Group Health Cooperative's Transformation Toward

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Jun 23, 2009 - Group Health Cooperative's. Transformation Toward. Patient-Centered Access. James D. Ralston. Center for Health Studies, Seattle, ...
Med Care Res Rev OnlineFirst, published on June 23, 2009 as doi:10.1177/1077558709338486

Group Health Cooperative’s Transformation Toward Patient-Centered Access

Medical Care Research and Review Volume XX Number X Month XXXX xx-xx © 2009 The Author(s) 10.1177/1077558709338486 http://mcr.sagepub.com

James D. Ralston Center for Health Studies, Seattle, Washington

Diane P. Martin University of Washington, Seattle

Melissa L. Anderson Paul A. Fishman Center for Health Studies, Seattle, Washington

Douglas A. Conrad University of Washington, Seattle

Eric B. Larson Center for Health Studies, Seattle, Washington

David Grembowski University of Washington, Seattle

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients’ access to care through the following changes: (a) offering a patient Web site with patient access to patient–physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage. Keywords:  patient-centered care; health care quality; health care access; health care evaluation; patient access to records; e-mail They give me exactly the help I want and need, exactly when I want and need it. —Don Berwick, Institute for Health Improvement (cited in Smith, 2001)

The Institute of Medicine (IOM, 2001) and the RAND Community Quality Index Study (McGlynn et al., 2003) conclude that the U.S. health care delivery system is 1

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plagued by low-quality care and in need of fundamental change. To improve health care, the IOM argues that health care systems must be redesigned to support six quality aims: safety, effectiveness, equity, timeliness, efficiency, and patient-centeredness. The IOM envisions these aims to be mostly complementary and suggests that delivery systems address all of the aims in concert. Patient-centered access is a concept and philosophy for redesigning health care that envisions supporting the IOM’s six quality aims. The IOM defines access as the timely use of affordable personal health services to achieve the best possible health outcomes (Committee on Monitoring Access to Personal Health Care Services, Institute of Medicine, 1993). Patient-centered access expands this definition to include appropriate and preferred medical assistance, explicitly honoring the value of patient choice (Berry, Seiders, & Wilder, 2003; Davis, Schoenbaum, & Audet, 2005; Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). The concept of patient-centered access implies that access is fundamental to health care quality (Berry et al., 2003). Enhanced access to care is also a core element of the Patient-Centered Medical Home, an approach envisioned by several professional societies that supports comprehensive primary care for children, youth and adults (Patient Centered Primary Care Collaborative, 2007). Finally, patient-centered access aligns with the rise of consumer forces in U.S. health care. As patients continue to pay more and more of their health care costs out of pocket, their preferences for care are driving systems to change. Despite its promise, however, the model of patient-centered access remains largely untested. Patient-centered system reform represents a historic shift for health maintenance organizations (HMOs). Managed care organizations have traditionally limited patient choice. Many managed care processes, such as primary care physicians acting as gatekeepers for specialty care, were thought to help improve the quality of care (Starfield, Shi, & Macinko, 2005) while limiting overuse and inappropriate use of health care services. Abandoning managed care in favor of multiple patient-centered reforms comes with risks to HMOs, including the possibility of uncontrollable costs from increased use of specialty care (Grembowski, Cook, Patrick, & Roussel, 2002; Grembowski et al., 2000) and negative impacts on providers’ work environment. Patients and the health care market, however, are pushing HMOs and other health care organizations to find novel means of meeting patients’ access needs and preferences. Group Health, a mixed-model health care system based in Seattle, attempted to improve patients’ access to care through the following five major changes in its Authors’ Note: This article submitted to Medical Care Research and Review on April 22, 2009, was revised and accepted for publication on April 29, 2009. This study was funded by Grant No. 52229 from the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization Initiative. Please address correspondence to James D. Ralston, MD, MPH, Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, Washington 98101-1448; e-mail: [email protected].

