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Research Questions

  1. What is the burden associated with the PAAS, particularly on health care providers?
  2. What issues surround the change in methodology between MYs 2017 and 2018 that removed a question from the survey script and changed the way compliance is measured?

Timely access to care is an important element of a high-performing health care system. There is, however, very little evidence to inform metrics and appropriate benchmarks. Given the limitations of the literature, the state of California has taken the lead in developing metrics, standards, and a methodology for collecting the needed data for monitoring timely access to care in the state. The California Department of Managed Health Care (DMHC) has developed the Provider Appointment Availability Survey (PAAS), which health plans that offer products regulated by the department are required to implement. The PAAS methodology has changed over time to address issues with the data collection and reporting process, but the methodology is set to be finalized in January 2020. Health plans have faced numerous challenges in collecting and reporting this information.

In this report, the authors focus on two specific concerns with the methodology that have been raised by health plans and other stakeholders: the burden associated with the PAAS (particularly on providers) and a change in methodology between measurement years (MYs) 2017 and 2018 that removed a question from the survey script and changed the way compliance is measured. Having conducted an environmental scan of timely access issues, undertaken discussions with stakeholders, and analyzed MY 2017 PAAS data for a subset of health plans, the authors use a multipronged approach to describe and document each of these issues and identify and assess potential solutions.

Key Findings

There are numerous options for reducing the provider burden associated with the PAAS

  • Centralized sampling with no other changes to the methodology could reduce outreach attempts by 60 percent for primary care providers (PCPs) and by 72 percent for specialists.
  • Centralized sampling with a sampling strategy designed to leverage overlap between health plans could reduce outreach attempts by 60 percent for PCPs in Los Angeles County.
  • Sampling office locations rather than specific providers could reduce outreach attempts by 70 percent for PCPs.
  • Improving contact list data could reduce the number of ineligibles by approximately 50 percent.
  • Updating the target sample size to reflect ineligibles could reduce the number of outreach attempts to reach target sample sizes.
  • Making greater use of nonsurvey methods of data collection could reduce provider burden if there is a move to other modes of data collection and reporting.
  • Improving communication and outreach to providers could improve providers' likelihood of responding.

There are several options for providing broader measures of timely access

  • These include surveying office locations, incorporating the DMHC's binomial probability calculation, reporting more nuanced access data, and incorporating nurse practitioners and physician's assistants into the sampling frame.

Recommendations

  • There needs to be a collaborative stakeholder process that includes the DMHC, health plans, providers, and consumers to consider the options, weigh the pros and cons, and make decisions about how to move forward.
  • Compliance standards need to be dynamic and should adjust to reflect differences in the supply and demand factors that affect consumers' access to care. These standards could be adjusted to account for characteristics of the market in which the health plan operates, characteristics that vary across areas, and characteristics that are outside of a health plan's control.
  • The standards may need to evolve over time as the health care system changes: Demographic and other factors will create growing imbalances between the supply and demand for physician services and bring shortages to medical specialty areas, and these shortages need to be addressed.
  • The way that access is defined and measured will need to be refined and allowed to evolve with changes in the health care delivery system. For example, there is growing use of nurse practitioners and physician's assistants to provide a wider range of medical services, and the current timely access method does not capture this element of health care delivery very well.
  • While there are important benefits to finalizing the PAAS methodology, there is also a need for flexibility and the ability to evolve over time.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    The Timely Access Data Collection and Reporting Burden

  • Chapter Three

    The Removal of the Alternate Provider Question from the Provider Appointment Availability Survey

  • Chapter Four

    Discussion

Research conducted by

This research was funded by the California Association of Health Plans and conducted by the Access and Delivery Program within RAND Health Care.

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