Medicare: A Strategy for Quality Assurance, Volume II: Sources and Methods (1990)

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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

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.

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

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

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.

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.

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

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

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.

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

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.

46 ALLISON J. WALKER issues, which do not necessarily relate to quality issues. Although the moderator tried to de-emphasize cost and access issues, these issues sur- faced quite frequently as problems faced by beneficiaries. Complaints in- cluded excessively high physician and hospital charges as well as balance billing by physicians who do not accept Medicare assignment. "It's gone way beyond the inflation factor. In other words, general cost of living may be up eight times. But hospital care has gone up about 12 or 15 times." (NYC, 65-74, M.) "You're talking about cost. But I want to tell you don't forget that doctors are human beings. And basically they are business people today. The mon- key only dances when you give him music. And the only thing they under- stand is money. It's a business like any other business. My doctor charges me $300. The next time I come to see him, I bring him a gift. He's going to heat me right. He's going to give me all the best that he knows." (NYC, 75+, F.) As previously mentioned, the majority of focus group participants seemed satisfied with their own physicians and rated them above average compared to others. However, some had to change providers at least once to find one with whom they were satisfied. Frequently mentioned as one area of dissat- isfaction with physicians was the feeling that fees varied with location, that is, the same services could cost more or less depending upon the part of town in which the physician practices or the patient lives. Several participants also stated that it was imperative to check every bill because patients were often charged several times for services they received only once or were charged for services never received. "My dad passed away August 25th. And we got a bill from the doctor, and the bill shows services rendered for August 26th and 27th. I called up the doctor. He couldn't come to the phone. I called again and I said to the girl, I'm refusing to cay. She not very indigent ~ said it'.c very simple .Rinre ~., an- --, ~o-- ~J ~--^^r~ ~1_ _ ~ _ _ ~ _ _ ~ ~ the doctor says he gave services two days after my father died, how do you account for this? And if I get another bill I'm bringing it up to the AMA. Never heard another word from them." (FL, 65+, F.) "One man in our building got a gynecology bill, something that a wo- man would have had taken care of. He called, and it was about $1,000." (FL, 65+, F.) Additionally, some participants expressed concern about Medicare fraud as a reason for excessive charges and cautioned against signing blank reim- bursement forms. "I think Medicare gets ripped off sometimes, because when I got a copy of my bill, it was 11 or 12 pages . . ~ some things you remember and some things you don't. And I saw a number of items on there that I know I did not get service on." (MN-HMO, 65+, F.)

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS "I just got a bill from the hospital and it gives me $32,000 worth of charges. And I see that on one day, four times we get charged for the same thing. And Medicare is paying for it. In the ultimate long run, I'm really paying for it; we are. Don't you think you ought to do something about it? Guess what the answer was? We don't care. It's just part of the charge." (FL, 65+, F.) 47 Although students of health care find it useful to distinguish "cost" prob- lems from "quality" problems, these focus group discussions suggest that these issues are often linked in people's minds. Patients sense that some physicians are so motivated by money indeed, are willing to commit fraud- that they may not really be interested in their patients' well-being. The loss of confidence that accompanies the suspicion that the provider's primary motivation is financial was an unmistakable undercurrent in some discus- s~ons. Many other comments pertained more directly to quality of care. These included difficulty in scheduling appointments, perceived differences in the treatment for elderly patients compared with that for younger patients, and staffing deficiencies (specifically nurses) resul ;ing in increased waiting times and less personalized attention. "The attitude from what I hear and what I see is when you're old, to hell with you. You're too old, so you're going to die anyway." (NYC, 75+, F.) "I wonder why they are cutting back on the nursing profession. And the girls are good and they want to spend time with the patients. But there aren't enough to go around." (SF, 75+, F.) The principal area of dissatisfaction that related to quality of care was the feeling that differences exist between physician practice in the office setting and in the hospital. With respect to hospital care, physicians were described as being less friendly, offering less personalized attention, and often hurrying patients more than those in office practice. "It's going to be different. The doctor just runs through your room in the hospital. At the office, they've got you in a room, and you talk." (NYC, 65-74, M.) "At the office I get a chance to find out everything I want. In the hospital I didn't find out anything." (NYC, 65-74, M.) Premature discharge was another concern expressed by participants, al- though none actually seemed to have experienced this. Financial incentives of the Medicare reimbursement system were cited as the main reason for premature discharge, with insufficient home health care and nursing home beds viewed as serious related problems. "I think it's a crime with the hospitals we have and the equipment the way they shove people out when they're still sick. What have we got hospitals for?" (MN-HMO, 65+, F.)

48 ALLISON J. WALKER "They push the older people out sooner than they really should go. From what I've read, it's a bonus factor in there to get you out sooner." (NYC, 65-74, M.) "DRGs. Medicare pays the hospital X number of dollars for a period of days. As a result, many people have been pushed out before they are well. And it has been documented. I know of a particular case where the man died be- cause he was pushed out of the hospital before he was able to be discharged. And that's wrong too . . . and we don't say anything. We don't open our mouths and it goes on and on and on." (NYC, 75+, M.) View of the Concept of Quality A general theme that surfaced quite frequently during the focus groups is the perception that those who receive medical care define and judge the quality of that care in ways that are different from those who provide care. Whereas professionals evaluate quality in terms of complex clinical indica- tors and outcomes, patients use "art-of-care" or interpersonal indicators when describing what they mean by quality of care. They may acknowledge (at least indirectly) a lack of information or capacity for making other types of judgments. "There are very few of us around- who can understand what quality is as far as the medical field [is concerned]." (FL, 65+, M.) Competency of the physician, along with the outcome of treatment (see below), was mentioned a few times as a factor by which to judge quality, but most responses centered on the physician's personality and interper- sonal skills. These included the amount of time doctors spend with a pa- tient, how much interest they show in who the patient is and in his or her well-being, how much information they provide, and whether they are com- passionate and understanding. "I think you can sum it all up in just a couple words, compassion and under- standing. This denotes the quality of the doctor." (FL, 65+, M.) "Well, even before the man gives you medicine he can make you feel good. But if he comes in, [and] his attitude is not good, then the cooperation is lacking. Then you become sure enough just a patient." (NYC, 65-74, M.) "I feel if a doctor I'm seeing introduces himself to you, sits down and talks to you and doesn't hurry you and even asks you things that do not pertain to what you went in for, and when you do start to tell them what's wrong with you, they start asking questions. When they seem to take an interest in your health, I think that's good care. But if they come in, and out he goes, I think, hey, I don't want that doctor anymore." (SF, 75+, F.) "The quality care is exactly how good a doctor is as a diagnostician. If he can diagnose your trouble, your problem is 99 percent of the cure. Bedside manner

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS doesn't mean a thing to me or how much time he spends with you. If he can pinpoint your illness, you've got it licked because the cure comes shortly afterwards through medication. That's quality care to me." (FL-HMO, 65+, M.) 49 Outcomes of care were noted by several participants as an indicator of quality. Most participants used positive or negative outcomes to make broad judgments about quality. They tended not to relate outcomes to the severity of illness or other factors outside the physician's control that may negatively affect the results of treatment. "This lady and I might be going to the same doctor. He takes the same care of both of us. But she is cured of all her ailments. I'm not. She thinks the doctor is great. I think he's lousy." (NYC, 65-74, M.) Medicare fraud and honesty were mentioned again in the context of de- fining and judging the quality of a physician. Patients felt they could not trust a physician who is "ripping off' the Medicare system through profes- sional preoccupation with financial incentives rather than with the patient. Quality of hospitals and nursing homes was judged on overall cleanli- ness, friendliness and helpfulness of the staff, and tastiness of the food. Also important was going to a hospital that is "not like a factory." The quality of an HMO was judged by how easy or difficult it is to schedule an appointment and the amount of waiting time in a physician's office. Again, very few clinical indicators of quality were mentioned. "The difference between a good and bad HMO [is] when the doctor doesn't have a million patients and you [don't] have to wait for 5 hours to get to see him for 5 minutes." (FL-HMO, 65+, F.) Quality of Care and Medicare When asked to rate "the quality of care received while on Medicare," some participants saw no connection between who pays the bill and the quality of care. (This view was contradicted, however, by others in the context Of who should be responsible for monitoring the quality of care, as discussed below.) "Medicare is all I have, so it doesn't make a difference. Whether he's a good doctor or a bad doctor, he's going to send a Medicare form in." (NYC, 65-74, M.) "Medicare has nothing to do with it. Medicare is nothing but an insurance company set up by the government who pays medical expenses. They pay the bills. That's all they do." (FL-HMO, 65+, M.) Other participants voiced concern about how Medicare's payment system affects quality of care, perhaps leading to underprovision of services or

