendall over 40 years ago (Merton and Kendall, 1946~. This technique has been advanced and improved over numerous applications since the original work. We designed He first set of focus groups to elicit attitudes and concerns of Medicare beneficiaries in five main areas: (1) personal experience and 35

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36 ALL lSON ~ . WALKER satisfaction with health care; (2) views on the concept of quality of medical care; (3) knowledge of quality assurance activities; (4) desire for informa- tion; and (5) ideas about how to improve the quality of health care. Simi- larly, the focus groups among practicing physicians were designed to elicit attitudes and concerns in six main areas: (1) positive and negative aspects of caring for elderly patients; (2) views on the concept of quality; (3) the Medicare program and its effect on quality of care; (4) identification of quality problems; (5) effectiveness of quality assurance mechanisms; and (6) ways to improve quality of care. Although focus groups do not involve "rigorous" survey methods that permit results to be generalized to an entire population, they add a very human element that is often absent in more quantitative research. Discus- sions guided by open-ended questions permit a more in-depth investigation of salient issues than do rigid survey instruments. Issues and insights can surface that otherwise might be missed. Focus group research is widely used and, some have argued, is the most "psychologically valid" form of opinion research in the United States. Nonetheless, the limitations to the generalizability of information de- rived from the focus groups should be understood. First, the sample size of participants is usually smaller than that which is required for statistical generalization. Second, regardless of how they are recruited, focus group participants are not representative of the population; willingness to partici- pate in focus groups is not randomly distributed throughout the population. Third, unmeasurable bias can be introduced by differences in question se- quence and phrasing in each focus group. An important component of statistical reliability in survey research is the requirement that each respon- dent will be exposed to the questions in the same order and manner. This cannot be easily achieved in focus groups. In the present case, the ideas that focus group participants expressed about quality in health care provide an understanding of common attitudes and opinions among Medicare beneficiaries and physicians treating Medi- care patients. The findings supplement information available to the com- mittee from the literature and through public hearings and site visits. STUDY METHODS Subcontractor Selection The subcontractor for this activity, Mathew Greenwald and Associates, Inc., was selected on the basis of several criteria: (1) previous experience with focus groups involving elderly people; (2) experience with focus groups on health care issues; (3) experience using focus groups for policy studies; and (4) proposed budget.

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MEDICARE BENEFICIARY AND PHYSICIA!J FOCUS GROUPS 37 Mathew Greenwald and Associates arranged for the use of focus group facilities and audiotaping and transcription for each group. In conjunction with IOM staff, the company drafted the screening criteria by which partici- pants were recruited and also prepared the moderator's guide listing the questions to stimulate the group discussions. Mathew Greenwald and Asso- ciates supervised the recruitment of participants, and Dr. Greenwald, presi- dent of the company, moderated all focus groups. Focus Group Site Selection Four main criteria guided the selection of sites for each set of focus groups: 1. The sites had to contain a high concentration of Medicare beneficiar- ies within a specific geographic region, for ease in recruiting both benefici- aries and physicians whose Medicare patient population was to be at least 20 percent. 2. Locating facilities and recruiting participants had to be relatively straightforward, essentially restricting the activity to urban areas. 3. At least two sites for each set of focus groups had to have a high concentration of health maintenance organizations (HMOs). 4. For the groups among beneficiaries, the four major census regions had to be represented. For the physician groups, at least two had to be comprised primarily of rural physicians. For the beneficiary focus groups, study staff selected New York City; Miami, Florida; Minneapolis, Minnesota; and San Francisco, California as the study sites that best met these four criteria. For the focus groups among practicing physicians, study staff selected Philadelphia, Pennsylvania; New Orleans, Louisiana; Chicago, Illinois; Los Angeles, California; and Albuquer- que, New Mexico. All the focus groups except two were conducted at facilities with which Mathew Greenwald and Associates had had previous experience. One group in New Orleans was conducted at a hotel in conjunc- tion with the annual conference of the American Academy of Family Physi- cians (AAFP), and the group in Albuquerque was conducted at the offices of the New Mexico State Medical Society, in conjunction with its annual meeting.2 Development of the Moderator's Guide For both sets of focus groups, the subcontractor and the study staff jointly developed the moderator's guides. Different guides were developed for separate focus groups of fee-for-service beneficiaries, nursing home resi- dents, and HMO enrollees. (Refer to Appendix A for one example of the

