West Coast doctors give HMOs low marks for quality initiatives in new survey
HMO Survey
July 31, 1997
4 minutes read
Physician Group Survey Results (for 272 Contracts in CA, WA, OR)
QUALITY MEASUREMENT
HMO provides:
incentives to collect data 33.1%
benchmark data to group 30.5%
HMO cooperates with group
to improve quality 12.9%
SERVICE AND EFFICIENCY
HMO cooperates to resolve
patient-level problems 72.4%
HMO’s drug formulary is rated as:
Good 21.3%
Fair 40.8%
Poor 22.1%
UTILIZATION MANAGEMENT
HMO allocates full UM responsibility to physician group for:
Referrals to specialists 92.6%
Prior authorization for
hospital admissions 84.6.% Concurrent review of
inpatient services 75.7% Case Management
for high risk patients 40.4%
FINANCIAL RELATIONSHIP
HMO adjusts payment based on:
Age and gender 68.8%
Disease severity 10.3%
ENROLLEE EDUCATION BY HMOS
Grievance/appeals process
Good 39.3%
Fair 41.2%
Poor 12.5%
Referral process to see specialist
Good 22.8%
Fair 53.3%
Poor 23.2%
Covered benefits under the plan
Good 18.0%
Fair 47.8%
Poor 25.7%
DATA REPORTING
HMO provides enrollment data:
Within 30 days 49.6%
Within 30-60 days 25.4%
60 days or longer 12.5%
Physician groups in California, Washington and Oregon don’t rate the HMOs they work with very highly on quality improvement initiatives, according to a second "physician satisfaction" survey conducted by the Pacific Business Group on Health (PBGH), a coalition of employers and major purchasers of health care.
Only 13% of the physician groups surveyed say HMOs cooperate with them to improve quality. Only 30% provide quality benchmark data to the physician groups.
"Health plans did best on service and efficiency and they scored the poorest on quality initiative and data transfer," said Nancy Oswald, executive director of the National Independence Practice Association Coalition in Oakland, CA which collaborated with PBGH and the American Medical Group Association (AMGA) on the survey.
While consumers are routinely surveyed on their satisfaction with managed care plans as a measure of quality, physicians are only beginning to be tapped for their views on how health plans perform. In the PBGH survey, responses were received from 66 medical groups and IPAs, representing 640 contracts, with the majority from California. Responding groups in California care for nearly 4 million members, about 47% of all HMO enrollees in the state.
"This does not bode well for continuous quality improvement," said Cheryl Damberg, director of quality for the PBGH. The survey also confirmed that electronic data transfer is woefully inadequate, according to Ms. Damberg. Purchasers want to see the electronic transfer of enrollment and eligibility data between health plans and physician groups as well as encounter data, she said. Purchasers also want centralized records so that providers know what services and drugs patients are receiving. The survey found that electronic data transfer, in fact, is still in its infancy. Ms. Damberg said physician groups reported that even enrollment and eligibility information is often provided in paper form.
Some key findings in data reporting:
• Nearly 50% of HMO contracts take more than 30 days to deliver enrollment data;
• 26% of HMO contracts cooperate to improve data reporting systems; and
• only 4% of California contracts invested resources with physician groups to improve data systems, compared with 18% of Oregon and Washington contracts. "Health plans did best on service and efficiency and they scored the poorest on quality initiative and data transfer."—Oswald
"The results indicate that plan-provider data reporting systems have a long way to go, and underscore the importance of PBGH initiatives to improve the health care data infrastructure," states a PBGH newsletter.
Physician groups were surveyed on data reporting, their service relationships and financial relationships with HMOs, utilization management, quality improvement, and on how well HMOs educated consumers. HMOs did a better job of educating consumers about the grievance/appeals process (39.3% good, 53.7% fair/poor) than they did about the referral process to see a specialist (22.8% good, 76.5% fair/poor), according to the physician groups. However, 72.4% of physician groups said HMOs cooperated to resolve patient-level problems.
Plans seem to have shifted much of the responsibility for utilization management to physician groups, according to Ms. Damberg. While much of the criticism on utilization management has been focused on health plans, it appears that physician groups are making many of the decisions about referring patients to specialists and authorizing hospital admissions. There may not be sufficient understanding in the market that many of these decisions are being made by physician groups, she said.
Much of the risk also is being shifted to physician groups. Most plans continue to adjust payments for patients on the basis of age and sex only and not on disease severity, which means the risk has also been shifted to physician groups.
Ms. Oswald said the managed care industry recognizes that the data infrastructure is not where it ought to be. "Many of the systems are proprietary and can’t speak to each other," she said. Like the banking industry, the managed care industry needs to find ways to transfer appropriate information while protecting what is proprietary. Other barriers include the lack of standardized formats to transfer data.
While scores on quality improvement are an area of concern, Ms. Oswald points out that one-third of physician groups responded that the plans were conducting quality studies, a first step in quality improvement. It is also important to remember that the score for quality improvement under fee-for-service would be 0%, she said.
Managed care as an industry is still trying "to locate the best arena of activity for quality improvement initiatives." Many physician organizations are taking the initiative themselves. "There’s creative tension on this issue," she adds.
Two of the largest health plans, HealthNet and Pacificare, which have followed a strategy of partnering with physicians, actually did score well with physicians, said Ms. Oswald. "This is a good sign, needless to say."
Contact Ms. Damberg at 310-396-7036 and Ms. Oswald at 510-267-1999.
West Coast doctors give HMOs low marks for quality initiatives in new survey
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