so ALLISON J. WALKER premature discharge. Yet other participants noted that decreases in services do not necessarily reduce quality of care. "Well, there's a lot of good and bad points since they've increased the number of seniors.... Lower the rates, get the people in, make the money, and then cut down your care. Because the physicians are too overworked. They'll give you 15 minutes, and if you're not through, that's too bad. And that's very unfortunate. I think a lot of people are missing a lot of things they normally wouldn't." (MN-HMO, 65+, F.) "Medicare restricts the hospitals from doing things for you and the doctors. I feel that I'm not getting the same care I did before I was 65." (MN-HMO, 65+, F.) "Well, I think getting the necessary tests that you need, not a lot that you don't need. I think maybe physicians are a little more conscious of that now because of DRGs and the way medical costs have risen above the cost of living. So I think that just getting the necessary things is part of quality." (MN-NH, 65+, P.) Quality of Care Now and in the Past Most focus group participants contended that the health care available today is better than that available 10 years ago. Reasons cited include improved technology, better trained providers, and increased longevity. "There have been new discoveries in the field of medicine. Longevity has been prolonged. And many of the hospitals that can afford it have gotten new equipment. On the whole I would say that medical care today is much better than it has been." (NYC, 75+, M.) "~e doctors today, they're better educated. More facilities [are] available to them. And they have staff members just doing the same expertise-type of medical care. And they talk with each other, and you conduct conversations before they make a move on you. Before, a room of doctors looked at you and said, well, let's try it and see if it works." (SF, 75+, M.) Participants in the two New York City groups felt that health care was better 10 years ago because of recent staffing shortages (specifically nurses), less personalized attention, and increased prices. "Everything's changing. The help, the hospitals and everything has changed so much that I guess that's true of everything. It's a changing world." (NYC, 65-74, F.) "Well, in some respects, it was better then. Of course now they have more tests and things. They've made a lot of progress. But as far as the hospital is concerned, they were cleaner, they had more nurses." (NYC, 65-74, F.)

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS Understanding How Health Care Is Monitored How Respondents Handle Problems 51 Most participants agreed that if they had problems with a particular doc- tor, they would leave that doctor and find a new one. A few people men- tioned reporting the problem doctor to other patients; others would call the "medical association." Most, however, would simply look for a new doc- tor. "You can drop one primary doctor and go to another if you feel as though you're not getting the right thing." (FL:HMO, 65+, F.) "We all have our good runs and our bad runs with the doctors. If you don't like your doctor, you're not obligated to see him again. When you call to make your next appointment you can say I want Dr. Timbuktu. I just don't want this doctor. And a lot of people do it." (SF, 75+, M.) "I had one doctor who never realized I was sitting In his office. He was writing and wnting, and I figured I'd be in a book one day. But he wasn't paying any attention to me. So I just stopped him. One day I met his nurse In town. She asked what happened, alla I said I don't think he knew I was there most of the time. I feel like I'm the only sick person in the world when I walk into that doctor, and I want him to look after me." (SF, 75+, F.) When asked what they would do if they experienced problems with a particular-hospital, most participants agreed that they would report the prob- lem to their doctor or the head nurse first. If that did not work, then they would proceed to the next level, the administration. Some participants believed that there are times when nothing can be done about problems in the hospital; although they were a minority, their view was stated with some vehemence. "Over the years I can only say you're at their mercy and there's not much that can be done. There's always people worse off than you are. And you say, well, [there] but for the grace of God go I. So keep your mouth shut, don't bitch too much about anything. Just get out of there." (SF, 75+, F.) HMO enrollees evidently would handle perceived problems in much the same manner. They might, however, be more likely to bring up an issue to an administrative person at the HMO rather than to their doctor. "If it's a serious matter, the consumer council in the HMO has a committee dealing with complaints about physicians, real or imaginary, which are then referred to the administrator or director of the hospital. Now if it's a serious matter, you sue the doctor. We're talking about relatively adjustable matters. You deal with the administrator' or your own physician and then the adminis- trator." (NYC, 75+, M.)

52 ALLISON J. WALKER When asked how problems in a nursing home should be handled, the non-nursing home respondents seemed to view the nursing home situation as presenting a different set of problems and that the patient has fewer options for taking action. Most thought that a family member or friend would have to raise the problem issue for the resident, rather than the resident himself or herself. '6If you're in a nursing home, then generally speaking, you're pretty sick. Secondly, you're going to be a little intimidated by trying to complain your- self. You're going to have to rely on your family or friends, whoever's taking care of you. You're not going to do it yourself." (NYC, 65-74, M.) Nursing home residents themselves had a different idea of what to do about problems. Some said family members could raise the issue, but many residents do not have family in close proximity to the home. The nursing home residents said they would raise problems themselves, through the nursing home complaint procedure or the ombudsman program. "They always say the squeaking wheel gets the oil. So I've learned to squeak . . . If you want anything, that's the way to go. It seems to get the results, any- way." (MN-NH, 65+, F.) "Well, if they speak up and voice their concerns [they get results]. Otherwise, they're going to lay there and just suffer." (MN-NH, 65+, F.) With very few exceptions, the nursing home residents responded to the moderator's questions in much the same manner as the rest of the focus group participants. The only major difference involved the way they handled problems within the nursing home versus the way they were perceived (by those outside the home) to handle problems. It should be stressed, how- ever, that the nursing home residents who were able to participate in our focus group are probably not typical; for instance, they were sufficiently mobile to be able to come to the focus group center. We had originally intended to conduct this group in the nursing home in order to gain the participation of typical residents, but the practical barriers proved too diffi- cult to overcome in the time available to us. Awareness of How Medical Care Is Monitored Many focus group participants did not think health care is monitored very closely. Others clearly assumed it is evaluated to one degree or an- other through accreditation of hospitals, licensure of physicians and nursing homes, or government monitoring. "We presume they're monitored. But I don't think anybody can tell. Because how would we know?" (NYC, 65-74, M.)

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS "It would be the head of the staff in the hospital. They know what's cooking in the hospital. So they observe the doctors. I'm assuming they do. How close they do, I don't know. But I'm assuming they do." (SF, 75+, M.) "Well, hospitals do get accreditation, whatever you call it. So I assume that there's some monitoring going on for them to be accredited. But I don't know exactly what it is." (FL, 65+, F.) "There's enough complaints to the state government that somebody would interfere and say, what's going on here? There's got to be regulations from the state in some manner. Otherwise, it would just be running rampant. But I do not know." (MN-HMO, 65+, M.) 53 In general, participants were not sure who is currently responsible for performing these functions and believed that care is not monitored closely enough. The increase in the rate of malpractice suits was mentioned several times as resulting from a lack of monitoring. As to what agencies or groups should monitor the quality of care pro- vided through Medicare, the participants' responses were quite varied. Some mentioned that it should be done by Medicare, because "they pay the bills"; this view was most forcefully expressed by HMO enrollees. Others were skeptical of this role for Medicare, evidently believing that Medicare may not be in a good position to "be its own watchdog." Some participants presumably extended this skepticism to the professions more generally. "I think Medicare must have control. Because they're paying hundreds of dollars a month for every patient . . . they must have some strings attached. They don't just give it up willy-nilly." (MN-HMO, 65+, M.) "They [Medicare] should have qualified personnel to go out and check these different doctors and different offices and see the quality of care. If an office is overcrowded, or if an office is understaffed, and the only reason the doctor is there is for the purpose of making money, but not to take care of the patients. Monitor different doctors." (FL-HMO, 65+ F.) "The more you have that Medicare monitors them, the less they'll take assign- ment. You have to have a different organization monitoring them." (FL, 65+, M.) Across all the groups, participants expressed a number of ideas about other possible ways for the quality of care to be monitored. These included patients themselves, ombudsmen, boards of directors at hospitals, insurance commissioners, and medical associations. "Nursing homes are monitored by ombudsmen that are appointed by your state legislature. So the nursing homes are monitored more closely than hospitals. And my suggestion is that there should be ombudsmen appointed to monitor hospitals." (FL, 65+, F.)

