Critical Path Network-Program overcomes barriers to staying healthy
Plan helps 500 physicians meet national standards
By Debbie Togger, MSN, RN
Quality Management Educator
Sharon Ross, MSN, CNP
Advanced Practice Nurse, Special Projects
St. John Medical Group, PC
Detroit
The Health Plan Employer Data and Information Set (HEDIS), a group of standardized measures used to evaluate the performance of managed care plans, was developed and implemented by the Washington, DC-based National Committee for Quality Assurance (NCQA), an independent organization that accredits managed care organizations and develops and disseminates information about the quality and performance of health maintenance organizations (HMOs). Most employer groups rely on HEDIS data to screen HMOs and make decisions about which plans to select for their employees. HEDIS helps employers and other consumers assess the value of their health care dollar, and it holds managed care plans accountable for their performance.
NCQA accreditation is voluntary now, but it may be required in the future. Plans to expand HEDIS criteria to include preferred provider organizations are currently under way. Some of the areas HEDIS evaluates are effectiveness of care (preventive screenings), use of services, and member satisfaction. HEDIS is relevant to hospitals that own physician practices because the HMOs with which hospitals contract would require the hospitals to ensure practices meet NCQA standards.
In many settings, managed care organizations (MCOs) offer physicians a financial reward for meeting certain thresholds for some of these indicators. For instance, the quality rating of the MCO for preventive screenings is dependent on the physicians who contract with them and provide care to members. When physicians are successful in getting their patients to obtain preventive screenings, everybody wins. The physician receives both a high quality rating and a financial reward, the MCO benefits with good preventive screening rates, and most importantly, the patient receives the screening tests that play a role in remaining healthy.
St. John HealthPartners in Detroit requested the assistance of the St. John Medical Group, PC (SJMG), in developing a comprehensive program to assist 500 physicians in their offices to meet HEDIS standards. For the past four years, a program has been in place to help physicians meet thresholds that result in financial reward, high quality rating, and benefits to the patient. SJMG focused on increasing the preventive screening rates for patients in need of Pap tests, mammograms, diabetic retinal screenings, and childhood immunizations.
Barriers to obtaining screenings included lack of notification and education of members about the need for screenings. Offices were not using every office visit as an opportunity to identify preventive screening needs. Another complicating factor arises when consulting or dual-choice physicians do not report their findings back to the primary care physician, who is ultimately responsible for ensuring preventive screenings have been performed. Primary care physicians also strongly felt that patient compliance was a barrier to achieving better screening rates.
SJMG has undertaken many activities to increase screening rates (see process algorithm, p. 120). In the broadest sense, these activities can be divided into two categories: education and process issues. The education category consists of both physician and patient education.
Physician education was accomplished in several ways. First, designated physician leaders discussed the importance of addressing prevention in their practices at departmental meetings. The presentations consisted of an overview of HEDIS and the significance of HEDIS to the practicing physician. Designated leaders were selected based on knowledge of the topic and ability to relate to their peers.
Also, one-on-one education was provided in high-volume offices. Several topics were discussed during these individual meetings, including tips to achieve goals, processes to establish to get patients screened, and individual physician rates as compared to their peers. The review of individual physician compliance rates for these indicators as compared to their blinded peers was very effective in gaining physicians' attention.
To address patient education issues, SJMG sent patients a letter early in the year to notify them of the need for screening. The letter included screening education material. A second notification reminding them of the need for screening was sent out in late summer either in a different format or with an attached incentive. Incentives were developed through partnerships that were formed with a pharmaceutical firm and a nationally recognized cosmetic company.
In addition, a registered nurse made more than 400 phone calls to patients to encourage them to obtain screenings. An alliance also was forged with a local ophthalmology practice that phoned patients with diabetes to schedule a diabetic retinal exam. This proved to be a successful way to overcome the barrier of making an appointment. A similar process was established with a mammography center to assist patients in need of this exam.
Process issues in physician offices also were tackled. Office personnel were encouraged to develop a mechanism to identify all patients in need of preventive screenings, regardless of type of insurance, whenever the patient presented to the office for a sick or well appointment. This type of process reduces the incidence of missed opportunities to assess for the need for preventive services.
The insurer records patient compliance with preventive screening only if a claim for the service has been submitted using a billing code that is recognized by NCQA. Many patients who had the screening tests done were recorded as noncompliant by the insurance company because the codes that are NCQA-recognized are not always the ones billed by physician offices and hospital departments. For this reason, hundreds of chart audits were performed to capture as many compliant patients as possible. These audited data provided valuable information. If the insurer recorded a patient as being noncompliant, but a copy of the screening exam was obtained indicating the test was completed, follow-up was done to determine the reason that the claim was not picked up. Relationships were developed with the laboratory, mammography, and physician offices to bill these services using NCQA-recognized billing codes in order to increase compliance rates.
Lastly, SJMG staff are in constant communication with the insurers to discuss issues related to achievement of targets and goals. Meetings are scheduled on a regular basis throughout the year with high-level personnel to review ways to improve the program.
The final 1999 compliance rates have not been released. However, preliminary reports indicate that increases in compliance rates were achieved in at least three of the four indicators. In particular, a 17% increase has been observed in the rate of diabetic retinal screening from 1998 for members of one of the hospitals of St. John HealthPartners. It is our hope that through persistent efforts and constant vigilance, patients will become more educated, obtain their screenings, and remain healthy, which is the ultimate goal of both the insurer and the physician.
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