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delivery system: (a) offering a patient Web site providing patient access to patientphysician secure e-mail, portions of their electronic medical records (EMRs), and to health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance the efficiency of care; (d) offering direct access to physician specialists (removal of primary physician gatekeeping); and (5) aligning primary physician compensation through new incentives for patient satisfaction, productivity, and secure messaging with patients. This study describes these collective changes, known as the Access Initiative, and provides an evaluation of the impact of the Initiative on patients’ experience with access to care, providers’ work environment quality and health plan enrollment.

Background Berry describes the concept of patient centered access as a patient’s ability to secure appropriate and preferred medical assistance when and where it is needed (Berry et al., 2003). Patient centered access includes aligning patient need with preference for type of access whether in person, over the phone, or online. Patient centered access also means serving a patient when service is needed by providing Advanced Access scheduling for office visits and timely access to specialty care.

Online Access Health care organizations are beginning to offer a wide variety of services through patient Web sites, including health promotion information, patient–physician messaging, medical record access, discussion groups, billing and insurance information, and appointment requests. The diversity of approaches to these Web sites represents both the different goals of organizations implementing the services as well as a varied understanding of where Web services provide value for patients, providers, and health care organizations. Secure patient–provider messaging and patient access to the EMR, show particular promise in improving patient-centered access. The IOM identifies patient access to physicians and to their own health-related information over the Internet as key components in the larger transformation of health care to better meet patients’ needs (IOM, 2001). Physicians and patients alike recognize the potential of electronic messaging to improve patient access and care (Bodenheimer, Wagner, & Grumbach, 2002; Houston, Sands, Jenckes, & Ford, 2004; Patt, Houston, Jenckes, Sands, & Ford, 2003; Ralston, Revere, Robins, & Goldberg, 2004; Shaw, McTavish, Hawkins, Gustafson, & Pingree, 2000). Early studies also suggest that promoting electronic communication with providers and patient access to medical records over the Internet may improve doctor– patient communication and help activate patients in caring for chronic conditions (Kaplan, Greenfield, & Ware, 1989; Ralston et al., 2004; Ross & Lin, 2003).

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Most patients want access to at least some of these online services. Approximately 90% of those online want the ability to communicate electronically with physicians (“Patient/Physician Online Communication,” 2002), and approximately half of patients would like Internet-accessible medical records (Connecting for Health, 2004). Many patients also prefer online access to administrative functions, such as appointment scheduling and prescription refills (Hassol et al., 2004; Katz, Nissan, & Moyer, 2004).

Advanced Access Advanced Access is the “ability of a patient to seek and receive primary care with the physician of choice at the time the patient chooses” (Murray & Tantau, 1999). It addresses the all-too-common problem of patients being unable to see a primary care physician in a timely manner. To meet the goal of Advanced Access, a health care organization must work to ensure both the uniform capacity of physicians to meet patient demand and the continuity of each patient with a primary care physician. Murray and Berwick (2003) identify six elements of Advanced Access, including balancing supply and demand, reducing backlogs, reducing the variety of appointment types, developing contingency plans for unusual circumstances, working to adjust to demand profiles, and increasing the availability of bottleneck resources (see also Murray, Bodenheimer, Rittenhouse, & Grumbach, 2003). Implementing these changes can be difficult. For many health care organizations, Advanced Access challenges long-held beliefs about how to provide care.

Direct Access Providing Direct Access to specialists is a shift from the traditional HMO practice of requiring primary care physicians to act as gatekeepers to specialty services. The gatekeeping model was intended to promote more coordinated and continuous care by the primary care physician and to control costs (Moore, Martin, & Richardson, 1983). More recently, gatekeeping has lost favor for two reasons. First, patients and employers are seeking more choice in health care services and are rejecting plans that continue to rely on gatekeeping for access to specialty services. Second, removing gatekeeping does not appear to substantially increase the use of specialty services (Escarce, Kapur, Joyce, & Van Vorst, 2001; Ferris, Chang, Blumenthal, & Pearson, 2001; Ferris, Chang, Perrin, Blumenthal, & Pearson, 2002; Joyce, Kapur, Van Vorst, & Escarce, 2000) or increase costs (Escarce et al., 2001). Gatekeeping by primary care physicians appears to be both unwanted and unnecessary.

