Community and Provider Health Care Project. It is the way they treat you that is the key community survey respondent.

Transcription

1 Community and Provider Health Care Project It is the way they treat you that is the key community survey respondent. Advocate for an environment of trust with physicians as allies in overall care of patients provider survey respondent. Jamson S. Lwebuga-Mukasa, MD, PhD. Associate Professor of Medicine Project Director, Director, Center for Asthma and Environmental Exposure Lung Biology Research Program Kaleida Health System Buffalo, New York January 31, 2008

2 Acknowledgements: This project was funded by a grant from Kaleida Health System to JL-M, the Project director. I would like to thank the project field teams, the community residents and physician providers who participated in the survey, the Center for Asthma and Environmental Exposure staff who made it possible to complete the project on time. I would especially like to thank Dr. Wesley Hicks Jr., President of the National Medical Association Buffalo affiliate, for his input and enthusiastic support of this project. 2

3 Table of Contents: Summary 4 Purpose of the Project 5 Study Design. 5 Data Analysis and Quality Control 5 Findings from Heads of Households Survey... 5 Selected Cross-tabulations.10 Categorized Responses to Open-ended Questions.13 Interpretation of Findings of Heads of Households Survey..15 Findings from Provider Survey.15 Responses to Open-ended Questions by Providers Interpretation of Provider and Heads of Households Surveys..18 Study Strengths.19 Study Limitations..19 3

4 Summary This is a report of a cross-sectional survey of 1658 heads of households and 27 physician providers on health care in Buffalo, New York. The survey was conducted and administered by the Center for Asthma and Environmental Exposure (CAEE). The project was sponsored by Kaleida Health System to provide empirical data from community residents and providers on health care in Buffalo and on how health care may be improved to best serve the community. The project sought to identify what is working or not working in the current health system from the patients and providers perspectives and to identify opportunities for the Kaleida Health System s collaboration with community health providers, agencies and organizations to increase preventive care of patients. 4

5 Purpose of the project This is a report on 1658 heads of households and 27 physicians (providers) who participated in a survey of health care in Buffalo, New York. The survey was conducted and administered by the Center for Asthma and Environmental Exposure (CAEE). The project was sponsored by Kaleida Health System to provide empirical data from community residents and providers on health care in Buffalo and how health care may be improved to best serve the community. The project sought to identify what is working or not working in the current health system from the patients and providers perspectives and to identify opportunities for the Kaleida Health System s collaboration with community health providers, agencies and organizations to increase preventive care of patients and decrease avoidable hospital admissions. Study design A cross-sectional house-to-house survey of heads of households was conducted from July 1, 2007 to August 31, 2007 by community surveyors who were trained by the project director. A protocol successfully used in 2002 to survey the community on environmental factors and respiratory health (Lwebuga-Mukasa et al., 2004, 2005) was followed. Surveyors received three hours of training on the study protocol, HIPAA regulations and practiced administering the questionnaire on one another, followed by discussion of any questions they had. In the field, surveyors were instructed to visit every 10 th house on a street and request permission to interview the head of the household for the survey. In an apartment complex or single room motels, they were instructed to visit every 10 th apartment or 10 th room. The head of household survey took 20 to 30 minutes to complete. A $10 gift certificate was offered to the participants for completion of the survey. The provider survey targeted a list of physicians who had been identified by heads of households as providing health care in the community. The providers were then sent questionnaires with letters requesting them to complete the questionnaires and return them to the CAEE in selfaddressed stamped envelopes during the month of December, The provider survey took 10 to 15 minutes to complete. Data analysis and quality control Data received from community and provider surveys was entered into Microsoft Excel 2003 spreadsheets by project staff. The data was examined for completeness and duplicates were removed. Descriptive statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) Version 16.0, (SPSS, Chicago, IL). Answers to open-ended questions were analyzed using SPSS Text Analysis for Surveys, version 2.1 (SPSS, Chicago, IL). For quality control, a sample consisting of 10 % of the community respondents was contacted by telephone to verify the data reported. Study findings I. Heads of households survey Demographics (n=1658) The project had 1658 completed surveys 82.9% of the targeted 2000 heads of households. Population: The study population consisted of 33.5% (561) males and 66.2% (1097) females. There were 50.2% (833) African Americans, 29.1% (482) whites, and 14.8% (246) Latino/ 5

