Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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3. Results of the Medicare Beneficiary and Physician Focus Groups
3. Results of the Medicare Beneficiary and Physician Focus Groups
Pages 35-90
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From page 35... ...
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 approach. 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 practicing physicians.
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From page 36... ...
Similarly, 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)
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From page 37... ...
For the focus groups among practicing physicians, study staff selected Philadelphia, Pennsylvania; New Orleans, Louisiana; Chicago, Illinois; Los Angeles, California; and Albuquerque, New Mexico. All the focus groups except two were conducted at facilities with which Mathew Greenwald and Associates had had previous experience.
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From page 38... ...
Focus Group Composition Although it is not realistic to seek representativeness or to estimate population 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, practice in the fee-for-service or prepaid group practice sector, rural or urban location, and specialty.
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From page 39... ...
Finally, each group was to have at least four people with recent "acute" or "nonroutine" health care experience; for instance, care in an emergency room, outpatient surgery, a hospitalization, 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 Albuquerque (in that order)
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From page 40... ...
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.
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From page 41... ...
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.
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From page 42... ...
42 TABLE 3.1 Selected Characteristics of Focus Group Participants ALLISON J WAL1~ER Recent Has Health Care Medigap Group Sex Age Racea Experience ~InsuranceC Group 1 F 74 H Y Y F 72 W N Y New York City F 71 H Y Y Community residents F 70 W N Y Fee-for-service Medicare F 68 W N Y Ages 65 to 74 F 67 W Y N M 72 W N Y M 69 W N Y M 69 W N Y M 69 B Y N M 66 W N Y Group 2 F 86 W N N F 79 B Y N New York Ci~r F 78 W N Y Community residents F 78 W N Y Fee-for-service Medicare M 87 W N N Ages 75+ M 79 W Y N M 78 B Y N M 77 W Y N M 77 W N Y M 75 W N Y Group 3 F 73 W N N F 71 W N N Miami, Florida F 70 W N N Communi~ residents F 67 B N N HMO enrollees ~F 67 B N N Ages 65+ M 82 W N N M 76 W N Y M 76 W N N M 72 W Y Y M 68 W N N Group 4 F 78 W N Y F 70 W N Y Miami, Florida F 69 W N Y Fee-for-service Medicare F 66 W Y Y Ages 65+ M 82 W Y Y M 78 W Y Y M 72 H N Y M 70 W N Y M 68 B Y Y
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From page 43... ...
~Although very few HMO enrollees reported an encounter with the health care system in the form of a hospitalization, a visit to the emergency room, or services from a home health agency, all reported that they had received care from their HMO since being covered by Medicare.
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From page 44... ...
. W~KER Sex Age HMO Affiliationa Specialty Philadelphia 1 M <45 N Orthopedic Surgery M <45 Y Thoracic Surgery M <45 Y Neurosurgery M <45 N Ophthalmology M <45 N Colon & Rectal Surgery M <45 Y Ophthalmology M <45 Y Urology F 245 N Obstetrics/Gynecology F 245 Y Obstetrics/Gynecology Philadelphia 2 M <45 N Intemal Medicine M <45 N ~temal Medicine M <45 N Intemal Medicine M <45 N Gastroenterology M <45 N Dermatology M >45 Y Pulmonary Disease M 245 Y Cardiology F 245 Y Neurology F 245 Y Allergy F 245 N Oncology AAFP M 245 N Family Practice M >45 N Family Practice M 245 N Family Practice M 245 N Family Practice M <45 N Family Practice M <45 N Family Practice M <45 N Family Practice New Orleans M 245 Y Urology M >45 Y Dermatology M <45 N Ophthalmology M <45 Y Intemal Medicine M <45 Y Dermatology F 245 N Obstetrics/Gynecology F 245 N Obstetrics/Gynecology
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From page 45... ...
AfEDICARE BENEFICIARY A[JD PHYSICIAN FOCUS GROUPS 45 Sex Age HMO Affiliationa Specialty Chicago M >45 Y Intemal Medicine M >45 N Ear, Nose, & Throat M 245 N Obstetrics/Gynecology M <45 Y General Surgery M <45 Y Ophthalmology M <45 Y Thoracic Surgery M <45 Y Intemal Medicine Los Angeles i M >45 N Family Practice M 245 N General Surgery M 245 N General Surgery M <45 N Family Practice M <45 N Ophthalmology M <45 N General and Vascular Surgery M <45 N Ear, Nose, & Throat F <45 N Obstetrics/Gynecology F >45 Y Ophthalmology Los Angeles 2 M >45 Y Ear, Nose, & Throat M >45 N General and Vascular Surgery M <45 N Urology M <45 N Urology M <45 Y Internal Medicine M <45 Y Internal Medicine M <45 Y Internal Medicine F >45 N Family Practice F <45 Y Obstetrics/Gynecology F <45 Y Obstetrics/Gynecology New Mexico M 245 N Neurology M <45 N Internal Medicine M <45 N General Surgery M <45 N Internal Medicine F >45 N Anesthesiology F <45 N Oncology aHMO is health maintenance organization, N is no, and Y is yes.