New Contribution This study builds on former evaluations of innovations in patients’ access to care. Changing to Direct Access to specialty care (Ferris et al., 2001; Ferris et al., 2002)

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and Advanced Access in primary care (Murray & Berwick, 2003; Murray et al., 2003) in other health care organizations has improved patient access to care while not substantially changing costs or utilization. Little is known, however, about the impact of opening up online communication with physicians or enabling patients to see information from their own medical record over the Internet. Effective strategies for simultaneously combining multiple access innovations in a single intervention are also unknown. This study describes the implementation of an organization-wide initiative targeting better patient access to care and evaluates the Initiative’s impact on patients’ experience with access to care, providers’ work environment and health plan enrollment. Findings contribute to the managed care, quality-of-care and organizational literature in several ways. First, the study examines a historic organizational transformation from the standard HMO model, with managed care controls restricting access and choice, to a more patient-centered model, where enrollees receive care when and how they want it from their choice of primary or specialty care provider. Second, patient dissatisfaction is greater in HMOs than in non-HMOs (Miller & Luft, 2002), and evidence about the effectiveness of Group Health’s intervention in improving patient ratings of care may indicate where policy makers and administrators can intervene to improve patient ratings in other health care organizations. Third, because organizational change and efforts to improve patient care experiences may negatively affect providers, parallel evidence is presented about the intervention’s consequences for the quality of the work environment.

Methods Setting This study was conducted at Group Health, a mixed-model health care financing and delivery organization in Washington state and north Idaho. More than 300,000 members receive care through Group Health’s integrated delivery system, which includes 20 Group Health–owned facilities and more than 500 Group Health primary and specialty care physicians.

Design Definition of the Access Initiative. We used a qualitative approach for defining the motivation, purpose, and components of the Access Initiative. First, we reviewed Group Health historical documents describing the organizational context and evolution of the Access Initiative. We then purposively sampled and performed semistructured interviews with 12 Group Health leaders responsible for the development and implementation of the Access Initiative. Two of the authors (JDR and DG) carried out all of the interviews and consolidated notes. We resolved discrepancies through

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discussion. We then checked and verified our description of the Initiative with a subsample of the Group Health leaders originally interviewed. Impact evaluation. The conceptual framework for the analyses of patient and provider experience and member enrollment was informed by Donabedian’s (1988) structure–process–outcome model. The analytic approach was based on the initiative as a complex social intervention in which the components act synergistically to produce outcomes (Walshe, 2007). The theoretic basis for the initiative is grounded in the concept of patient centered access (Berry et al., 2003) and three of the six aims of the IOM (patient-centeredness, timeliness, and efficiency; IOM, 2001). Further description of the conceptual framework for the evaluation is presented elsewhere (Grembowski et al., 2008). We defined pre-Initiative, rollout, and post-Initiative time periods based on the implementation dates of the Initiative’s components (Figure 1). Each of these three time periods was 2 years: pre-Initiative 2000-2001, rollout 2002-2003, and postInitiative 2004-2005. All the Initiative’s components were rolled out between 2002 and 2004 with the exception of the launch of the patient Web site in 2000. However, most of the Web site services related to goals of the Access Initiative, including secure messaging with providers and access to the shared EMR, were added between April 2002 and August 2003, which is consistent with the rollout period for the other Initiative components. We hypothesized that the changes collectively known as the Access Initiative would be associated with better patient report of access to care, no change or a decline in provider report of work environment quality and stable or improving health plan enrollment compared with statewide trends. Patient access to care measures. We used Group Health’s annual Consumer Assessment of Healthcare Providers and Systems survey (CAHPS 2.0 and 3.0) to compare patient experience with access to care before versus after the Access Initiative. Group Health administers the survey by mail to a sample of plan enrollees during the second quarter of each year, according to existing National Committee for Quality Assurance (NCQA) sampling standards for comparing CAHPS results between health plans (NCQA, 2007). The evaluation was limited to adult respondents (≥18 years) receiving care in Group Health’s Western Washington Integrated Delivery System. Items were selected for comparison based on relevance to the aim of the Access Initiative. These included the eight items in the two CAHPS composites of “Getting Needed Care” and “Getting Care Quickly” and an additional 11 of the CAHPS items rating satisfaction and global care experience. Since CAHPS data were only available after 2001, we compared results in the rollout period of the Initiative (2002 and 2003; n = 5,260) with the full implementation period (2004 and 2005; n = 5,243). We used the NCQA standards for reporting CAHPS results (NCQA, 2003). Composite analyses were adjusted for age, education, and self-reported health status. Chi-square tests for equal proportions were used to determine statistical significance