6 Hispanics, 5.9% (97) other race/ethnicity. Nearly all participants (96.3%) (1596) resided in the City of Buffalo, New York. The ages of participants ranged from 16 (emancipated minors) to 83 years old. The mean age was 43.3 with a standard deviation of 15.3 years. Age: Table 1 Age categories (years) N % (407) (809) (133) 8.1 Missing (308) 18.6 Education: The majority (72.7%) (1206) of the population had high school/ged or higher education; 26.5% (439) had not completed high school. 23.6% reported having access to internet. Housing: Table 2: % Own Rent Missing % (468) owned their homes, 69.1% (1146) rented, and 2.7% (44) did not provide home ownership information. Most (79.2%) (1322) lived in private rental housing, 275 (16.2%) lived in public housing, 60 (3.7) did not provide this information. Vehicle ownership: 796 (48.0%) reported that they did not have a car. Income: Table 3: Income category % <$1000 per month $1000 per month Did not wish to tell

7 Zip code areas from which survey participants came are shown in the Table 1 below. Table: 4 Zip code Area East: 14215, 14214, 14211, 14208, Near west side: 14222, 14209, West: 14207, 14213, South Buffalo: 14212, 14206, 14210, Buffalo suburbs Missing zip code information Survey participants (n=1658) 35.6% (590) 12.5% (207) 29.6% (491) 16.4% (272) 0.6% (88) 10.0% (10) Source of health care: Most 52.1% received health care from clinics, 24.4% from private offices, 9.2% from emergency departments (ED) or nowhere and 8.2% did not provide information on where they received health care. Nearly 30% reported that they did not have a regular doctor and 40.4% reported that they did not have a regular place where they received medical care (a medical home). Twenty percent of the respondents reported having been seen in an emergency department (ED) in the past 12 months. Health insurance type: Most heads of households (42.9%) had public health insurance (Medicaid, Medicare, Health Plus). 30.5% had commercial insurance, 18.0% had no health insurance, 8.2% were missing health insurance information. Community survey participants reported that many private health care providers did not accept patients with Medicaid health insurance. Health Insurance: Table 5: % Insurance category Private commercial HMO Public No health insurance Missing Chronic conditions: Asthma prevalence was 17.4% (289). 30.2% (501) of the heads of households were current smokers. 20.9% (347) reported living with a smoker. 51.0% (844) of the heads of households had a body mass index (BMI) greater than 25kg/m 2, which is in the overweight to obese category. Table 6: BMI category % kg/m 2 < > Missing

8 Having a medical home (a regular place one receives medical care): Table 7 % Have a medical home No medical home Missing When to go to see a doctor Table 8 % Never Only when sick For screening and regular check up For follow up of a chronic condition Missing No health care provider Table 9 % No doctor Have doctor Missing Emergency department use Table 10 % Used ED in past 12 months Did not use ED in past 12 months Missing Last experience with health care Table 11 % Rated experience as good to very good Understood the doctor Had Adequate time with doctor Had questions answered Received follow appointment

