NRSA Workshop: Improving Quality by Aligning Physicians—Exploring Substance Abuse Treatment Centers

Slide Presentation by Sayeda Haq

On June 2, 2007, Sayeda Haq made a slide presentation on Improving Quality by Aligning Physicians at the 13th Annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the slide presentation (PDF File, 245 KB). PDF Help.

Slide 1

Improving Quality by Aligning Physicians—
Exploring Substance Abuse Treatment Centers

Sayeda Haq
Schneider Institute for Health Policy,
The Heller School for Social Policy and Management,
Brandeis University

Slide 2

Substance Abuse Care & Alignment

Alignment is crucial in SA care as…

• Most physicians work for specialized treatment centers, often for multiple organizations
• Treatment modalities vary sharply
• Diverse treatment philosophy and orientation among all providers
• Large number of non-physician providers

Thomas 2007

Slide 3

Quality Chasm in Substance Abuse Care

• People with a substance use disorder: 22 million*
• People receiving care: 3.5 million*
  *2001 (aged 12 or older)
  SAMHSA, DHHS Pub #SMA 05-3999, 2005

• Effective treatments exist and continually improve.
  However, as with general health care, deficiencies in care
  delivery prevent many from receiving appropriate
  treatments.
  IOM Quality Chasm Series, 2006

Slide 4

New Medication - Buprenorphine

• Offers several clinical advantages over Methadone
• Can be prescribed in physicians’ office
• Does not have severe withdrawal symptoms
• Daily dosing not needed due to long-acting effects
• No detectable ‘high’
• 2000: Federal Legislation allows MDs to prescribe in office visits
• 2002: FDA approves outpatient prescription

However…

• Four years after legislation, not incorporated into common
  treatment of substance abuse

Slide 5

An Alignment Problem?

In multivariate result, organizational support remained important in MD’s adoption decision, after controlling for MD demographics, case mix, practice characteristics etc. Chart depicts the following:

When Organization Recommends:

• MD Prescribes: 74%
• MD Does Not Prescribe: 26%

When Organization Does Not Recommend:

• MD Prescribes: 44%
• MD Does Not Prescribe: 56%

Thomas 2007

Slide 6

What Determines Alignment?

• Financial incentives - most studied domain
• Administrative strategies, e.g. utilization review, referral
  requirements
• Significant number of studies
• Structural characteristics of organization, e.g. location of
  practice site, availability of services, supporting staff and
  governance style
• Some studies
• Normative influence, e.g. formal and informal interaction
  and feedback from professional colleagues, organizational
  culture
• Very few studies
• Difficult to measure

Landon et al (1998)

Slide 7

Conceptual Framework

Adler and Borys, 1996

Slide 8

Research Question & Hypotheses

What specific structural or normative strategies used by organizations are effective in aligning physicians?

Physicians’ alignment (loyalty, commitment) increases when:

1. Organizations offer value-added services, such as training, supporting staff, etc.
2. Governance-style is consensus-based and participatory.
3. Leadership shares information leading to goal-congruence.
4. Free flow of information, frank discussion of failures, collegial relationship exists among employees.

Slide 9

Analytical Model

Organizations:

• Treatment
• Organization

Strategies (independent variables):

• Structural
  • Value-added
  • Operational

• Normative/informative
  • Formal
  • Informal

Alignment (dependent variable):

• When organization adopts and affiliated MDs prescribe

Bulleted items are in three boxes. Arrows go from the first box (Treatment and Organization) to the second box (Structural and Normative/informative) to the third box (When organization adopts and affiliated MDs prescribe).

Slide 10

Sample – Study Population

Part of a larger study by Schneider Institute

• MD Survey – Addiction specialists and facility directors
  • N = 271 (69% response rate)
• Organization survey – Facility directors
  • N = 125 (51% response rate)
• Analysis on merged dataset
  • N = 72 MDs, representing 46 organizations
  • Unit of analysis is respondents (N = 72)
  • Aligned = 24 (33%); Not-aligned = 48 (67%)
  • 6-point scale independent variables
    • 1 through 4: not much
    • 5,6: very much

Slide 11

Preliminary (Bivariate) findings

* p-value < 0.1, ** p-value < 0.05, *** p-value < 0.01

Slide 12

Research Implications

• Health services research is consistent with broader organizational theory of governance
• Organizations indeed affect physician’s practice-behavior
• This study explicitly measures, specifies and evaluates strategies that organizations can adopt to align autonomous professionals
• Policy Implication
  • Findings help bridge the gap between knowledge and practice both in SA treatment and in general health care system

Current as of October 2007

Internet Citation:

Haq, Sayeda. Improving Quality by Aligning Physicians—Exploring Substance Abuse Treatment Centers. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/haqtxt.htm

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