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Figure 1 Group Health Cooperative Access Initiative 1997

2000

2001

2002

2003

2004

2005

2006

2007

Web Access (MyGroupHealth) Patient Web Site August 2000

Advanced Access to Primary Care April 2002

Primary Care Redesign

November 2002

Direct Access to Specialists

January Physician Payment Reform

2003 April 2003

Web Access (MyGroupHealth) with EpicCare™ CIS July 2003

of differences in ratings between the two time periods. Based on the limited background literature for defining a meaningful change (Lipsey, 1998), the study team considered an absolute difference of 4 percentage points in each measure to be “practically significant” for the population of individuals receiving care. Response rates for the survey ranged between 43% (2004) and 49% (2002). We were not able to compare the characteristics of respondents to nonrespondents. However, age, gender, and insurance type of respondents were similar to the overall Group Health population. Respondents in the rollout phase compared with the postInitiative phase were also similar in gender, ethnicity, age, education, and self-rating of overall health (data not shown). Provider quality of work environment measures. We analyzed eight questions from the annual Work Environment Assessment of providers employed by Group

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Health. Items for comparison were selected based on domains in the work environment that the Access Initiative could affect. The annual survey included all physicians, doctors of optometry, osteopathic doctors, and advanced registered nurse practitioners and physician assistants who self-identified as medical staff. Providers responded to questions using a 5-point Likert-type scale ranging from Strongly disagree (1) to Strongly agree (5). Group Health mailed the six-page survey with a stamped and self-addressed return envelope. We used the mean and standard deviation for reporting results due to the normal distribution of the responses to most items. T-tests were used to compare the mean scores from the pre-Initiative period with those from the rollout and post-Initiative periods. Based on guidelines for practical significance from the psychology and educational literature (Kirk, 1996) combined with an understanding of the study setting and research questions, the study team considered a priori a 15% change from the overall mean to the nearest endpoint for each item to be the minimal practically significant difference. The provider response rate in 2004 was 46% (411/893). For years 2000 through 2003, we could not directly calculate response rates; based on the number of surveys returned during these years, we estimate the response rates were between 40% and 50%. We were not able to compare the characteristics of respondents with nonrespondents or with separate respondents by medical department or medical specialty. Health plan enrollment measures. We compared annual enrollment in the 2 years pre-Initiative with the 2 years of rollout and the 2 years post-Initiative. To account for statewide trends, enrollment in Group Health was compared with the estimated proportion of Washington State residents with health care coverage. Annual coverage rates in Washington State were estimated using results from the annual Behavioral Risk Factor Surveillance System Survey (Washington State Department of Health and Center for Disease Control and Prevention, 2000-2005).

Results Purpose of the Access Initiative In response to declining membership and revenues, the Group Health Board of Trustees met with administrative leaders to develop a reconceptualization of the organization. In developing a redesign agenda, the Board tried to understand the needs and preferences of Group Health’s membership. Member surveys and focus groups indicated that access to care was the chief concern. Members wanted better access to their own physicians and more timely access to health care services overall. Members also wanted secure electronic messaging with physicians and other online health care services. The purpose of the Initiative was to transform Group Health from an organization that controlled patient care and access through

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Table 1 Access Initiative Components Web Access

Advanced Access Primary Care Redesign

Direct Access Physician Payment Reform

• Secure e-mail with physicians • Medical record access • Medication refills • Appointment scheduling • Discussion groups • Health promotion information • Appointments with a patient’s primary care physician at the preferred time of the patient • Reduce variation in physician productivity • Team members to work at high end of expertise • Reduce wait times for patients on the phone and during appointments • Increase physician influence and accountability for daily practice environment • Direct Access to specialty care, or removal of gate-keeping (16 specialties) • 80% to 120% variable compensation around baseline salary • Variance dependent on patient satisfaction, physician productivity, and coding accuracy

traditional managed care strategies to an organization that removed many managed care controls and enhanced access whenever a patient contacted the system.