9 Factors influencing choice of a medical home: Overall care (90.7%), doctor s attitude (90.4%) and receiving a new diagnosis (90.4%) were the top three most important factors in choosing a medical home. One respondent summed it up most eloquently: It is the way they treat you that is the key. Staff attitude (88.6%), having one s own doctor (88.4%), receiving explanation for treatment (88.7%), the hours the office is open (86.8%) and waiting time for an appointment (86.5%) were the next most important factors in choosing a medical home. Language spoken by the staff (84.9%), days facility is open (84.0%), language of the doctor (82.6%), medication cost 82.2%) and appearance of the facility (80.2%) were also important. The last group included location (77.9%), transportation (76.1%), co-pay (74.9%), security at the facility (69.7%), parking (65.2%), location on the bus route (60.6%) reputation of the community (60.6% ), and lastly the doctor s race (28.3%). Factors influencing choice of a medical home Table 12: % Overall care Doctor s attitude New diagnosis Explanation of treatment Attitude of staff Having one s own doctor Hours open Waiting time Language of staff Days open Language of doctor Medication cost Facility appearance Location Transportations Co-pay Security Parking Location on bus route Community reputation Doctor s race The majority (64.2%) (1064) of the heads of households reported that they take into consideration their insurance when choosing a medical home. They believed that people with different insurance types (65.8%), disabilities (56.7%), speak a language other than English (52.8%), of different race/ethnicity (51.2%), or different sexual orientation (48.2%), or religion (43.8%) receive different type of health care. 9

10 Factor heads of households feel influence different care received Table 13: % Insurance Disabilities Speaking language other than English Race Sexual orientation Religion Source of health information: Physicians (53.9%) and family members (51.8%) were the most frequent source of health information. Newspapers (25.6%), internet (23.0%), radio (18.5%), and other sources were infrequently used. About the same percentage of individuals (23.0%) that had access to internet used it as a source for health information. Where people get health information: Table 14: % Physician Family Clinic Health organizations Drug store Emergency department Television Public health officials Newspapers Internet Radio Clergy Religious groups Social groups Hair dresser Other Selected cross-tabulations: Categories (when one goes to see a doctor) 1) Never 2) Only when sick 3) For screening and regular check up 4) For follow up of a chronic condition 10

11 When to go to see doctor and emergency department use in past 12 months Table 15 Used ED did not use ED 1 16 (16.2%) 83(83.8%) 2 91 (15.9%) 481(84.1%) 3 177(22.0%) 628(78.0%) 4 49(43.8%) 63(56.2%) People with chronic health conditions or go for screening and regular check up are more likely to have used the emergency department in the past 12 months than those who never go to the doctor or only go when they are sick. Insurance categories 1) Private commercial 2) HMO 3) Public 4) No health insurance Insurance category and use of emergency department Table 16: Used ED did not use ED 1 87 (17.4%) 414 (82.6%) 2 2 (40%)* 3 (60%)* numbers too small (26.2) 517(73.8%) 4 46(15.6%) 248 (84.4%) People with public health insurance are more likely to have used the emergency department in the past 12 months individuals with commercial insurance or no insurance. Insurance category and having a medical home Table 17 Medical home No medical home (79.4%) 103 (21.6%) 2 2 (40.0%) 3 (60.0%)* numbers too small (62.7%) 263 (37.3%) 4 50 (17.1%) 242 (82.9%) People without health insurance are more likely not to have a medical home. 11

12 Insurance category and not having a doctor Table 18 No doctor have doctor 1 73 (14.9%) 293 (80.1%) (100%)* numbers too small (37.3%) 299 (62.7%) (57.1%) 115 (42.9%) People without health insurance are less likely to have a regular doctor. Emergency department and not having a regular doctor Table 19 Used ED Did not use ED No doctor 94 (21.3%) 348 (78.7%) Has doctor 161 (21.3%) 595 (78.7%) People who report having a regular doctor are equally likely to have used the emergency department as those not having a regular doctor. One head of household indicated that I first go to my doctor then go to the ER and wait Emergency department use and reporting a medical home Table 20 Used ED Did not use ED Has medical home 219 (23.0%) 734 (77.0%) No medical home 116 (17.7%) 538 (82.3%) A larger percentage of people reporting having a medical home also reported having been to the emergency department in the past 12 months than those without a medical home. This observation and the one above, about the having a doctor not having an effect on emergency department use suggests that the quality of medical homes needs improvement and deserves further study. Ability to reach own doctor and emergency department use in past 12 months Table 21 Used ED Did not use ED Can always reach doctor for questions 210 (24.7%) 640 (75.3%) Can not reach doctor for questions 76 (17.7%) 402 (82.3%) Patients who reported having no difficulty reaching their providers had a higher percentage of emergency department visits than those who could not regularly reach their providers. 12