54 ALLISON J. WALKER Desire for Information About Quality of Care Much of today's health policy rests on notions of competition and the related concepts of information and choice. We touched on these issues indirectly during the focus groups. One question for the participants was whether Medicare beneficiaries want to be able to select their own physi- cians and other providers (as is presently guaranteed to them in the fee-for- service portion of Medicare). Related questions concerned variation across providers in quality of care and how patients learn about which practitio- ners or facilities provide what levels of quality. Patient Choice Most focus group participants agreed that being able to choose their own physician is very important to them. The ability to do so seemed especially relevant because they evidently perceive that different providers do render different levels of quality of care (see below). HMO focus group participants acknowledged that although they still choose their own physicians, they have a smaller, predetermined set from which to choose. Several (seven persons in Miami and five in Minneapolis) had had to change their physicians on joining the HMO, but they generally did not view this as a problem. Most respondents claimed that they generally have enough information available to choose a primary care physician. They received a majority of that information from two sources: friends (through word-of-mouth or their friends' experiences) and physicians (referrals and recommendations). Nev- ertheless, participants also believed there is a certain amount of luck in- volved in choosing a physician for the first time. "there's always an element of chance." (NYC, 65-74, M.) "You have to go through the experience. You never know." (NYC, 65-74, F.) With regard to choosing specialists and hospitals, most participants said that their primary care physician refers them to specialists as well as to hospitals. For instance, they would go to the hospital where the physician was on staff and, therefore, would not actually have a great deal of input in choosing a hospital. Participants evidently did not question this pattern very often. "I would say if you have full confidence in your own physician, you go along with him" (NYC, 65-74, F.) With respect to selecting a nursing home, three of the participants in the nursing home focus group said they made their own choice as to which home to enter and that they had enough information available to make this choice. Of the remaining participants, two reported that their family mem

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS ORO UPS 55 hers made the decision as to which home to enter, and one was referred to the nursing home by her physician. Variations in Quality of Care Participants strongly believed that providers of health care are not uni- form with respect to quality of care. They were nearly unanimous in claim- ing that differences exist in the quality of care available to patients in different hospitals, from different physicians, and from different HMOs. Most people say they avoid those physicians, hospitals, and health plans that they feel offer substandard or inconsistent care. Their comments reveal a great deal about what they think of as quality of care. "There are some doctors that are fine, that you can absolutely trust, and others that for some odd reason don't want to work very hard on a patient and are rather short with you or cursory." (MN-HMO, 65+, F.) "mere is no real consistency. There's no uniformity. Depending upon the doctor you get.... In other words, different doctors will give you different treatments. You could go to one hospital and get one kind of treatment. You could go to another hospital and get another kind of treaunent. Some hospi- tals are personal; some are very impersonal." (NYC, 65-74, M.) A few participants implied that this variation in quality is not necessarily related to the range of services or equipment offered. The general sense was that quality would not be harmed if different hospitals provided differ- ent or limited arrays of services instead of all hospitals providing all ser- vices. "Some of the things about the new equipment they should have better ad- ministration. Because I think one hospital should have all those things. Not all the different hospitals. Every hospital thinks they have to have certain things, and they don't." (MN-HMO, 65+, F.) Sources of Health Care Information Apart from information about health care from friends and primary care physicians, Medicare beneficiaries also reported health care associations and the media as sources of information. When asked from which sources they would like to receive additional information, several people mentioned the American Medical Association (AMA). A few mentioned federal and state government and other health care associations. Types of Information Desired Although most participants felt that they generally have enough informa- tion available to choose a physician or a health plan, many sensed that they

56 ALLISON J. WALKER do not have enough information to judge adequately the clinical quality of care they receive. As previously mentioned, participants evaluate their health care according to interpersonal or art-of-care indicators, partly be- cause they lack either clinically based information or the ability to use it. Some participants contended that they rely heavily on their physician to supply as well as interpret this type of information. "Well, the question is when you make these decisions or you just listen to someone . . . does it really help to have more information? Or do you just have to do what the doctor or specialist says?" (SF, 75+, M.) "It's probably my fault. Because I really just don't know what to ask when he suggests these things. I know he has made examinations . . . and things have really helped me. But I don't know. He doesn't sit down really and explain things to me. And I don't know what to ask." (MN-NH, 65+, F.) Participants were asked about the availability and usefulness of certain types of information relating to health care and, at least by implication, to the quality of that care. Four types of information that are commonly suggested (in health policy circles) as useful in this regard were specifically raised by the moderator: (1) hospital mortality rates; (2) the frequency with which a physician performs a particular operation; (3) the number of mal- practice claims against a particular physician; and (4) nursing home inspec- tion reports. The majority of respondents agreed that these four types of information would be very useful in making decisions about health care, but they did not feel that this information was readily available. Interestingly, several noted that mortality rates need to be looked at in relation to the severity of the cases and the type of hospital (e.g., teaching hospital versus community hospital). "We don't know the circumstances. The people who come to one type of hospital that handles emergencies, the rate of deaths will be higher than aT~- other hospital that handles less severe situations." (FL-HMO, 65+, M.) "That [mortality rate] in itself doesn't mean anything. Because some hospi- tals take very seriously ill patients. Others won't admit them. You have to know the average age of the person and how sick they were." (NYC, 65+, M.) "He [the doctor] can't guarantee a life. He's going to open you up and use a knife on you. He's going to do the best he can. But he has no way of knowing how you look inside." (SF, 75+, F.) Some participants remarked that the number of malpractice suits must be looked at in relation to the number of successful claims. "The information should state how many times the doctor won and how many

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS OR O UPS times he lost. Just to say he's been sued . . . anybody can bring suit. Any- body with a frivolous cause can bring suit." (NYC, 75+, M.) 57 Some respondents suggested that nursing home inspections need to be more comprehensive and that perhaps nursing homes should be rated on a scale in the same manner that restaurants are rated. Participants were espe- cially interested in these reports as they realize the possibility of one day having to enter a nursing home. Finally, some individuals expressed an interest in having more informa- tion about specific diseases, such as the cause of disease, treatment alterna- tives, and outcomes. This interest was volunteered; the moderator had not probed directly on this point. Knowledge of Medicare Part B Toward the end of each focus group session, the moderator asked how many participants were covered by Part B of the Medicare program. He then probed their understanding of how the program works (e.g., what Part B covers, how much the premium costs, and who is eligible). Those participants who were covered by Part B were very well informed. They knew the amount of the monthly premium almost to the penny, that it covered physician services as opposed to inpatient hospitalization, and that it was a voluntary program paid for by a monthly premium. "My impression is that Part A is for hospitalization, and that's mandatory. You get that automatically. And Part B is for the doctor. And At's what you pay the $24.00 for." (SF, 75+, M.) The participants who were not covered by Part B. however, seemed not to understand the different aspects of the Medicare program. Although this may not be too surprising, given that they were not covered by Part B. it does suggest that some Medicare beneficiaries lack the information they need to make certain health care decisions. "Part A is all medicine, and the B would be the hospitalization." (SF, 65+, M.) "One pays the doctor and the other pays the hospital. I think B pays the hospital and A pays the doctor." (MN-NH, 65+, F.) Suggestions for Improving the Quality of Medical Care The last section of each focus group centered on ideas for improving the quality of medical care in the future. In fact, responses from participants went far beyond quality of care per se. We have grouped the specific points

58 ALLISON J. WALKER that arose during these free-ranging discussions into three main categories: (1) quality issues, (2) cost issues, and (3) generic issues relating to health care. Recommended actions with regard to quality included increased staffing levels for nurses and allied health professionals, which may help to ensure more personalized attention and more time with the physician (two impor- tant criteria that participants use to judge the quality of their health care). More "regulatory" suggestions included raising the level of monitoring of care, increasing the number of investigations, and enforcing stronger pun- ishment for Medicare fraud. These steps were seen as a way to decrease the number of malpractice claims and to reduce questionable billing practices, both of which also have implications for reductions in cost. The most frequently mentioned ways to address rising Medicare costs involved the adoption of a catastrophic coverage plan (which should in- clude prescription drugs) as well as a long-term-care insurance package. Participants expressed a great deal of concern about rising nursing home costs and the possibility of developing a catastrophic illness. Lowering the cost of hospital care was another suggestion to improve medical care in the future. Two other suggestions related to patient costs for outpatient care. One was to encourage physicians to accept Medicare assignment. The other was for Medicare to increase its payments to physicians in order to eliminate balance billing for amounts not reimbursed through Medicare. Finally, two general suggestions relating to Medicare were advanced. The first was to ensure that Medicare will be available for future genera- tions. The second suggestion was to continue speaking with more Medicare beneficiaries. Focus group participants felt that it is extremely important to obtain the views of the population being served by the Medicare program because they know how well the program works (or does not work) through first-hand experience. Interestingly, the suggestion was made several times to conduct more focus groups among Medicare beneficiaries throughout the country (similar to these conducted for the IOM study). "I think Medicare should be widened, broadened. These people are saying we have enough money for Medicare now, next few years. But maybe for our children's children, will they have Medicare for them? Will they be taken care of?" (SF, 75+, M.) "I would say that Medicare should question the patient, and ask the patient, was he satisfied with the treatment? Are there any suggestions he would like to make?" (NYC, 75+, M.) "I think what you're doing right now. In that little tape recorder and the gal back there writing down the notes. It lets somebody smarter than us take care of it." (MN-HMO, 65, M.)