Components of the Access Initiative The five components of the Access Initiative are summarized in Table 1 and des­ cribed below. These components were seen as dependent on one another for achieving the overall aim of improving patient access to care. Figure 1 shows how Group Health phased in these elements over a 3-year period.

Advanced Access to Primary Care Group Health launched Advanced Access as part of its patient-centered transformation in 2003. Consistent with Murray’s definition of Advanced Access (Murray & Tantau, 1999), patients could schedule appointments with primary care physicians on the same day or whenever they prefered. Scheduling occurred by phone or through Group Health’s patient Web site. Group Health also sought to extend the bounds of traditional Advanced Access programs by improving the timeliness of all care. This meant achieving enhanced service and shorter wait times whenever an enrollee touched the system, whether through phone contact or in laboratory, radiology, or pharmacy services.

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Primary Care Redesign More uniform productivity across physicians was seen as necessary to ensure adequate capacity to achieve the goals of Advanced Access to primary care by all patients. To meet the combined needs of Advanced Access and a lower overall health plan enrollment, the Primary Care Redesign downsized the primary care provider group and shifted Group Health from a focus on physician panel-based management to a mixed salary- and productivity-based compensation model for physicians. Productivity was measured by the number of daily outpatient visits and was adjusted for the complexity of patients seen. Group Health also sought greater efficiency by reorganizing medical center staffing and patient flow at medical centers. Staffing in primary care clusters was switched in 2000 from a 2-1-1-4 staffing model (2 physicians, 1 mid-level provider, 1 registered nurse, and 4 licensed practical nurses/ medical assistants per team) to a 5-1-2-7 staffing model (5 physicians, 1 mid-level provider, 2 registered nurses, and 7 licensed practical nurses/medical assistants per team) in an attempt to enable each member of the team to operate at a higher level of expertise and to better support workflow efficiencies. These efficiency improvements were seen as important for the sustainability of Advanced Access in primary care. Advanced Access could fail if the majority of physicians were not able to meet common productivity expectations.

Direct Access to Specialists Direct Access to specialty care followed on the heels of the Advanced Access rollout in primary care. In January 2003, enrollees could schedule their own appointments with many specialists without referral by their primary care physician, eliminating the requirement that the primary physician play the gatekeeper. Group Health limited the implementation of Direct Access to specialty providers within the integrated delivery system. Access to specialty care outside of the integrated delivery system continued to require a primary care referral. Table 2 details the Group Health specialties available for Direct Access before and after the Initiative as well as specialties that continued to require physician referral.

Changes in Primary Physician Compensation To support Advanced and Direct Access and the Primary Care Redesign, the method of primary physician compensation changed from 100% of guaranteed salary to a variable compensation plan that incorporated productivity, patient satisfaction, and coding accuracy. By February 2004, all primary care physicians received an 80% guaranteed base salary plus additional variable compensation up to 120% of the guaranteed base. Productivity, including the number and intensity of in-person patient encounters, remained the main component of this flexible compensation

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Table 2 Access to Specialty Care at Group Health Cooperative Direct Access Prior to 2003

Direct Access Added in 2003

Mental Health Services Optometry Manipulative therapy Obstetrics/gynecology Smoking cessation

Allergy/immunology Audiology Cardiology Dermatology Gastroenterology General surgery Hospice Nephrology Neurology Occupational medicine Hematology/oncology Orthopedics Otolaryngology Physical therapy Speech Urology

Referral Required Anesthesia Bariatric surgery program Consultative internal medicine Genetics Home health services Infectious disease Occupational therapy Pediatric endocrinology Pediatric neurology Physiatrist Plastic surgery Radiation therapy Radiology Respiratory therapy Radiation oncology Thoracic surgery Vascular surgery Endocrinology Neurosurgery Nutrition counseling Pulmonary/sleep disorder Rheumatology

plan. Physicians, however, had to meet a benchmark for patient satisfaction based on a random survey of patients seen in order to qualify for the productivity incentive. Physicians who achieved outstanding patient satisfaction also received a bonus beyond their variable compensation. These changes in compensation were focused on primary care providers.