13 Not having a doctor and follow up appointment Table 22 Follow up No follow up No doctor 204 (46.7%) 233 (53.3%) Have doctor 482 (64.9%) 270 (35.9%) People without a regular doctor are less likely to receive follow up appoint. Insurance category and receipt of follow up appointment Insurance categories 1) Private commercial 2) HMO 3) Public 4) No health insurance Table 23 Follow up No follow up (69.6%) 150 (30.4%) 2 3 (60.0%) 2 (40.0%)*numbers too small (62.6%) 257 (37.4%) (37.2%) 181 (62.8%) Receiving follow up appointment depends on insurance type one has. People without insurance were less likely to report receiving follow up appointment. Less than a high school education, lower than $1000 monthly income, and living in a rental were also associated with having a medical home (data not shown). Analysis of open ended questions: Open ended questions (#s79-80b) were asked to elicit experiences that had not been captured by the closed questions of the survey. The open ended questions fell in three categories. In the first category we wished to find out what the respondents felt were the reason(s) individuals chose to receive care at a private office, clinic, or an emergency department. The second question sought to find out what respondents recall about their recent experience with health care. The third question asked what the responds are looking for in a medical home. Responses from each case were condensed into terms and categories that were then ranked by frequency of occurrence for each question. Reason for choice of private office, clinic or emergency department: The reasons given fell into twelve categories that were listed at least 10 times by the respondents. The total number does not add up to the number of cases because some respondents listed more than one term which may belong to more than one category. 297 individuals answered don t know indicating that they did not know why some people decided to go to private offices, clinics or to emergency departments for health care. Fourteen terms were not categorized 13

14 because they were listed less than 10 times which was an arbitrary frequency chosen as a cut off for a category. The categories were: Personal service (308) Insurance (293) Service given (271) Waiting time (208) Cost (145) Location (85) Convenience (75) Comfort (46) Reliable (46) Doctor (35) Privacy (15) Emergency department- unqualified (10) The most frequent category of responses was receipt of personal service, followed by insurance, service received in general, and waiting time. Open question about respondents last experience with health care; categories with frequency of at least 20 responses are listed below in order of frequency. Satisfied with service (741) Service (709) Not satisfied with service (405) Waiting time (249) Don t know (42) Insurance (42) Doctor (47) No answer (31) Cost (26) Question #80b: An open ended question about what the respondents would like to see in their medical homes. Personal care Accessible providers Prompt care/service Caring/concern Compassion/empathy Respectful attitude Friendly atmosphere Explanation of treatment 14

15 Answers to health questions Affordable care Up to date facilities Experienced providers Reliable, clean, neat and safe environment and staff Convenience More Spanish doctors and staff More Spanish translators More health information in English and Spanish Fully staffed facilities with staff that are not stressed out Attention to seniors and people with disabilities Play area for children Large waiting rooms In answer to open ended questions #80a and 80b about what heads of households look for in a medical home, they indicated that they are looking for clean medical homes that are near their own residences, where they are welcome and treated with respect by experienced health care providers who are familiar with their medical histories and where they expect to receive quality medical care at affordable cost. Clinic patients indicate that they wait for a long wait to get appointments, wait to be seen, and not having a doctor who knows them during follow up of their health care. Interpretation of heads of household survey findings The survey population is low income, undereducated, and predominantly female heads of households. The majority of the population relies on clinics for health care. Many rely on emergency departments as sources of regular medical care. Having a medical home appears related to insurance status and to socioeconomic status as indicated by education, home ownership and income. Having a regular doctor appears to be related to having commercial insurance. That patients without health insurance are less likely to receive follow up appointment suggests one of the ways health insurance may influence the health care rendered. It is noteworthy that the first five items selected as important in choosing a medical home have to do with a sense of being welcome and overall quality of care received. The way the patients feel they are being treated influences whether they will return for follow up appointments. These factors are frequently unobserved in most studies. The patients desire clean medical homes that are near their homes. Type of health insurance appears to mediate where the patients are welcome and treated. The observations that having a regular doctor, a medical home or ability to reach a doctor for questions do not guarantee less emergency department use deserved further study. II. Provider survey findings One hundred and ninety-five surveys were mailed out. At the time of preparation of this report 44 have been returned. In sixteen cases the addressees no longer worked at the facilities. One survey was not completed because the individual was a nurse practitioner, not a physician. Twenty seven surveys were filled out by physicians. 15