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38 ALUSON J. WALKER moderator's guide.) Each guide addressed the same five topics but was modified as appropriate for the group in question. For the focus groups among practicing physicians, one moderator's guide was developed to pro- vide direction on the six topics to be discussed (Appendix B). The Recruiting Process Recruiting focus group participants can be done in several ways. Two of the more common approaches are to use files previously developed by the research facilities and to use randomized telephone dialing. Each approach has drawbacks and advantages, including a tradeoff between cost and unbi- ased selection. To minimize disadvantages and maximize advantages, we decided to combine the two approaches to ensure some degree of randomness and to decrease the bias that might be associated with using only one of the previ- ously mentioned methods. Thus, in most of the groups, half of the partici- pants were recruited through the use of facility lists, and half were recruited from telephone listings selected randomly from telephone directories. Each research center was responsible for recruiting its own sets of participants according to these methods. All participants in the New York City beneficiary focus groups were recruited exclusively through the use of facility lists because of the high cost of recruiting through random digit dialing in that city. For the group of nursing home residents, participants were selected on the basis of ability to travel and attend the focus group session at a facility outside of the nursing home. Recruiting for the AAFP physician group was conducted using the conference pre-registration list and random dialing, and the group in New Mexico was selected by the Executive Director of the state medical society. Focus Group Composition Although it is not realistic to seek representativeness or to estimate popu- lation parameters using focus groups, we went to some lengths to achieve diversity. By design, therefore, we obtained elderly participants who brought with them perspectives that may be affected by age, race, sex, recent health care experience, and HMO membership, and in the case of physicians, prac- tice in the fee-for-service or prepaid group practice sector, rural or urban location, and specialty. Pre-recruitment Specifications of the Beneficiary Focus Groups Eight beneficiary focus groups were conducted: two each in New York City, Miami, Minneapolis, and San Francisco (in that order). The composition

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MEDICARE BENEFICIARY AND PHYSICIA;N FOCUS GROUPS 39 of the groups was varied by design two groups comprised participants ages 65 to 74; two groups had participants ages 75 and above; and one group was diverse by age with all participants being at least 65 years old. Most participants in these five groups obtained their health care largely through the fee-for-service system. Two other groups (one in Miami and one in Minneapolis) consisted of only HMO enrollees, both groups being diverse by age. One group (in Minneapolis) had only nursing home residents. The recruitment criteria required that each focus group should have as even a male-female ratio as possible and some ethnic diversity. The groups in New York City, San Francisco, and Miami were to have at least three nonwhite or Hispanic participants; the groups in Minneapolis were to have at least one nonwhite or Hispanic member. Finally, each group was to have at least four people with recent "acute" or "nonroutine" health care experi- ence; for instance, care in an emergency room, outpatient surgery, a hospi- talization, admission to a nursing home, or home health care. Pre-recruitment Specification of the Physician Focus Groups Eight physician focus groups were conducted: two in Philadelphia, two in New Orleans, one in Chicago, two in Los Angeles, and one in Albuquer- que (in that order). Again, the composition of the groups was varied by design. The variables included specialty, HMO concentration, and urban- rural mix, and the recruitment criteria required that each focus group should have as even a male-female ratio as possible and some ethnic diversity. Final Composition of the Groups For the beneficiary focus groups, individuals were invited to participate In each group through recruitment procedures based on a screening instru- ment fielded by the focus group facility. (Appendix C gives an example of the recruiting "screener.") To ensure that an adequate number of persons would be available, 14 individuals were invited with an aim of having groups of 10 participants. Ultimately, five groups had 10 participants, one group in New York City had 11 participants, one group had 9 participants, and the nursing home group had 6 participants, for a total of 76 partici- pants. At those facilities where more than 10 recruits appeared on the day of the focus group, selection to reduce the number of participants was made on the basis of previously mentioned criteria to achieve the desired diversity in participants. People who were not asked to stay were thanked and reim- bursed for their time and travel expenses by the research facility staff. Those who did stay for the session were also paid a nominal fee by the research facility for their time and travel expenses.