Web Access Prior to the launch of the patient Web site (www.ghc.org), Group Health found that enrollee access to the Internet had increased from 24% in 1996 to 71% in 2000. Furthermore, enrollees continued to see physicians and the health care team as their preferred source of health care information but were increasingly turning to the Internet as a mode of accessing health care information (Endresen, 2000). Group Health launched its patient Web site in 2000 with the goal of providing online services that patients value and that support the patient–physician relationship. The Website allowed patients to: exchange secure messages with their health care team, including primary and specialist physicians; access in real time their

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EMR, including laboratory data, problem lists, medication lists, allergy history, and immunization history; obtain after-visit summaries with hyperlinks to the Healthwise knowledge base, a 5,000+ topic, searchable health and drug reference library; obtain refills on medications with free shipping to patients’ homes; and schedule office appointments online with physicians. Patient access to the EMR over the patient Web site was provided through a direct link to Group Health’s clinical information system (CIS), EpicCare. All Group Health physicians, nurses, and other providers in its Integrated Delivery System used the EpicCare CIS, which integrates clinical communication and information processes into a single interface that includes physician order entry (e.g., laboratory tests, prescriptions, referrals), systematic clinical documentation, clinical decision support, clinical messaging among physicians, secure online messaging with patients, and automated reminders at the point of care. Group Health providers were expected to engage in secure messaging with patients. Providers were given a financial incentive beyond their salary to encourage electronic messaging with patients. All normal and most abnormal laboratory tests were visible to patients at the same time as they become available to physicians. A full description of the patient Web site’s integration with clinical care is provided elsewhere (Ralston et al., 2007). To meet patients’ needs and preferences for better access to care, Group Health implemented the patient Web site in advance of other physician-focused CIS components such as computer physician order entry and integrated physician documentation tools. Physician leadership was seen as key to the success of the early rollout of the patient Web site, particularly around patient–physician secure messaging (Handley & Eytan, 2005).

Linkage Among Components Group Health leaders saw a critical dependence of one initiative element on another. For example, Advanced Access, Direct Access, and the Primary Care Redesign would enable one another. For Direct Access to work, Advanced Access had to be in place in primary care. Otherwise, patients might seek specialty care solely because a primary care physician was not available. To ensure consistent Advanced Access across the organization, Group Health needed to establish uniform expectations for access and performance feedback to physicians. The Primary Care Redesign provided this consistent metric and an expectation for physician productivity that was viewed as necessary to enable a patient to be seen by the patient’s personal physician at the time of the patient’s choice. Group Health leaders also anticipated conflict among the Initiative components. For example, the Primary Care Redesign and the implementation of the EpicCare CIS could undermine Advanced Access in primary care. Downsizing in the primary care group came right after Advanced Access; primary care physicians were simultaneously faced with increased panel sizes while trying to work down backlogs and

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Table 3 CAHPS Survey Results for Adult Group Health Members, Member Composites Getting Needed Care

Rollout, 2002-2003 (n = 5,260)

Post-Initiative, 2004-2005 (n = 5,243)

Not a Problem (%)

Not a Problem (%)

How much of a problem, if any, was it to . . . Get a personal doctor/nurse you are happy with 66.7 66.8 See a specialist that you needed to see 69.3 67.3 Get care you or your doctor believed necessary 77.8 81.5 Get care while awaiting approval from your health plan 53.8 62.9a Compositeb 67.0 69.7 Getting Care Quickly (HEDIS)

Always/ Usually (%)

Always/ Usually (%)

How often do you . . . Get help you needed when calling clinic 85.6 86.5   during regular hours Get appointment for routine care as soon as you wanted 80.0 81.8 Get care for illness or injury as soon as you wanted 85.3 85.7 Get taken to exam room within 15 minutes 44.2 72.7a   of appointment time Compositeb 73.8 81.8a

p Value .90 .12