MEDICARE BENEFICIARY AND PHYSICAL FOCUS GROUPS FINDINGS OF THE PHYSICIAN FOCUS GROUPS 59 Positive and Negative Aspects of Medical Care This section summarizes the themes from the eight focus groups con- ducted among practicing physicians, with points illustrated by verbatim quotes. Notations following these quotes signify the location and sex of the respondent.4 As a warm-up question, the moderator asked the physician participants to describe either the most positive and negative aspects of medical care in general or the most and least rewarding aspects of caring for elderly pa- tients in particular. The most frequently mentioned positive aspect of medical care was that health care was readily available to virtually everyone. In addition, it was felt that physicians still have the freedom to practice medicine the way they want (although this is changing) and have access to state-of-the-art equip- ment and technology to complement their practices. Finally, our respon- dents frequently mentioned the feeling of being able to do something good for other people as an important positive aspect of practicing medicine. "I think the positive aspect that I see is that we have quality health care available for everybody in this county in comparison to over countries ~rough- out the world." (PA2, F.) "One of the up sides of medicine here is that you're allowed to choose what you want to do, go in what specialty, open where you want to, go independ- ent, go with a group, do whatever you want in Mat regard. So Here's some choice." (PAT, M.) "I guess the best aspect of it is the feeling. And it's a feeling that when I go home 98 percent of the time you've done a good job for He public." (PA2, M.) The most frequently mentioned negative aspect of medical care was the extent to which the quality and availability of care (mainly the amount and type of care, not initial access to care) depended on the financial status of the patient. The continual threat of a malpractice suit was also mentioned. One of the more rewarding aspects of canny for elderly patients was the fact that the elderly appreciate the physician's care more than younger pa- tients do. The elderly often question their ability to survive, and the physician's reassurance is very welcome. Also, caring for the elderly popu- lation presents many more challenges. Multiple medical conditions and limited financial resources malce the physician's job more difficult and a positive outcome more rewarding. Finally, elderly patients have a wealth of experience that they share with the physician.

60 ALl]SON J. WALKER "I think one of the most rewarding things is that patients of that age have serious doubts as to whether they're going to be able to survive. And when you're able to reassure them or allay some of their fears, I find them very much more appreciative than younger people who perhaps expect to have good health and they're angry if they don't." (CH, M.) "I think the reward to me is to have the privilege to treat a population of patients who constantly are presenting real challenges to your abilities as a physician. They tax all your ingenuity and ability to treat them with the highest quality of medicine you can provide them." (CH, M.) The least rewarding aspects of caring for the elderly population include constraints related to the Medicare payment system. Reimbursement policy and medical liability create opposing forces; to be covered against the threat of malpractice, the physician performs extra tests and services (defensive medicine) that may not be reimbursed. In addition, the amount of regula- tion, paperwork, and monitoring associated with Medicare reimbursement was often cited as a negative aspect of caring for the elderly. "And the whole thing too is when you brought him in the hospital you have to find a certain diagnosis. Then you have overutilization and underutilization. And your final diagnosis, whether that agreed with your initial diagnosis and whether you did the correct test. All these things go through your head. You're worrying so much about the guidelines that you almost forget about the pa- tient. You're worried about following all the rules in the book." (CH, M.) "I had dinner with a friend who is still in private practice. And he had a Medicare patient for whom he gave a B-12 injection. That patient was sent a letter from the government saying that this B-12 shot was not indicated, should not have been given, Hat this was bad medicine. Interestingly enough, this patient has a diagnosis of pernicious anemia. Ibis sort of thing is absolutely unreal and yet it is happening all the time and it is getting worse and worse." (AAFP, M.) "The stack of regulations are creeping. I mean, one of these days we're going to have certification exams for janitors and maids." (NM, M.) Our respondents also commented on other negative aspects of canny for this population that are not the result of the reimbursement system. For example, they noted that elderly patients demonstrate less compliance to treatment plans than do younger patients, perhaps because older patients may not understand or remember their treatment plan. In addition, elderly patients require a greater amount of support outside the acute care facility, which may not be available or covered under Medicare. Finally, the physi- cian has no control over a large set of social issues that affect the elderly population. One final point should be made about caring for the elderly. On the one hand, Medicare has made health care available to people who previously

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS 61 might not have been able to afford care. On the other hand, many people have been accustomed to receiving essentially as much medical care as they want because of generous third-party insurance. When the person becomes eligible for Medicare, he or she may not realize that Medicare coverage and payment policies may be more restrictive. This causes great anxiety among those seeking health care. "I think Medicare has made medical care available to many people who would not have had it otherwise. But the reverse is true, too. People have been used to having good care with good insurance. So when they get old everything seems to be shrinking on them. And the medical cost is not shrinking. It's a very sudden change in life for them. As long as they're working they have good insurance. Once they retire, it's different. I think they're in a big dilemma." (NO, F.) Views on the Concept of Quality One finding from the beneficiary focus groups was that those who re- ceive medical care think they define and judge the quality of that care' in ways that are different from those who provide care. For example, the elderly evidently believed that professionals define quality in terms of com- plex clinical indicators and outcomes whereas patients use interpersonal indicators to describe what they mean by quality of care. The focus groups among practicing physicians did not substantiate this distinction. Most of the definitions of quality that we heard from physician participants did not center on clinical indicators of care, although compe- tency of the physician and the outcome of treatment were mentioned several times. (For example, one physician stated that quality involves making the correct diagnosis and formulating an effective treatment plan it is more than being nice to the patient.) Many of the physicians' definitions of quality were similar to those offered by the beneficiaries. These included providing the care you would like your family to receive, giving the patient what they need and not giving them what they do not need, using reason- able judgment in rendering decisions, and recognizing one's (i.e., the physician's) limitations. "I think quality care is the care you would like for your very best friends and your family to receive. I think it means if you need certain medications you provide them. I think it also means if you don't need a lab and X-ray test you don't do it and you don't do anything to make the situation worse." (AAFP, M.) "Quality of care is not just medicine. It's taking care of the patient, coddling him, getting through whatever. I think it's not just what you've learned in medical school, but what sort of human being you are. I don't think just

62 ALLISON J. WALKER knowing how to work a computer or to work an instrument, being able to give the right amount of pills is quality of care." (PA2, M.) These physicians definitely felt that quality does not depend solely on the physician, but also on the care provided by others and on the patient's physical condition and diagnoses. "I don't think we should delude ourselves, either, to think that quality of care is directly related to the physician. I can name a hundred instances where nurses and other ancillary health professionals made the difference between life and death" (PAT, M.) "It's a standard of care for a community. And it's very difficult to be more specific because we all represent different specialties. And what's quality care for someone who has a cold, or what's quality of care for someone who has a brain tumor is very different. But what it means is a competent physi- cian delivering what is currently acceptable treatment as would be found in a current textbook. And of course, that physician should have some personal qualities." (PAT, M.) Although most of the physicians offered definitions of quality, a few felt that not enough information is available to define and identify quality accu- rately, other than as a minimum standard of care. This skepticism carried over to their views about quality assurance as well. "Quality assurance has always been the business of looking at what goes on either from a structure point of view, from a process point of view, and from an outcome point of view. Then you take all that stuff and show it to the people who did this and you say, what do you want to do about ~is? And then you say, based on the data from so and so, we know we need this and that. So it comes down to providing some sort of feedback. Then at point X later on you look and say gee, did it work? That's what it's supposed to be. The problem is, for me at any rate, I don't think we know enough to do that sort of thing." (AAFP, M.) "Quality of care is like pornography. I know it when I see it. It's more difficult to define, though." (AAFP, M.) Does the Medicare Program Affect the Quality of Care Physicians Provide? When asked about the Medicare program and its effect on quality of care, most physicians agreed that the Medicare reimbursement system may affect the way care is delivered but not the quality of care per se. The physicians also stated that they see no difference between the quality of care provided to Medicare beneficiaries and that which is provided to oth- ers. (This same point was made in the beneficiary focus groups. They did not feel that quality of care differed by virtue of whether it was received