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40 ALLISON J. WALKER Table 3.1 displays the main characteristics of the beneficiary groups. Overall, we had 39 women (51 percent of the total) and 37 men. The youngest participants were 66 years of age (eight individuals); the oldest were 90 (in the nursing home group) and 87 (in a community-resident group). The participants were overwhelmingly white (79 percent); four groups (both of those in San Francisco, one in Minneapolis, and one in New York City) met the target for ethnic diversity. The groups were less likely to have had recent acute or nonroutine health care experience than we had initially planned; 12 persons in the fee-for-service groups reported such an encoun- ter in the previous 3 months. All the HMO participants (in Miami and Minneapolis) reported that they had had an encounter with their HMO since being covered by Medicare, although most of the encounters were consid- ered to be nonacute. Finally, a considerable number of participants (55 individuals or 71 percent) reported having some form of Medigap insurance to supplement their Medicare coverage. For the physician focus groups, 12 individuals were invited to participate in each group through recruiting procedures similar to those used for the beneficiary groups. (Appendix D gives an example of the recruiting `'screener".) In these groups, the aim was to have 8 to 10 participants. Ultimately, two groups had 10 participants, two groups had 9 participants, three groups had 7 participants, and one group had 6 participants, for a total of 65 participants. Table 3.2 describes the main characteristics of the groups. Focus Group Process Before each session, participants were asked to complete a form to verify basic demographic information including age, sex, and primary occupation or medical specialty. In addition, the participants were served lunch, din- ner, or light refreshments, depending upon the time of the session. The moderator then explained the purpose of the focus groups and indi- cated that the sessions were being tape-recorded and observed through a one-way mirror. Finally, the moderator explained the "three rules" of focus group sessions: (1) that people speak freely and honestly; (2) that discus- sion be among participants and not directed only to the moderator; and (3) that only one person speak at a time to ensure that everyone is heard. To open the discussion, the moderator began by posing a question: "What are the most positive aspects of medical care, and what are the most nega- tive aspects of medical care?" Participants then discussed the question in subgroups of two or three people before reporting their views to the rest of the group. This approach helped to make people comfortable with speaking among themselves as well as with the moderator. The moderator then proceeded through the remaining sections of the guide. Each focus group session lasted approximately 2 hours.

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MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS FINDINGS OF THE BENEFICIARY FOCUS GROUPS 4 This section summarizes the main points that emerged across the eight beneficiary focus groups. These main themes are illustrated in the verbatim quotations from the participants. Notations following each quote signify the location, type of group, and sex of the participant.3 Personal Experience and Satisfaction with Health Care Recent Experience Before being asked any questions about "quality of care," participants were asked about their experiences and satisfaction with medical care. As would be expected, some of these Medicare beneficiaries had had consider- able experience with the health care system. Twenty-one participants re- ported during the screening stage that they had some acute or nonroutine care in the previous 3 months. At the focus group sessions, 16 participants said that they had used emergency rooms, 4 had received home health care, and 3 had had outpatient surgery. Most of the participants believed they were in good health. Satisfaction with Care Almost all the focus group participants expressed satisfaction with their own primary physician and the medical care they received. High among the positive aspects of the health care system was the Medicare program itself. Many beneficiaries asserted that adequate health care would be a financial burden without the assistance of Medicare. (As recorded in Table 3.1, however, many also rely on other insurance to supplement their Medicare coverage.) The general perception among participants was that medical care is very good in the United States much better than in most other countries. Other positive aspects of medical care frequently mentioned were scientific ad- vances, the high state of medical technology, increased efficacy of drugs, and a higher skill-level among providers of care. "As far as I'm concemed, the general medical care you gee has been pretty good. I mean, I've come across a lot of competent doctors." (NYC, 65+, M.) `'The best is the high state of development that has been attained and what it can do for the individual. It's a great process of medical development." (NYC, 65-74, M.) Participants occasionally experienced"system" problems such as finan- cial and access barriers. A majority of the negative points focused on these

