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Defining quality physicians.

In the past two years, physicians at CIGNA Healthplan of Arizona have developed and implemented a physician evaluation system based on meaningful, quantifiable measures of performance. We define a quality physician as one who excels in quality of care, quality of service, and cost-effectiveness. We believe that a physician who performs well in these three critical areas is the ideal physician for a managed care organization from both the purchaser's and the medical group's perspective.

Our evaluation weighs quality of care at 30 percent, quality of service at 30 percent, cost effectiveness at 30 percent, and the manager's evaluation at 10 percent. Significant problems in a physician's quality of care preclude an acceptable evaluation, regardless of the other parameters. Quality of care standards must always be met first. Aquantitative score for the overall evaluation is calculated, with a maximum of one hundred, and physicians are then rank ordered. The results are shared with individual physicians, their department chairs, and the chief of staff. Positive feedback as well as plans for improvement are discussed. Planwide trends are monitored and management actions are determined.

Quality of Care

Our approach to evaluating quality of care is to use peer review of medical records and colleague assessment questionnaires. Every physician reviews five medical records of a colleague every month, using a standard evaluation form that includes housekeeping questions (problem lists, medication lists, legibility, etc.) as well as clinical questions (appropriateness of evaluation, follow up of abnormal laboratory tests, health screening, etc.). In addition, specific information is required for all unsatisfactory scores on the clinical questions, all of which are reviewed by the Quality Management Medical Director.

Problems noted in a physician's clinical quality of care are tracked and followed up by confidential audits, whereas poor scores in housekeeping questions simply result in immediate feedback outlining what areas need improvement. Messages are also sent to recognize outstanding performance on monthly peer reviews.

Peer assessments are made on a five-point Lickert scale for questions about a colleague's ability to manage difficult cases, willingness to help out when needed, etc. This assessment provides the ability to quantify and track people's impressions. The tool is much more powerful than the more traditional solo and subjective evaluation by a manager. In addition to peer surveys, we also get feedback from specialists about primary care physicians and vice versa.

Quality of Service

The major measure of quality of service is a structured telephone survey of our patients conducted on a regular basis by an outside firm. Patients are asked about their perceptions of their care, including questions such as how well their physicians listened to them, how well they explained the treatment plan, and how satisfied patients were with physicians. We also use our patient surveys to get information about other aspects of our practice, such as the courtesy of our staff and satisfaction levels with appointment availability. The other service measure we use is waiting time for routine appointments.

Cost Effectiveness

Our approach to evaluating costs is to track department or health care center goals as well as individual goals in an attempt to promote teamwork and to minimize issues of severity differences among panels of patients. Because most of our costs are due to hospitals, referrals, and salaries, these are the variables we consider most important, although we also track laboratory, pharmacy, and radiology costs. Primary care physicians (family practice, pediatrics, and internal medicine) are evaluated on the basis of parameters different from those for specialists.

For a family practitioner, there is a fairly even balance on a variety of measures, whereas for specialists, hospital and referral costs have more weight. All of our patients are assigned to primary care physicians, and all costs are tracked to each physician through his or her panel. Costs are usually measured on a per member per month (PMPM) basis, which is a standard accounting methods.

Manager Evaluation

The purpose of the manager evaluation is to allow interpretation of the quantified results, identify relevant contributions not reflected in the data, and set written goals for the next appraisal period. In addition, managers are expected to override any gross inequities caused by this system in the cost areas. For example, a pediatrician who cared for the bulk of growth hormone patients would have an exaggerated pharmacy PMPM relative to peers, and the manager would be expected to make an adjustment.


Our performance in quality of care, quality of service, and cost effectiveness has resulted in measurable improvements in each area. In our peer review, overall scores have increased over time, largely because of better record keeping. We have also noted a significant decrease in the number of negative clinical audits (i.e., substandard care identified), because we have been able to track poor performance and manage it aggressively over the past two to three years.

Patient satisfaction increased dramatically in our first year and has continued to increase since then. In evaluating cost effectiveness, while many variables play a role, health plan profitability has improved significantly for the past two years. Our ability to assign ownership for costs and to track them by department and health care center has been a powerful tool for improving our performance.


There are several key issues that have surfaced in our physician evaluation system.

First, acceptance and buy-in of performance evaluations is a challenging management task. Our system is tied to annual raises and bonuses and therefore comes under close scrutiny by our physicians. It is important to maintain a positive, constructive approach to evaluations, because the more specific they are, the more threatening they can be. While "bad apples" will occasionally be found, most physicians are quite competent. However, there is little question that purely subjective evaluations are becoming less acceptable to purchasers of health care.

Second, when we started, we naively believed that cost effectiveness evaluation would be the easiest. What we learned is that this is the most difficult, for two reasons. One, we are mainly measuring cost and balancing it with a variety of quality of care checks rather than evaluating true cost effectiveness. Two, there are no readily usable methods of severity indexing for an outpatient practice, so one physician's costs, while higher than another, may be appropriate. In addition, most physicians feel they take care of sicker patients than do their colleagues.

Third, we have found it important, but difficult, to keep our evaluation system simple. Our latest modification is to try to reduce the number of parameters and to increase the weight of the manager's evaluation. However, we maintain that a balance between quality of care, quality of service, and cost effectiveness is critical.

As our medical group has become more involved with continuous quality improvement, we are learning new ways to look at our data. Specifically, we are moving away from forced ranking of scores and are focusing more on reducing variation within the group and improving overall performance.

Zachary B. Gerbarg, MD, is Vice President and Medical Director, and Clifford J. Harris, MD, FACPE, is Vice President, Quality Management, CIGNA Healthplan of Arizona, Phoenix. Dr. Harris is a member of the College's Society on Managed Health Care Organizations and Forum on Quality Health Care. Dr. Gerbarg is a member of the Society on Managed Health Care Organizations.
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Title Annotation:CIGNA's appraisal system
Author:Harris, Clifford J.
Publication:Physician Executive
Date:Nov 1, 1991
Previous Article:Performance appraisal as a modifier of physician behavior.
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