MEDICARE BENEFICIARY AND PlIYSICIAN FOCUS GROUPS 63 before or after being eligible for Medicare; evidently this was because they viewed Medicare simply as a payment system for health care services and not a delivery system.) Our physician respondents recognized that having Medicare coverage may influence whether or how easily someone is ini- tially accepted into the health care system, but they believed that once a patient was in the system, Medicare would not affect Me quality of care that patients obtained. "A Medicare patient or any other patient gets exactly the same type of care. There is no difference. I don't pay any attention to what's going on in age or anything else." (CH, M.) "It iMedicare] doesn't affect how I treat a patient. It may affect whether or not we initially accept them as a patient. But once we've taken the responsi- bility for their care, everyone's treated the same." (PAT, F.-) When asked how the Medicare program affects the way care is delivered, the physicians spoke about the reimbursement policies and the restrictions these policies placed on caring for elderly patients with respect to treatment settings, length of stay, and covered services. They also spoke about ways to "get around" these restrictions. "You see, what's happening is you're putting the doctor in a vise between what he feels he wants to do for the patient and what the hospital administra- tor wants to tell the doctor about how he should take care of the patient. There are a lot of MBAs between us and the patient telling us what care we can administer, for how many days, what they will pay for and what they won't pay for." (NO, F.) One example of the perceived restrictions on treatment settings cited in two different groups is that of same-day, outpatient hernia repair. Although ou~aiient surgery may be appropriate for a 35-year-old patient, the same setting for a hernia repair on a 70-year-old patient may not be appropriate because of age and physical condition of the patient. The 70-year-old patient typically requires hospitalization, which is not reimbursed by Medi- care unless the patient has a specific complication that warrants admission. Therefore, the physician will indicate a complication on the chart so the patient can be hospitalized and the procedure reimbursed by Medicare. "Medicare doesn't really recognize the differences in patients. The same rules and regulations we're supposed to follow for outpatient procedures apply to a patient who is 66 years old as well as a patient who is 86 years old." (NO, M.) "Getting them in [the hospital] when they ought to be in you have to be very imaginative sometimes. And keeping them in when they ought to be in you have to be imaginative. And the hospital says, well, if you just put it in the notes that this patient still had chest pains today, nobody's going to argue

64 ALLISON J. WALKER with you. So you sit and you say, but she didn't tell me that. Should I put it in?" (CH, M.) Restrictions on length of stay Las determined by payment policies di- rectly applied by hospitals in response to the Medicare prospective payment system (PPS)] were cited as having a possible effect on quality in the form of premature discharge. (This had also been mentioned in the beneficiary focus groups; many of the participants had heard about premature discharge, although none had actually experienced it.) The physician participants stated that they would keep a patient in the hospital as long as medically neces- sary, regardless of the pressure to release the patient, and they were also willing to take responsibility for this action. "Having to send patients home prematurely after their recovery. That makes physicians feel guilty. They'd like to keep the hospital fiscally sound and not send it down the tubes. But at the same time, the patient is the primary responsibility. And you're a patient's only and best advocate. You talk about quality of care. But that's quality- fighting for the patient and deciding that you're not going to let the hospital or members inside it intimidate you into discharging a patient prematurely." (CH, M.) Also perceived by physicians to affect the overall quality of care were denials of payment and letters of noncoverage or "substandard care." The respondents were especially angered by the notices sent to the patient with- out the physician's knowledge.S "There's a new situation where the patient now receives a letter from Medi- care stating that the quality of care you received was inadequate. I've had one or two friends who have received notification of some of these letters. The letters were initially sent to the patient, which leaves a wide door open for litigation." (NO, M.) With respect to coverage, our respondents frequently mentioned that Medicare does not adequately cover preventive services, home health care, or prescription drugs. Most physicians in the focus groups believed that prevention is one of the main ingredients for quality care. To ensure that preventive care is reimbursed, the physician will list on the bill false diag- noses and treatments that the patient did not receive. One physician in the group thought that the government is not a very prudent buyer of health care because it does not invest in preventive services that may save money in the long run, nor does it invest in home health care, which may be less expensive than inpatient care. "One of the main problems in terms of quality of care is that Medicare doesn't cover preventive screening. The government can recommend that everyone have their cholesterol checked. But if you put down a routine exam as the reason you had the cholesterol, they won't pay for it. The standard of care

MEDICS BENEFICIARY ^D P=SICI~ FOCUS GROUPS includes preventive medicine. That is good medicine. And they're not pay- ing for good medicine." (NO, M.) "You talk about patients remembering to take their medication. But how about affording the medication? I spend an hour or more a week talking to drug reps [representatives], which I don't care the slightest about, so I can get free medicines from them to give to the people that can't afford them." (NM, M.) "With respect to Medicare, the ability of these people to get home care sup- plied to them afterwards is a real drawback. If the interest is in saving money, it's a lot cheaper for them to be taken care of at home. It cuts down on the expense." (NM, M.) 65 Similarly, the argument was made that reimbursement limitations may cause underutilization of certain services. This affects quality and continu- ity of care if patients avoid seeking necessary care. "Older people don't come to the doctor enough because they're worried about cost. Therefore, I find that they're a lot sicker than they ought to be. And they've suffered a lot more than they should have at home, by themselves. And I think that's the system. From a personal point of view that upsets me." (AAFP, M.) Finally, the amount of paperwork required for Medicare reimbursement, the continual monitoring and oversight of physician activities, and the time it takes to deal with regulations were seen by many to be significant bur- dens. Our participants speculated that some physicians may leave the medi- cal profession and others may stop accepting Medicare patients because they are beginning to feel overwhelmed and perceive the declining benefits from practicing medicine. Specifically, physicians were becoming impa- tient with nonmedical personnel in the Medicare reimbursement offices; they were also tired of having to explain their treatment plans to govern- ment agents who they claimed know little about the intricacies of medicine, only about "cookbook methods" of care. "We put people in the hospital and the first thing that often happens to me is that I start getting reviews from the Medicare provider [i.e., the Peer Review Organization (PRO) or Medicare contractor], saying how long is this person going to be in? What drugs am I going to use to treat them? As soon as somebody comes in, the monitoring and the pressure to push [the patient] out comes, and I feel that. And I don't think that at this point in my life I have changed what I would do based on the fact that someone is pushing me, it just adds time to my day because I have to take telephone calls from so-and-so, and I resist the urge to be nasty on the phone saying, what do you think I'm going to treat this case with? I'm going to treat them with whatever I see fit, thank you." (NM, F.) "We appeal every single thing that's denied [by Medicare] and we always win. But it just takes three or four letters and a lot of time to do it." (NM, M.)

66 ALLISON J. WALKER Identification of Quality Problems After a discussion about quality and the Medicare program, the physician focus group participants were asked to identify, first, some general quality problems and, second, more specific problems with respect to overuse of services, underuse of services, and poor physician skills. Government restrictions and gaps in benefit coverage were the most fre- quently cited general quality problems. In several sessions the physicians stated that the amount of regulation and monitoring imposed by government is excessive. They also believed that government policies are changing the physician-patient relationship, in part by removing decision making from the hands of practitioners and patients and in part by making doctors re- sponsible for societal choices, not single patient-provider choices. Woven throughout this was the subtheme of concern about malpractice liability. "The problem is the government doesn't know how to practice medicine. And it's trying to tell us how to treat people, patients. They are now in the business of practicing medicine. And they don't belong there." (LA1, F.) "We as doctors are being asked to be much more cost effective and by various councils to be assuring people of quality of care. Frankly, I could take some of these issues and turn them back on the bureaucracy. Is the bureaucracy cost effective? Is the bureaucracy assuring quality?" (CH, M.) "The government has done everything it can to break up the physician-patient trust everything to make the physician and patient adversaries rather than trust. They've changed our ability to keep confidentiality because we have to report certain things. To a certain extent they've changed our ability to practice in the way we want because they're regulating certain things we can do. And the threat of malpractice always tells you that no matter how much you like this patient, this patient is a potential adversary." (PAT, M.) With respect to more specific quality problems, almost all the physician participants stated that overuse of services was common and more pervasive than underuse of services. They offered several reasons for this view. First, many physicians feel compelled to provide a full range of tests and services to protect themselves against the threat of malpractice, even though all these tests and services may not be clinically indicated. "It's a legal defensive type thing in some cases. In some cases it's pure ignorance. In some cases it's financial gain-ordering a study that maybe you are interpreting or you own your own machine. And then there's this nebu- lous category where a patient is complaining bitterly about something. And you want to show the patient and the family how much you care by ordering a whole myriad of tests." (PA2, M.) "There is a certain amount of overuse in defensive medicine. That may be overuse to you. But it's not overuse to me who pays tens of thousands of