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42 TABLE 3.1 Selected Characteristics of Focus Group Participants ALLISON J. WAL1~ER Recent Has Health Care Medigap Group Sex Age Racea Experience ~InsuranceC Group 1 F 74 H Y Y F 72 W N Y New York City F 71 H Y Y Community residents F 70 W N Y Fee-for-service Medicare F 68 W N Y Ages 65 to 74 F 67 W Y N M 72 W N Y M 69 W N Y M 69 W N Y M 69 B Y N M 66 W N Y Group 2 F 86 W N N F 79 B Y N New York Ci~r F 78 W N Y Community residents F 78 W N Y Fee-for-service Medicare M 87 W N N Ages 75+ M 79 W Y N M 78 B Y N M 77 W Y N M 77 W N Y M 75 W N Y Group 3 F 73 W N N F 71 W N N Miami, Florida F 70 W N N Communi~ residents F 67 B N N HMO enrollees ~F 67 B N N Ages 65+ M 82 W N N M 76 W N Y M 76 W N N M 72 W Y Y M 68 W N N Group 4 F 78 W N Y F 70 W N Y Miami, Florida F 69 W N Y Fee-for-service Medicare F 66 W Y Y Ages 65+ M 82 W Y Y M 78 W Y Y M 72 H N Y M 70 W N Y M 68 B Y Y

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MEDICARE BENEFICIARY AND PHYSICI0 FOCUS GROUPS Recent Has Health Care Medigap Group Sex Age Racea Experienceb InsuranceC Group 5 F 80 W N N F 79 W N Y Minneapolis, Minnesota F 69 W N Y Community residents F 67 W Y Y HMO enrollees ~F 66 W N Y Ages 65+ M 82 W Y Y M 80 W Y Y M 75 W Y Y M 69 B N Y M 68 W N Y Group 6 F 90 W N N F 81 W Y Y Minneapolis, Minnesota F 77 W Y Y Nursing home residents F 74 W N N Fee-for-service Medicare M 83 W Y Y Ages 65+ Group 7 F 74 B ~Y F 74 W Y Y San Francisco, California F 69 H N Y Community residents F 66 B N Y Fee-for-service Medicare F 66 W N Y Ages 75+ M 70 W Y Y M 68 W N Y M 66 W N Y M 66 H N Y M 66 W N Y Group 8 F 83 B Y Y F 79 W N Y Sar~ Francisco, California F 78 W ~Y Community residents F 76 H N Y Fee-for-service Medicare F 75 W N Y Ages65to74 M 86 H N N M 77 W N N M 77 H ~Y M 76 W N Y M 76 W N Y 43 bB is black; H is Hispanic; W is white. Y is yes and signifies ~at the participant reported a "nonroutine" encounter with the health care system (e.g., a hospitalization, a visit to the emergency room, or services from a home health agency) in ~e previous 3 months; N is no. cy is yes and signifies that the participant reported having some form of a sup- plemental health insurance in addition to Medicare; N is no. ~Although very few HMO enrollees reported an encounter with the health care system in the form of a hospitalization, a visit to the emergency room, or services from a home health agency, all reported that they had received care from their HMO since being covered by Medicare.

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44 TABLE 3.2 Charactenstics of Physician Focus Groups ALLISON ]. W~KER Sex Age HMO Affiliationa Specialty Philadelphia 1 M <45 N Orthopedic Surgery M <45 Y Thoracic Surgery M <45 Y Neurosurgery M <45 N Ophthalmology M <45 N Colon & Rectal Surgery M <45 Y Ophthalmology M <45 Y Urology F 245 N Obstetrics/Gynecology F 245 Y Obstetrics/Gynecology Philadelphia 2 M <45 N Intemal Medicine M <45 N ~temal Medicine M <45 N Intemal Medicine M <45 N Gastroenterology M <45 N Dermatology M >45 Y Pulmonary Disease M 245 Y Cardiology F 245 Y Neurology F 245 Y Allergy F 245 N Oncology AAFP M 245 N Family Practice M >45 N Family Practice M 245 N Family Practice M 245 N Family Practice M <45 N Family Practice M <45 N Family Practice M <45 N Family Practice New Orleans M 245 Y Urology M >45 Y Dermatology M <45 N Ophthalmology M <45 Y Intemal Medicine M <45 Y Dermatology F 245 N Obstetrics/Gynecology F 245 N Obstetrics/Gynecology

