Report on quality: Do health plans really care about outcomes?
Commitment to quality varies widely, HEDIS scores show
Thousands of lives could be saved each year if health plans did a better job of providing preventive care and proven interventions to their members.
Yet behind that recent assessment of the State of Managed Care Quality by the National Committee for Quality Assurance (NCQA) in Washington, DC, lies another troubling truth: Too few health plans, purchasers, and providers have made a commitment to monitoring and managing outcomes.
"[Even] the high performers are off the mark from the potential American health care could [achieve] if quality management was really taken seriously," says Arnold Milstein, MD, MPH, who leads the clinical consulting practice of William M. Mercer consulting firm, which is based in New York City.
Slow as progress may seem, however, outcomes measures such as the NCQA’s Health Plan Employer Data and Information Set (HEDIS) are driving the nation toward an outcomes-based health care delivery system, says Milstein, who is also medical director of the Pacific Business Group on Health, a purchaser coalition based in San Francisco.
"We are at the very beginning of it even dawning on American consumers and purchasers that there are significant quality differences between health plans, doctors, and hospitals," he says.
"Quality Compass," which was released in its second version in October, has become a tool for quality comparison. This year, 329 health plans voluntarily submitted their scores, almost a third more than in last year’s version. The scores were reported in such national publications as USA Today and U.S. News & World Report. (See boxes, at right and p. 135. for national averages and high and low average scores.)
Although many health plans in a given market sign up overlapping networks of doctors, NCQA executive vice president Cary Sennett, MD, PhD, asserts that quality differences are apparent. Plans influence HEDIS measures through disease management programs, support for physicians, and member education programs, he says.
"Within any given market . . . there are some measures that vary widely, and I think patterns emerge," he says. "I know there are plans that consistently demonstrate superior performance. What we’re seeing there is a pretty consistent signal that the plan is a high quality plan."
Certainly, plans vary tremendously around the country. For example, the best performing plan provides beta blocker therapy to 100% of patients after a heart attack when use was not contraindicated. The worst plan reported giving the treatment to only 15% of appropriate patients.
Some measures such as mammograms and pap smears are clearly influenced by patient education and access to care, which may be more limited in rural areas. But physicians can expect health plans to exert increasing pressure to track and administer HEDIS care.
Providers and health plans, and perhaps even consumers, are more attuned to the care expectations in New England, which consistently outscored the national average. In light of the Quality Compass report, plans (and therefore doctors) in the South-Central United States, including Louisiana, Tennessee, and Mississippi, may face pressure to improve a dismal performance.
High-scoring physician practices will have an edge in managed care contracting as health plans seek to improve their own scores and public image, says Sennett. The NCQA also points out that available data indicate that managed care plans overall outperform fee-for-service in many of these areas.
Milstein likens the emerging concerns about health care quality to the automobile safety movement. In the 1950s, consumers bought cars based on style and price. Today, safety is another major consideration, and manufacturers tout their safety records.
Likewise, price far outweighs quality as a factor in health care purchasing but the trend is changing, says Milstein.
"For the physician in the trenches, this is like hearing a rooster crow at 4:30 in the morning," he says. "You realize you don’t actually have to get up until 7. But you know it’s coming. Quality sensitive demand curves are coming just like car safety [did]."
Medicare promises to be a major catalyst toward consumer awareness of health plan and physician quality, says Jeffrey Kang, MD, MPH, chief medical officer of the Center for Health Plans and Providers of the Health Care Financing Agency (HCFA) in Baltimore.
Later this year, HCFA plans to publish HEDIS scores for Medicare managed care plans. They hope to make the information widely available in a consumer friendly manner, so plan members can make choices based on quality.
"What’s different about the Medicare market is it’s an individual market," says Kang. "Individuals make decisions to go to plans themselves. If we give them this information, beneficiaries may start choosing their plans based on performance.
"What beneficiaries really want is value quality divided by cost," he says. "What they have is the cost information. What they’re missing is the quality information."
HCFA also is requiring plans to submit audited data, a stipulation that does not yet exist in Quality Compass. Kang notes that it’s impossible to tell how much of the variation in HEDIS scores reported by the NCQA is due to poor data collection or inaccuracies.
The NCQA just released auditing standards earlier this year and is beginning to certify auditors.
"We believe it’s important for these data to be audited," he says. "At some point, we will close our database to data that have not been audited, [but] we need to move deliberately in this path."
Until the public becomes more aware of varying health plan quality, purchasers are the ones promoting quality in the market. For example, the Pacific Business Group on Health ties 2% of HMO premiums to certain quality improvement goals.
HCFA will respond to HEDIS scores in a number of ways, says Kang."If we find a plan performing terribly on all these indicators, that I think is a reason for HCFA to drop a plan or put it on corrective action or cease enrollment," he says. "We’ll be able to identify bad-performing plans.
"The other purpose of this measurement is to set targets for improvement. You can do that on a contractual basis [by saying], Your mammography rate was 60%. We’d like to see you do better next year.’"
Ultimately, the plans may say the same thing to physician groups. "We hold the plans accountable," says Kang. "The plans in turn will hold the physicians accountable."
[Editor’s note: For more information about Quality Compass ($2,500 for a CD-ROM version), contact the National Committee for Quality Assurance Publications Center, 2000 L St., NW, Suite 500, Washington, DC 20036. Telephone: (800) 839-6487. Internet: www.ncqa.org.]
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