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From page 46... ...
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.
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From page 47... ...
Premature discharge was another concern expressed by participants, although 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.
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From page 48... ...
Whereas professionals evaluate quality in terms of complex clinical indicators 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)
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From page 49... ...
Patients felt they could not trust a physician who is "ripping off' the Medicare system through professional preoccupation with financial incentives rather than with the patient. Quality of hospitals and nursing homes was judged on overall cleanliness, friendliness and helpfulness of the staff, and tastiness of the food.
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From page 50... ...
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.
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From page 51... ...
Just get out of there." (SF, 75+, F.) HMO enrollees evidently would handle perceived problems in much the same manner.
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From page 52... ...
Others clearly assumed it is evaluated to one degree or another through accreditation of hospitals, licensure of physicians and nursing homes, or government monitoring. "We presume they're monitored.
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From page 53... ...
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.
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From page 54... ...
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 physicians and other providers (as is presently guaranteed to them in the fee-forservice portion of Medicare)
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From page 55... ...
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.
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From page 56... ...
hospital mortality rates; (2) the frequency with which a physician performs a particular operation; (3)
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From page 57... ...
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.
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From page 58... ...
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)
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From page 59... ...
"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 ~roughout 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 independent, go with a group, do whatever you want in Mat regard.
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From page 60... ...
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.
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From page 61... ...
For example, the elderly evidently believed that professionals define quality in terms of complex 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.
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From page 62... ...
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.
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From page 63... ...
But once we've taken the responsibility 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.
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From page 64... ...
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.
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From page 65... ...
Our participants speculated that some physicians may leave the medical 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 impatient with nonmedical personnel in the Medicare reimbursement offices; they were also tired of having to explain their treatment plans to government agents who they claimed know little about the intricacies of medicine, only about "cookbook methods" of care.
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From page 66... ...
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.
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From page 67... ...
"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.
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From page 68... ...
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.
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From page 69... ...
Initial board certification was viewed as a positive step in assuring quality of care, but the idea of recertification met with mixed views. Some participants believed that recertification is necessary to assure that practicing physicians keep up with changes in their fields.
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From page 70... ...
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)
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From page 71... ...
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.
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From page 72... ...
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 affect quality in a positive manner by reducing the threat of litigation and its negative consequences.
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From page 73... ...
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 Medicare beneficiaries about the quality of the health care received and provided under the auspices of the Medicare program. This information was intended to aid the IOM study committee in identifying key issues of concern that should be addressed in designing a more coherent strategy for reviewing or assuring quality of care in the program.
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From page 74... ...
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,
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From page 75... ...
Third, hospital-based peer review programs are viewed as the most effective means for monitoring 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.
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From page 76... ...
2. We would like to acknowledge the help of Randy Marshall, Executive Director 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.
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From page 77... ...
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?
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From page 78... ...
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?
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From page 79... ...
SAME QUESTION FOR HOSPITALS, HOME CARE, EMERGENCY ROOMS, NURSING HOMES, BALTH MAINTENANCE ORGANIZATIONS 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?
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From page 80... ...
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 reports on nursing homes H
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From page 81... ...
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.
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From page 82... ...
A General Quality Issues "Now let me turn the discussion to the Medicare program.
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From page 83... ...
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)
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From page 84... ...
PRO program for Medicare b. exclusion from the Medicare program c.
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From page 85... ...
1. "What one change do you think practicing physicians would most readily support that would most improve the quality of care Medicare patients receive?
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From page 86... ...
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.
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From page 87... ...
The discussion leader will be an expert in this area, whose name is Mathew Greenwald. About 10 other people like yourself will participate.
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From page 88... ...
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 .
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From page 89... ...
TERMINATE CONVERSATION IF DOCTOR IS A PSYCHOLOGIST, AN ALLERGIST, A PEDIATRICIAN, OR AN EMERGENCY ROOM PlIYSICIAN. 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.
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From page 90... ...
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.
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