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AfEDICARE BENEFICIARY A[JD PHYSICIAN FOCUS GROUPS 45 Sex Age HMO Affiliationa Specialty Chicago M >45 Y Intemal Medicine M >45 N Ear, Nose, & Throat M 245 N Obstetrics/Gynecology M <45 Y General Surgery M <45 Y Ophthalmology M <45 Y Thoracic Surgery M <45 Y Intemal Medicine Los Angeles i M >45 N Family Practice M 245 N General Surgery M 245 N General Surgery M <45 N Family Practice M <45 N Ophthalmology M <45 N General and Vascular Surgery M <45 N Ear, Nose, & Throat F <45 N Obstetrics/Gynecology F >45 Y Ophthalmology Los Angeles 2 M >45 Y Ear, Nose, & Throat M >45 N General and Vascular Surgery M <45 N Urology M <45 N Urology M <45 Y Internal Medicine M <45 Y Internal Medicine M <45 Y Internal Medicine F >45 N Family Practice F <45 Y Obstetrics/Gynecology F <45 Y Obstetrics/Gynecology New Mexico M 245 N Neurology M <45 N Internal Medicine M <45 N General Surgery M <45 N Internal Medicine F >45 N Anesthesiology F <45 N Oncology aHMO is health maintenance organization, N is no, and Y is yes.

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80 ALLISON J. WALKER "Now I'd like to explore a little more the question of where you get information on the quality of health care services." For instance: E. Where do you usually get most of your information on the quality of health care? F. What do you hear about heath care quality on TV or the radio? 1. What do you read about it in the newspapers or magazines? G. What other kinds of information do you think is available to you about the quality of health care services? USE AS EXAMPLES 1. Hospital mortality rates 2. How often a type of operation is performed by a doctor or in a particular hospital 3. information on malpractice claims or physicians inspector's re- ports on nursing homes H. From what sources would you like to receive additional information on the quality of health care? I. Would you be likely to make use of such information services if they were available? For instance: 1. If you or someone close to you were going into the hospital for surgery, would you like to know beforehand the mortality rate of that hospital or of particular physicians for that kind of operation? 2. Would you like to know the mortality rate of hospitals in your area, in case you ever had to go to one in an emergency? V1. SUGGESTIONS FOR IMPROVING THE QUALITY OF MEDICAL CARE (15 min) (At this point, the moderator will leave the room to confer with the observers to see if they have any points they would like the group to address in greater depth) "What is the one thing that most needs to be done to care?" ASK EACH PERSON IN GROUP i: mprove quality of

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MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS APPENDIX B MODERATOR'S GUIDE FOR THE PHYSICIAN FOCUS GROUPS INTRODUCTION AND WARM-UP (10 minutes) A. Introduction of the moderator B. Introduction of sponsor and purpose of the focus group 81 "The Institute of Medicine is part of the National Academy of Sciences. It is a private research institution established in 1970 to conduct studies for and provide advice to a wide range of government agencies and private concerns and foundations. Congress has asked the Institute of Medicine to develop strategies to review and assure quality within the Medicare program. As part of this process, last spring the Institute conducted a series of focus groups around the country with elderly Medicare beneficiaries to understand their views about quality of care. The expert committee overseeing this study is also holding public hear- ings with testimony from physician groups, hospital groups, consumer groups, and other health care organizations. A series of site visits are under way to cities around the country to talk with people in hospitals and other health facilities. The focus group you are participating in today is one of eight to be held in different areas of the country in which we are specifically seeking the views of office-based physicians who care for the elderly. I will be asking for your opinions and advice about assuring quality of care for Medicare patients." C. Stress focus on quality, not cost. Not intended as criticism, but opportunity to give physicians a chance to provide input on important issues pertaining to health care. D. Description of focus group process and ground rules Mention tapes, observers, confidentiality, one-at-a-time, and refresh- ments. E. Introduction of participants Introduce and identify specialty and type of practice. Rotate asking most rewarding aspect of providing care for Medicare patients and most difficult part of providing care for Medicare patients.