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS 67 dollars a year in malpractice insurance and doesn't want to pay anymore. To me that's a necessary realization." (PA2, F.) Second, some physicians may overuse certain services for financial gain, especially those with high reimbursement rates. This was cited, however, as more of an institutional than an individual problem. "I think that services are provided where reimbursement is also provided. So the pressure to overutilize, I suppose, would be where reimbursement is high. The pressure to underutilize would be where reimbursement is low." (AAFP, M.) Third, overuse may occur from the desire to do everything clinically possible for the individual patient, perhaps in response to patient or family wishes or complaints. "Because I (as a neurologist) see so many elderly patients, I wonder virtually every day if what I'm doing aggressively to treat a very elderly patient, and I'm talking about a population 85 and older, is really appropriate. Specifi- cally, when a 90-year-old patient ends up in the ICU [Intensive Care Unit] on a respirator and is in the hospital for 5 weeks before they die. And it is very unclear to a lot of us what is appropriate in that kind of situation." (PA2, F.) Finally, limitations in physician skills and knowledge may be a factor in overuse of services; for example, when a physician is uncertain about the appropriate course to take and orders every possible test. Almost all of the focus group physicians found it very difficult to esti- mate the amount of overuse of services. Some groups felt that approxi- mately 10 percent of all services provided could be categorized as overuse, but another group estimated it to be between 20 and 30 percent. However, all groups cautioned that overuse varies by individual provider, institution, and geographic area. "I think overutilization is very difficult to define because not everybody ar- rives at a diagnosis or uses the same type of treatment. All doctors are individuals, do different things. And what may be overutilization for one person is a standard way of operating for another person. And we have run into a lot of difficulties when the government or some outside person tries to define what overutilization or inappropriate utilization is." (LA1, M.) As previously stated, underuse of services was not seen to be as perva- sive a problem as overuse' although one group estimated the amount of underutilized services to be approximately 10 to 20 percent. Reasons for this include lack of coverage for services (financial bamers to access), lack of knowledge about what is covered and to what extent, and geographic barriers to access. "I think underprovision of services is somewhat encouraged by Medicare rules and regulations. For example, in nursing homes, visits are allowed only once

68 ALLISON J. WALKER a month. So if a nurse calls you up and says your 76-year-old male patient has a little fever and cough, well that may be pneumonia. But you already saw him last week. So if you go and see him again, you probably won't get reimbursed. If you lie and write down that there's a diagnosis, then they'll pay you another $14.40 for that diagnosis. That didn't help me the last time I went to a nursing home. I got a parking ticket, which cost me $22.00." (AAFP, M.) "It's a task to keep up with the latest things that are happening in medicine. But above and beyond that, to keep up with what Medicare is or in scat ravine for currently. And a lot of time, you're the physician, and you have to express, well, this is not really in my hands to determine. And you have to get involved with the counselors in the hospitals about what they are and are not paying for." (CH, M.) ~, - ~- ~ r A ~~~o The physician with poor skills was the final problem area specifically probed by the moderator. Most participants believed that Were are and will always be physicians with poor skills. The number, however, is fairly small because the health care market is competitive enough to eventually "weed out" these physicians through word-of-mouth or legal action. Again, the participants found it difficult to estimate the number of physicians with poor skills, but they believed the range to be from less than 5 percent to approximately 10 percent. When asked whether the physician with poor skills could improve his or her competency, the participants felt that 90 to 95 percent could theoretically improve with education and monitoring but that probably only about 65 percent actually do improve. "There are certain physicians you see that lie on the fringe. And there will always be problems. We're human beings just like everyone else." (NO, M.) "The marketplace is competitive enough that a physician who does not meet the standards is weeded out very quickly. If not by his colleagues, by the hospital. And God forbid, if not by the hospital, by the legal system that will hit everybody." (CH, M.) "I think the way to address the outdated or poor skills is education, because I think the average person who's got poor skills has either been undertrained or has just lost contact for a while." (PAT, M.) "There's probably a lower percentage of bad does than bad insurance sales- men. But nobody really cares about that." (NM, M.) Almost all the focus group participants believed that it is very difficult to deny privileges or revoke licenses of physicians with poor skills. The legal system was cited as a big roadblock. "Attempts have been made to deny privileges, to pull out medical society membership or to call this person on it and say, listen, you can't keep doing strange things. And the reaction that was obtained was, you try to yank my privileges and I'll sue you." (NM, F.)

MEDICARE BENEFICI~Y^D P=SICI~ FOCUS GROUPS Effectiveness of Quality Assurance Mechanisms 69 The effectiveness of specific mechanisms for maintaining or improving quality was explored by the moderator in several categories. Participants were asked to evaluate individually focused mechanisms, hospital-based mechanisms, and external quality assurance mechanisms. The individually focused mechanisms for quality assurance included state licensure, board certification, and continuing medical education. Across the eight physician groups, we heard no real consensus about the effective- ness of these mechanisms. Some participants felt they were very instru- mental in assuring quality whereas others felt that they played no part. Although most participants felt that state licensure was necessary, they said that it was a very low hurdle to jump and, therefore, not very effective. "It's [licensing] a very basic minimum. I think that's about it." (PAT, M.) "I think the licensing helps, but I don't think you weed out many people that way." (NM, M.) Initial board certification was viewed as a positive step in assuring qual- ity of care, but the idea of recertification met with mixed views. Some participants believed that recertification is necessary to assure that practic- ing physicians keep up with changes in their fields. Others, however, said that recertification is expensive, takes a great deal of time to prepare for, and tests the ability of the physician to take an examination, not the clinical competency of the physician. "A lot of the questions they ask are of no clinical application. It would have to be something that would be related to what the clinician practices In medi- c~ne, what he is seeing. The academicians do have a slightly different view of what's going on than the people in the trenches." (NO, F.) "I see these things every day, 30, 40 times a day, day in and day out . . . if it was a clinical test it wouldn't be any problem for me. Is it going to be to anyone's advantage for me to take this test every 6 years? I'm not so sure. Would it prove my level of medical care? I'm not sure. Because with practice every day, I just get better and better every time." (NO, M.) "I think there are good test takers who are terrible clinicians." (NO, M.) Finally, with respect to individually focused mechanisms for quality as- surance, our participants broadly debated the effectiveness of continuing medical education (CME). Some physicians felt that CME is worthwhile for those who are truly interested in keeping up with advances in medicine. Others believed that CME is a waste of time and money. Opinions differed about the value and cost-effectiveness of courses versus reading the pub- lished literature in medical journals.

70 ALLISON J. WALKER "Education is one answer. The government can require us to fill out all kinds of paper and crap like that. It's irrelevant. But to require us to have educa- tion in our own subspecialty once we've finished our Pairing is reasonable." (CH, M.) "It depends on what value you place on your time. To me it's better to go to meetings and spend a couple of days to learn the most important things than it is to spend time trying to separate wheat from chaff in all these journals. You could literally spend hours reading, whereas you can get most of the impor- tant stuff from CME. And I think it's probably the most important thing a physician can do." (NO, M.) "It's very hard to justify these courses on a cost-effective basis. They're $450 to $600 for 2 to 3 days. You can learn just about as much by subscribing to $80 worth of journals." (NO, M.) One type of education that was valued by most physicians was hospital- based clinical conferences, where problems are discussed among peers and proper diagnosis and treatment plans are formulated using "real-life" ex- amples. In essence, physicians can learn from other physicians in a nonthreat- ening manner. "And you tank about CME. A point comes across very strongly. When art error is made arid you say to yourself, gee, I could have made that same error. And a specialist gets up and tells you what the proper approach to the problem should have been, then that's a form of CME. That is more educational than listening to some guy ramble on about the new methods of Heating whatever." (PA2, M.) "I do think that certainly having your peers review your work or criticize your work in the form of mortality and morbidity conferences is good. I think this is a strong conference in every hospital or it should be. I think that's the conference that either makes you or breaks you as a doctor." (CH, M.) In general, hospital-based or internal peer review was thought to be more effective in quality assurance than any other mechanism, especially more effective than the external review of the Peer Review Organizations (PROs). "Review should be done. But it doesn't have to be done through the govern- ment, Trough some outside agency. It can be done through individual hospi- tals that set up policies for quality assurance arid review. It doesn't have to be some outside guy coming into a strange hospital and reviewing charts. It should be a colleague reviewing the chart who works with the physician and knows him and what kind of patient he has and what kind of care he gives." (PA2, M.) These physicians were, however, concerned about confidentiality and legal liability in an internal peer review system. Many physicians stated that although they were willing to serve on peer review committees, they

hIEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS 71 were worried about the possible ramifications of having to implement cor- rective action against another physician. "You have to assure confidentiality in any kind of peer review mechanism that the physician who works in that peer review, utilization review, and quality assurance will not be threatened himself with the actions he wants to take, say legal action or something like that." (NO, M.) Immediately following the discussion about the internal peer review, the moderator probed the effectiveness of external review by PROB. Again, most of the physicians felt that internal review was much more effective for assuring quality than the external review of PROB. Many of the physicians equated PRO review with harassment, saying that PROs are capricious and that they should publish their review criteria so that the physicians would know what they are being judged against. Our participants also felt that PROs may be able to weed out"gross abuse" but that they mainly do fiscal, not quality, reviews. Finally, there was some criticism as to who was actually doing the PRO reviews. "they're very capricious. You never know what they want. They review only charts, they never look at the patients. So you don't know what is expected, what they're looking for. They should publish their screens that they're going by so you know what their criteria is." (NO, M.) "Lee PROs they're nothing. It's a fiscal review. I don't think it's quality of care." (NO, M.) "I find that more and more what's happening is that the government is trying to create a system, using a cookbook and rather cheap labor by paying LPNs [licensed practical nurses] and RNs [registered nurses] to sit and review charts, to see if for every diagnosis certain things were done. The point is that it's very difficult to quantify quality of care. And that's what the government would like to do. And I don't think it's going to work. I think a much better way is to have doctors at their own hospitals reviewing the charts within their hospital, reviewing their colleagues. I think that's a much more effective way of dealing with the problems internally rather than the government doing it. Coming in and hiring cheap labor and labor that's ill-informed to go over these charts. I don't think a nurse cart adequately do that, even the best." (PA2, F.) Ways to Improve Quality of Care The last topic discussed during the physician focus groups was ideas for improving the quality of medical care in the future. Although many of the suggestions from the beneficiary groups were related to cost, most of the ideas for improving quality from the physician groups centered on educa

72 ALLISON J. WALKER lion (both physician and patient education) and on decreasing the amount of government regulation. Some focus group participants believed that nationwide Cam is one way to improve the quality of medical care. Currently, fewer than one-half the states require CME. "The skills of the physicians will always be represented by a bell-shaped curve. What we ought to try to do is move the whole bell upward or forward. Just try to make everybody better. And the way to do that is education." (CH, M.) These respondents also advocated stronger patient education efforts. They believed such activities will improve quality as people learn what to expect from their medical care, how to judge quality, and how to use the health care system to get the most from their health care dollars. In addition, participants suggested that caps on malpractice insurance premiums and on amounts of malpractice settlements would ultimately af- fect quality in a positive manner by reducing the threat of litigation and its negative consequences. Also, allocating more money for preventive care or adding a preventive care benefit to the Medicare package would benefit quality. Ultimately, less money would be spent on expensive, inpatient hospital care as problems were detected earlier and treated in less expen- sive, outpatient settings. The last category of ideas to improve quality of care involved decreasing the amount of government regulation and allowing physicians to practice medicine the way they were trained instead of constantly worrying about meeting regulatory requirements. In addition, the physicians felt that inter- nal or hospital-based review, which allows actual peers to review cases, will improve quality more than relying on external PRO review. "You give them full autonomy to decide when de's proper to send a patient home or bring one into the hospital without imposing all the constraints that basically challenges the physician's independence as a professional. And I Fink it weakens the soul to Mow that you've spent all these years in medical training and your professional decision is being challenged by nonmedical people or people who don't have a clear idea of what you're trying to achieve. It really taxes all of your cunning, your style, your ability to withstand a lot of the pressure that has been imposed by government." (CH, M.) "The quality was tilers long before Medicare. The best thing that could be done for improving the quality of care would be allow us to deliver. Medi- care does not allow us to deliver. It creates roadblocks." (NM, M.) Finally, many participants felt that quality of care is as good as it is going to be and that nothing can be done to improve it further except the natural course of progress in medicine.

MEDICARE BENEFICIARY AND PlIYSICIA!J FOCUS GROUPS "You tale like it's poor quality care and we're trying to tell you that the quality of care is good. It's the quality of the bureaucracy that's bad." (NM, F.) "The quality of care In this country has become too good. We are keeping people alive for a longer period of years. The technology has been advanced. People live into their 80s and live useful and productive lives. It would have been unthinkable two or Tree generations ago. But now all of a sudden nobody wants to pay for this care. We've done our job too well." (NO, M.) CONCLUDING REMARKS 73 The primary objective of the focus group projects was to elicit opinions and attitudes of both Medicare beneficiaries and physicians who treat Medi- care beneficiaries about the quality of the health care received and provided under the auspices of the Medicare program. This information was in- tended to aid the IOM study committee in identifying key issues of concern that should be addressed in designing a more coherent strategy for review- ing or assuring quality of care in the program. Findings from the Beneficiary Focus Groups Overall, as would be expected from the large literature on people's gen- eral satisfaction with care, our beneficiary participants were basically satis- fied with the medical care they received. The major areas of concern related to the costs of care and basic access to services, especially services that are presently not covered or covered only very minimally in the Medi- care program. The concepts and dimensions to quality of care of greatest importance to patients and beneficiaries were not markedly dissimilar to those of practi- tioners and professionals. By and large, the participants' definitions of quality center on the "art of care" and interpersonal aspects of the medical encounter, rather than on more technical or clinical areas. Although the beneficiaries emphasized interpersonal aspects in making judgments about care from physicians and hospitals, they recognized that it is a limited basis for evaluating quality. Very little information is available to them, how- ever, about technical aspects of care. In emphasizing interpersonal dimensions of care as the basis on which they evaluate physicians and the care they render, our elderly participants seemed to be seeking more than a friendly relationship with someone they like. Rather, they saw or sensed important links between the way a physi- cian relates to the patient and the likelihood that the patient will benefit from the encounter. That physicians spend time with their patients, get to know them, and are patient and considerate were also very important. These

74 ALLISON l. WALKER behaviors help physicians uncover problems that patients might not other- wise mention and will generally reinforce the considerable reservoir of confidence and trust that patients have in their physicians. The complaints about physicians' behaviors were neither about technical aspects of care nor about disappointing outcomes but were about disinterest in patients and excessive interest in financial matters. Some comments related to unfair or fraudulent billing practices, which raised the possibility to respondents that their own health interests were not of primary impor tance. Beneficiaries attached great importance to being able to select their own physicians, at least in the area of primary care. They reported that they rely heavily on suggestions from family and friends about physicians. If initial choices prove disappointing, they tend generally just to seek a new physi- cian rather than to try to remedy the situation or to voice complaints any- where. Our respondents were relatively comfortable with letting their pri- mary physicians recommend specialists, consultants, and hospitals. This behavior is consistent with the points made earlier about the extent to which patients trust and rely on their primary physicians (or want to be able to do so). The average age of our participants was almost 78 years, which means that most have been covered by the Medicare program for many years. That they did not see the program per se as having much effect on quality of care is of interest, even recognizing that their views are not necessarily generalizable. The one exception concerned the perceived effect of "DRGs" on hospital care (i.e., diagnosis-related groups as the basis for PPS hospital reimbursement) specifically, on the likelihood of being discharged so early that one's health might be put in jeopardy. Nonetheless, most apparently believed that the care available to them now is better than it was a decade ago, owing mainly to technologic and scientific advances and not to changes or improvements in the program. Elderly participants knew little about whether and how the quality of health care is monitored, although they assumed that something was being done by someone. They were largely unaware that professional organiza- tions or governmental agencies (i.e., PROs) might be involved in systematic programs, or that quality-related information might be available to them. Not surprisingly, these individuals also believed that quality needed to be monitored more thoroughly than they believe it is today. Finally, we were intrigued by the interest in these topics expressed by the members of these focus groups. Even allowing for the substantial self- selection bias inherent in this process, these participants were willing to engage the issues forcefully. Their general satisfaction with the health care available through the Medicare program was leavened by the expressed desire to be asked about how well the program is working and how satisfied they are and to have a way to make suggestions for improvement. In this,