16 Demographics (n=27) Age: Age range years of age; mean age 49.7 years; median 53.0 years. Four providers did not give their ages or birth dates. Gender: There were 77.8% (21) males and 22.2% (6) females. Race/ethnicity: 81.5% (22) were white; 19.2% (5) were of other race/ethnicity. Practice locations: Twenty-one (77.8%) of the 27 providers had practices within the city of Buffalo. The remainder had practices in suburbs. One provider had an office located in Buffalo and another in one of the suburbs. Types of Practice: 37.0% (10) of the providers worked in clinics; 30.0% (9) worked in private practices; 32.2% (8) worked in other practice settings. Number of years in practice: The providers had been in practice for periods ranging from four to 38 years. All had practiced in the Buffalo area for periods ranging from 4 to 38 years. Residence from office: Twenty-three (85.2%) providers lived within five miles of their practice sites. Patients per week: Twenty-one (60.0%) of the 27 providers saw 41 to more than 60 patients per week in their practices. Health insurance: Twenty-five providers accepted patients with all health insurance plans including the uninsured. One provider indicated that they counseled the uninsured to get insurance before they would be seen. One provider did not take Medicaid health insurance. New patients: All but one provider indicated that they were accepting new patients. Factors important for choosing a place to practice medicine (n=27): Accessibility of office for patients 70.3% (19) Security at the office 62.9% (17) Location of the office 62.9% (17) Number of patients 55.5 % (15) Type of insurance the office takes 55.5% (15) Commute to the office 55.5% (15) Physical appearance of office 48.1% (13) Language of staff at the office 48.1% (13) Living in the community 48.1% (13) Physical appearance of surrounding community 40.7% (11) Reputation of community 40.7% (11) Other: Colleagues and partners 16

17 Factors that providers feel may contribute to different health care (n=27) People who speak language other than English 55.6% (15) People with different insurance types 51.8% (14) People with disabilities 37.0% (10) People of difference race/ethnicity 33.3% (9) People of different sexual orientation 25.9% (7) Question # 22: Providers were asked to share their recent experience with the current health care system. The following were identified: 1. Poor coordination of medical services in general. 2. Poor communication between hospitals and primary care providers and the vice versa. 3. Poor communication between psychiatrists and general medical practitioners which contributes to poor medical care of patients with mental problems. 4. Poor communication among providers contributing to poor care of patients with substance abuse problems. 5. Unreimbursed services for example, filling mandated insurance forms or telephone advice for patients and prior authorization required by insurers. 6. Poor compensation for coordination of care -- low re-imbursement for coordination of care for primary care providers despite large amount of responsibilities. 7. Problems with obtaining timely consultations for subspecialties in areas such as rheumatology, endocrinology and hematology. 8. Lack of affordable electronic medical record systems for community practitioners in general that can allow information sharing between systems. 9. Compartmentalization of medical problems such that difficult patients are passed on from one practice to another without resolving underlying problem. 10. Focus on expensive high-end tests that benefit only a few patients especially at end of life while neglecting or underfunding preventive measures that would benefit large numbers of patients. 11. Lack of health insurance increases health costs for all because individuals who do not have health insurance differ preventive screening until they have advanced disease and require more expensive treatments. 12. Poor maintenance of facilities where the poor and patients with mental illnesses receive treatment communicates disrespect for patients. 13. Lack of one tertiary care system (a central university hospital and faculty practice) with all critical services on one campus to avoid duplication and strive for excellence one cardiac catheterization program, one training program, one stroke program with all necessary support services. 14. Individuals on social disability have a disincentive to come off public assistance and gain employment when such employment results in the loss of health benefits with only a marginal increase in their income which does not cover medical insurance. 15. Unproductive competition among hospital systems that does not benefit patients. 17