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82 II. DEFINITION OF QUALITY HEALTH CARE (15 minutes) ALLISON J. WALKER A. "Before we talk about the Medicare program, can we talk in general about defining "quality" in medical care? How would you define qual- ity in medical care what are the dimensions of quality?" B. What differentiates good health care from poor health care? III. QUALITY OF CARE IN THE MEDICARE PROGRAM (10 minutes) A. General Quality Issues "Now let me turn the discussion to the Medicare program. From your perspective as a practicing physician . . ." 1. "Does the Medicare program and the way it is run affect the quality of care you and other doctors provide to your patients?" (focus on any limitations caused by the Medicare payment system, review system, or other factors) B. Location of Quality Problems "We've been talking about a lot of different issues so far. If you could generalize about problems in care affecting Medicare patients, what would you say that the main problems in quality are?" PROBE IF NOT MENTIONED SPECIFICALLY: overuse of services underuse of services . . . ~. 1. 2. 3. poor physician SklllS 4. outdated physician skills 5. physician training/retraining 6. poor lab services or other support services 7. personal problems of physicians (substance abuse, etc.) 8. something else? PROBE: HOW SERIOUS OR PERVASIVE ARE THESE PROB LEMS? C. Other issues to probe (OPTIONAL) "I'd like to ask about some specific quality of care issues we have been hearing about from the elderly and in our public hearings." SKIP ANY ISSUES THAT HAVE ALREADY BEEN RAISED 1. lack of information for decision-making 2. not enough time with physicians

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MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS 3. continuity of care who is responsible 4. conflict of interest 5. differences among physicians and hospitals in the same area 83 PROBE POINTS: HOW SERIOUS OR PERVASIVE ARE THE PROBLEMS AND WHAT ARE TEN REASONS FOR TOM? IV. AREAS TO TARGET FOR QUALITY ASSURANCE (30 minutes) A. Focus of Quality Assurance Efforts "In terms of all the quality-of-care issues that the Medicare program might be concerned with, what (in your view) is the relative importance of dealing wig poor practitioners as contrasted with Dying to improve the general or "average" quality of health care provided?" B. Analysis Using Schematic Aid "I'm handing out to you a schematic table with two dimensions along which problems in health care quality exist that are under the control of the physician." DESCRIBE HANDOUT 1. Where would you say most of the problems in quality lie? 2. For each category, what proportion of care by all physicians could be put under each category? 3. What proportion of doctors can be defined as outliers? HANDOUT Type of Average Outlier Quality Problem Physician Physician Over Provision of Services Under Provision of Services . Poor Physician Skills or Knowledge Outdated Physician Skills

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84 ALLISON J. WALKER 4. For each problem, what would be the most effective quality assurance mechanism? V. ASSESSMENT OF MAJOR QUALITY ASSURANCE MECHANISMS (40 minutes) A. Knowledge of Quality Assurance Mechanisms "Now I'd like to turn our attention to something different the mechanisms for maintaining or improving quality." 1. What procedures or systems are most important for assuring the quality of medical care? PROBE UNDERSTANDING OF PEER REVIEW SYSTEM 2. For each of the problem areas we have been talking about: a. What ideas do you have for addressing He problem? b. How difficult/costly would it be to address the problem? c. What role should Medicare play in addressing the problem? d. How much progress do you think can be expected? e. Is it worth it? B. Are there any ocher mechanisms of quality assurance? IF ANY OF THE FOLLOWING HAS NOT BEEN MENTIONED, ASK ABOUT IT. 1. Individually focused mechanisms a. state licensing and state board of medical examiners b. specialty board certification/periodic recertification c. continuing medical education 2. Hospital-based mechanisms a. hospital privileging process 1. admitting privileges 2. privileges to perform certain kinds of procedures b. master physicians who serve as proctors (as corrective ac- tions for doctors identified as providing poor quality) c. hospital peer review activities d. private review such as Joint Commission accreditation 3. Externally based mechanisms a. PRO program for Medicare b. exclusion from the Medicare program c. the legal system - malpractice