MEDICARE BENEFICI~Y^D P~SICI~ FOCUS GROUPS 75 they are certainly in line with the emerging recognition of "patient satisfac- tion" as an important dimension of the quality of care-that is, the domain most directly related to measuring the interpersonal aspects of care. Findings from the Physician Focus Groups Three main themes can be drawn from the physician focus groups. First, they believed that the Medicare program does not affect quality of care per se, but it does greatly influence the setting for care and the way in which care is delivered. Second, quality of care is often defined in terms of the "art of care" as well as technical and clinical terms. Third, hospital-based peer review programs are viewed as the most effective means for monitor- ing quality of care. Overall, as we anticipated from the results of the focus groups among Medicare beneficiaries, most of the physicians did not feel that Medicare patients were different from those patients under age 65 or that the quality of health care differed between the ova groups. However, they felt that reimbursement policies place far more constraints on the delivery of care to Medicare patients than to patients under age 65 and that government inter- vention and paperwork imposed a huge burden on physicians. As a result, some physicians thought that they may in the future serve fewer Medicare patients and may eventually stop accepting them altogether. Some of these points appear to correlate with issues raised by the Medicare beneficiaries themselves. Many dimensions to quality of care of importance to physicians matched those of greatest salience to patients. That is, art-of-care and interpersonal aspects of the medical encounter were important to physicians in addition to the technical or clinical aspects of quality, which one might assume would be of greatest importance to clinicians. The Medicare beneficiaries in our focus groups saw a link between the way a patient is treated by a physician and the likelihood that the patient will benefit from the encounter. The physicians echoed some of the same feelings and described quality to be the care you would want your family or friends to receive. Even though physi- cians can and do judge quality on the basis of technical and clinical indica- tors, they recognize the importance of interpersonal skills in effectively treating the whole patient. Technical and clinical indicators were viewed as important aspects of quality, and good interpersonal skills would not substi- tute for poor technical skills. The feeling that hospital-based peer review programs are probably the most effective and well-received quality monitoring systems among physi- c~ans has Implications for the future of quality assurance. The punitive, confrontational aspects of public and external quality assurance programs were decried, and PROs were not seen as effective quality assurance mecha- nisms. There did not seem to be consensus about the value and effective

76 ALl~SON J. WALKER ness of CME, although some positive views were expressed about con- sumer-patient and physician education. Other professional issues raised involved the general loss of autonomy ("others" making decisions and tak ing control out of the hands of the physician and patient) and conflicting pressures of malpractice, cost-containment, and professional judgment. NOTES 1. The assistance of Mathew Greenwald, of Mathew Greenwald and Associates, Idc. (a Washington, D.C.-based company specializing in focus group activities around die nation), in preparing this background description and in conducting the focus groups is gratefully acknowledged. 2. We would like to acknowledge the help of Randy Marshall, Executive Direc- tor of the New Mexico State Medical Society; Robert Graham, M.D., Executive Vice-President, AAFP; and Daniel Ostergaard, M.D., Vice-President, Education and Scientific Affairs, AAFP. We greatly appreciate the time they devoted to our focus group project and their interest in our study. 3. The codes are as follows: NYC, New York City; FL, Miami; MN, Minneapo- lis; SF, San Francisco; HMO, the Health Maintenance Organization groups; NH, the nursing home groups; 65+, the groups diverse by age; 65-74 and 75+, the groups with restricted age ranges; F. female; M, male. 4. Codes for the notations are as follows: PA1 and PA2 are the two groups in Philadelphia; CH is the Chicago group; AAFP is the group conducted among family practitioners at their annual meeting in New Orleans; NO is the other group in New Orleans; NM is the group conducted in Albuquerque at the state medical society meeting; LA1 and LA2 are the two groups in Los Angeles; F. female; M, male. 5. Chapter 8 on the Medicare Peer Review Organization program describes this issue in more detail. Close to a year after these focus groups took place, this policy was changed so that physicians are notified and given an opporturuty for the case to be reconsidered before a payment denial or "substandard care" letter is sent to the beneficiary. REFERENCE Merton, R.K., and Kendall, P.L. The Focused Interview. American Journal of Sociology 6:541-547, May 1946. APPENDIX A MODERATOR'S GUIDE FOR THE BENEFICIARY FOCUS GROUPS Fee-For-Service, Non-Institutionalized Groups I. INTRODUCTION AND WARM-UP (15 MINUTES) A. Purpose of focus group

MEDICARE BENEFICIARY AND PHYSICIAN FOCUS GROUPS B. Use of tape recorder and one-way mirror C. Objectivity of respondents and moderator D. Collect basic demographic/categorical questionnaire 77 E. Warm-up Question: Ask half the group, "What are the most positive things about health care today," other half of group, "What are the most negative things about health care today." II. PERSONAL EXPERIENCE WITH HEALTH CARE (10 minutes) A. What sorts of health care experiences are represented around the table here? (Get a show of hands) In the past year or so, 1. How many have been in the hospital? 2. How many have had home health care? 3. How many have had outpatient surgery? 4. How many have had to go to the emergency room? 5. Other? B. For those of you who have had a recent experience with health care, what would you say you learned about health care as a result? PROBE POINTS: FACTORS OF QUALITY OF CARE, AVOID COST OR PERSONAL ASPECTS OF THEIR HEALTH CONDITION C. Based on your experiences, how satisfied are you with the health care available to you today? 1. What things were good? 2. What things were not so good? PROBE POINTS: FINANCING, ACCESS, AVAILABILITY, TECH- NOLOGY, QUALITY, PERSONAL CARE ISSUES 3. How does your doctor and hospital compare with what you think the average is? D. How would you rate the quality of care you've received while on Medicare? 1. Why do you say/think that? III. PERSONAL VIEWS ON THE CONCEPT OF QUALITY MEDICAL CARE (45 min) "I'd like to get a feeling for what the group thinks about the quality of health care, in general, and the quality of the care available to them . . ." A. How would you define quality health care?

78 ALLISON J. WALKER GO AROUND THE TABLE, ASKING PEOPLE TO EACH ADD A DIMENSION TO THE DEFINITION OF QUALITY HEALTH CARE 1. What differentiates good health care from poor health care? B. You people are all on Medicare; is there anything different about the care you get through Medicare than in other types of health care? 1. Why do you say/think that? C. How would you rate the quality of care you've received while on Medicare? 1. Why do you say or think that? D. Costs are always a problem, but what do you feel are other prob- lems people face in getting quality health care? 1. Is good health care readily available? E. Do you have any major concerns about: 1. doctors? 2. hospitals? 3. emergency rooms? 4. home care? 5. nursing home care? 6. care you might get through a health maintenance organization? 7. any other health care provider? F. How does the health care available today compare to the care avail- able 10 years ago? 20 years ago? (avoid cost issues, probe for definition of improving or deteriorating quality. PROBE POINTS: CLINICAL, PERSONAL, OUTCOME) G. Do you believe there are any differences in the quality of care available to patients in different hospitals or from different emergency rooms? 1. How large are those differences? 2. Are they big enough to make you avoid some hospital facilities and choose others? H. Do you believe there are any differences in the quality of care available from different doctors or other types of practitioners such as home health care agencies? 1. How large are those differences? 2. Are they big enough to make you avoid some physicians or practitioners or to choose others?

MEDICAREBENEFICIARYANDPHYSICIANFOCUSGROUPS 79 IV. UNDERSTANDING OF HOW ALTO CARE IS MONITORED, REVIEWED (15 min) DO QUESTIONS A, B. C, D FOR HOSPITALS, HOME CARE AND (if time) NURSING HOMES A. If you were unhappy or had a problem with the quality of your DOCTOR'S/HOSPITAL'S/HOME CARE PRACTITIONER'S/ NURS- ING HOME CARE, what would you probably do? B. Where would you turn for advice if you felt the need to know more about the quality of your health care? C. In your opinion, how closely is the quality of your DOCTOR'S/ HOSPITAL'S/ HOME CARE PRACTITIONER'SINURSING HOME'S care monitored? 1. Who is doing it? D. Who should be responsible for making sure DOCTORS/HOSPI- TALS/HOME CARE PRACTITIONERS/N1~SING HOMES provide good quality care? V. DESIRE FOR INFORMATION ON QUALITY OF CARE (30 min) A. How important is it that you be able to choose your own doctors, hospitals, home care nurses, or other health care providers? B. Do you generally have the information you need when choosing a doctor? 1. Do you feel you need more information? a. If so, where could you get it? SAME QUESTION FOR HOSPITALS, HOME CARE, EMERGENCY ROOMS, NURSING HOMES, BALTH MAINTENANCE ORGANIZA- TIONS C. Do you think patients need help in identifying or choosing who would be the best hospital, doctor, or other health care providers for them? 1. If so, what sort of help would they need? 2. Should the Medicare program play a role in helping you select a hospital or doctor? D. If you needed the care of a specialist, who do you think should pick your specialist-that is, should it be you, or your doctor, or somebody else? 1. Should Medicare play any role here in picking a specialist?

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

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.

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

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

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

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?"

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

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:

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

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

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