18 Question #23: Changes providers would like to see in current health care system. These are not ranked in order of importance or frequency. Reimbursement of primary care providers for coordination of care Single payer health system Consolidate hospitals to eliminate duplicative services Commitment of hospitals to support a state of the art central university hospital Timely access to specialty consultation More collaboration among providers Attention to needs of an aging population All providers should came for some Medicaid and self-pay patients to lessen burden on any one group of providers Electronic medical records No health maintenance organizations (HMOs) One tertiary care center (a central university hospital and faculty practice) with all critical services on one campus to avoid duplication and strive for excellence one cardiac catheterization program, one training program, one stroke program with all necessary support services Improvements that providers recommend (closed question #21) (n=27): Changes in the way doctors get reimbursed 85.2% (23) Electronic medical records 77.8% (21) Compensation for filling patient insurance forms 74.1% (20) Improved access to patient records 63.0% (17) Physical improvements in facilities 59.3% (16) Provide information about medical costs 33.3% (9) Other comments: Collaboration with other providers Improved work ethic for staff Better quality staff Universal health insurance that is affordable Compensation for scope of responsibilities Primary care and subspecialty access TORT reform Providers and insurers should have equal periods of time (e.g. 30 days) within which the providers can file or insurers can deny payment of a given claim. Interpretation of provider survey results Accessibility, security and location of practice sites were at the top of providers lists in factors influencing the site of an office. From the patients perspective, it is how comfortable they feel with overall care at a given site, and that is the key to their selecting a medical home. For the providers, the next tier is number of patients seen at the office and insurance types the office takes. For patients, it was staff attitude, having one s own doctor, receiving explanation for treatments, waiting times for appointments, and convenience before location. 18

19 Among factors that contribute to differences in health care received, both heads of households and providers indicate that insurance type and speaking a language other than English contribute to differences in health care received. In general, greater percentages of heads of households indicate that these factors contribute more than that indicated by the providers. Providers identify many factors listed above that are not working in the current health care system. Most prominent are poor coordination of medical care in general, lack of collaboration among providers and between hospitals and community providers, and lack of electronic medical records. Providers have difficulty obtaining records from prior providers especial in cases of mental illness. Providers have difficulty obtaining consultation for self-pay and Medicaid patients. Providers also indicate problems with referrals and lack of a central university hospital resource. Providers indicate that prior authorization which was meant cut down on unnecessary utilization of services has actually resulted in a burdensome expense to providers since their office personnel must spend hours negotiating with insurers for services on behalf of their patients. Providers also indicate systemic factors that act as disincentives for patients to get off public assistance for fear of losing their medical benefits. Providers see opportunities for improvements by changing the way they are reimbursed, reimbursement for filling out insurance forms and for telephone or other electronic consultations with patients as well as coordinating the care of their patients. They also indicate a need for community-wide portable electronic medical records, physical improvements in facilities and access to patient medical records and more integrated outpatient care in which providers work as patient allies in preventive care. There is general agreement in the information obtained from the open ended questions and the closed questions seeking information about experience with current system and recommended improvement in health care by providers. Results from providers and community heads of households surveys were complementary and provide candid assessments of the current health care system. The results also provide many helpful suggestions that would be useful in restructuring the system to best serve the needs of patients. Study strengths This project was successful in reaching targeted community residents and physicians. The community survey included a population which is frequently not reached in surveys that rely solely on telephone or the internet. The study was able to probe areas that involve interactions between patients and providers which are usually not observed. Survey results can be incorporated in the decision-making process involving health care delivery in Buffalo and Western New York. Study limitations Cross-sectional nature of the study is subject to recall bias. The provider sample may have selected for the providers that held the strongest opinions about the issues raised in the survey. 19