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MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS 4. Information-based mechanisms 85 a. analysis and feedback of physician or provider-specific in ~ . formation 1. making public certain kinds of information about the quality of care of hospitals or doctors 2. public disclosure of hospital-specific mortality rates b. review of office-based records against physician-developed criteria surveying patients about practitioners C. How do physicians acquire new skills or upgrade existing skills once out in practice? D. To what extent can a physician keep up with the knowledge explo- sion in medicine? How do they do so? RELATE TO QUALITY ASSURANCE MECHANISMS OF LICENS- ING, CERTIFICATION, RECERTIFICATION, PRIVILEGING, CON- TINUING EDUCATION, MASTER PHYSICIANS, AND PEER RE- VIEW. E. How effective are these quality assurance systems? 1. generally 2. for dealing with the outlier physician F. Addressing Specific Problems "The study committee has been asked to consider some specific kinds of problems. So, how adequately do you think existing quality assur- ance methods address each of the following problems?" 1. the impaired physician (psychological or substance abuse) 2. a physician whose skills and knowledge are out of date 3. a provider in a rural or otherwise isolated setting who gives substandard care 4. a physician or hospital that has a pattern of poor performance or patient outcomes G. What can Medicare do to address each of these problems? MODERATOR LEAVES THE ROOM TO CONFER WITH THE OBSERVER H. Suggestions for Change (15 minutes) 1. "What one change do you think practicing physicians would most readily support that would most improve the quality of care Medicare patients receive?"

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86 ALLISON J. WALKER APPENDIX C RECRUITING SCREENER: MEDICARE BENEFICIARY FOCUS GROUPS Fee-For-Service Groups New York City, NY San Francisco, CA Hello, I am from . We are conducting a study of health care for the Institute of Medicine of the National Academy of Sciences. For this study, we are seeking the opinions of people ages 65 and over. 1. Do any men age 65 and over live in this household? a. YES May I speak with him please? b. No- Do any women age 65 and over live in this household? 1. YES May I speak with her please? 2. NO terminate. QUOTA: AT LEAST 6 MALES IN FINAL GROUPS, AND NO MORE THAN 8 (When speaking to the appropriate person) Hello, I am_ from . The Institute of Medicine of the National Academy of Sciences is doing a study of health care today. We will be inviting a small number of older Americans to take part in a research discussion of their experiences and views about health care. We would like a diverse group for this discus- sion, and would, therefore, like to ask you a few questions. All of your responses will be kept confidential. First, I need to ask you a few questions. 2. Are you covered by Medicare? a. YES b. NO-terminate 3. May I ask your age? a. YES b. NO May I ask if you are: a. 65 - 74 b. 75 and over GROUP A: 65 - 74 GROUP B: 75 AND OVER If respondent wiI1 not give age, terminate conversation. QUOTA: AT LEAST 5 PEOPLE IN EACH GROUP NEED TO ANSWER "YES" TO QUESTION 4

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MEDICARE BENEFICIARY AND PHYSICI~ FOCUS GROUPS 87 4. In the past 3 months, have you (or your spouse) been a patient in a hospital, had surgery when you did not have to be hospitalized, had to go to a hospital emergency room, or had nursing home or home health care? a. YES b. NO IF QUOTA NOT MET, TERMINATE CONVERSATION 5. Has your primary occupation been in the health field; that is, have you been a doctor, nurse, hospital administrator, or other health care profes- sional? a. YES-terminate b. NO 6. As I mentioned before, we would like to learn the views on health care of a diverse group of people. As such, may I ask your racial or ethnic background? QUOTA: AT LEAST THREE NON-WHITE OR HIS- PANIC IN EACH GROUP We would like to invite you to join us for a discussion group on health care issues. The sponsor of the group is the Institute of Medicine of the National Academy of Sciences. Our purpose is to learn about people's views toward health care. No one will try to sell you anything. The discussion group will be held on at Refreshments will be served. We are located at . The discussion will take approxi- mately two hours. The discussion leader will be an expert in this area, whose name is Mathew Greenwald. About 10 other people like your- self will participate. You will receive $30 for your hme and pariicipa- tion, and your transportation expenses will be paid. Will you be able to attend? a. YES b. NO is there anyone else in your household above age 65 who might be able to attend? 1. YES-May I speak with him/her? repeat screener 2. NO terminate conversation NAME: ADDRESS: TELEPHONE:

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88 ALUSON J. WALKER Let me repeat your name and address to make sure we have it correct. REPEAT NAME AND ADDRESS Would you like me to repeat the discussion group date, time, and loca- tion to make sure you have it written down correctly? IF YES, REPEAT DATE, TIME, AND LOCATION Thank you. You will be receiving a reminder post card and we will call again to make sure you will be able to attend. APPENDIX D RECRUITING SCREENER: PHYSICIAN FOCUS GROUPS High HMO Concentration Groups Los Angeles, CA Hello, I am from . We are conducting a study of the quality of health care for the Institute of Medicine of the National Academy of Sciences. For this study, we have been asked to contact a group of doctors in your area. Dr. 's name was selected at random, and we would like to ask him/her a few questions for this study. 1. Is doctor available to speak with us? a. YES May I speak with him/her for just a few minutes? b. NO ARRANGE FOR A RETURN CALL OR CALL BACK TIME (When speaking to the appropriate person) Hello, I am from . The Institute of Medicine of the National Academy of Sciences is conducting a study of physician's opinions about quality of health care. We will be inviting a small number of doctors from your area to take part in a research discussion of their views about health care quality. We would like a diverse group for this discussion, and therefore, need to ask you a few questions. All of your responses will be kept confidential. 2. First of all, do you maintain an office-based medical practice? a. YES Are you affiliated with an HMO or IPA? (NOTE: HEALTH MAINTENANCE ORGANIZATION OR INDEPENDENT PRACTICE AS SOCIATION) 1. YES With which HMO are you affiliated? 2. NO

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fEDIC~E BENEFICIARY ED P~SICI~ FOCUS GROUPS 89 b. NO Are you a staff physician for an HMO (Health Maintenance Organization)? 1. YES-With which HMO are you affiliated? 2. NO-terminate conversation. QUOTA: AT LEAST 4 HMO PHYSICIANS, AND NO MORE THAN THREE FROM ANY ONE HMO 3. Would you say that at least 20% of the patients you have treated over the past year were over age 65? a. YES b. NO terminate conversation. 4. What is your medical specialty? TERMINATE CONVERSATION IF DOCTOR IS A PSYCHOLOGIST, AN ALLERGIST, A PEDIATRICIAN, OR AN EMERGENCY ROOM PlIYSI- CIAN. QUOTAS: RECRUIT NO MORE THAN IWO FROM EACH OF THE FOLLOWING SPECIALTIES: INTERNAL MEDICINE Cardiovascular Disease Gastroenterology Pulmonary Disease Neurology Dermatology FAMILY MEDICINE GENERAL PRACTICE 5. Are you under age 45 or older? a. under 45 b. over 45 6. DON'T ASK, BUT RECORD SEX 7. SURGERY General Surgery Neurology Otolaryngology (ENT) Colon and Rectal Surgery Thoracic Surgery Urology Obstetrics and Gynecology a. Male b. Female QUOTA: AT LEAST TWO FEMALES Have you been a participant in a focus group within the past three months? a. YES-terminate conversation b. NO

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9o ALL lSON J. WALKER We would like to invite you to join us for a discussion group on health care issues. The sponsor of this group is the Institute of Medicine of the National Academy of Sciences, a private research institution not associated with any government agency. Our purpose is to learn about physicians' views towards the quality of health care. No one will try to sell you anything. The discussion group will be held on at_ . Re- freshments and a buffet will be served. The discussion will take approxi- mately two hours and you will be paid for your time and participa- tion. About 10 other doctors will participate. The discussion leader will be Mathew Greenwald, who has a great deal of experience with research in this area. Will you be able to attend? a. YES get name/address information b. NO Is there another physician in your office who might be able to attend? 1. YES May I speak with that doctor please? REPEAT SCREENER 2. NO thank and terminate conversation. NAME: ADDRESS: TELEPHONE: Let me repeat your name and address to make sure we have it correct. REPEAT NAME AND ADDRESS Would you like me to repeat the discussion group date, time, and location? IF YES, REPEAT DATE, TIME, AND LOCATION Thank you. You will be receiving a reminder post card and we will call again to make sure you will be able to attend. Should your schedule change, making it impossible for you to attend, please let us know as soon as possible so that we may find a replacement. Our number is