Ultimate outcome: Are patients better or worse?
Health of Seniors measure tracks health status
For the first time, health plans are being evaluated on the essence of their job: Over time, are the changes in patients’ mental and physical health better or worse than would be expected?
Some 279,000 Medicare beneficiaries responded to surveys last summer for the "Health of Seniors" measure, and they will be surveyed again in 2000 for a comparison of changes in their health status.
While this first true outcomes measure applies only to Medicare managed care, health status is evolving as a performance measurement tool for medical groups and for use with younger patients as well. In fact, the Health Care Financing Administration (HCFA) is conducting a pilot project with medical groups using the Health of Seniors survey to monitor fee-for-service patients.
The Pacific Business Group on Health in San Francisco included a short version of the health status questionnaire in its Physician Value Check Survey, which is being used to create report cards on medical groups. "We’re defining outcome as the change in your score," says John E. Ware Jr., senior scientist at The Health Institute of the New England Medical Center in Boston and developer of the SF-36 health status survey that forms the core of the Health of Seniors survey. The measure was developed jointly by HCFA and the National Committee for Quality Assurance in Washington, DC.
"We subtract the baseline score from the outcome score [after two years]," he says. "We’re holding the plans [and medical groups] accountable for maintaining health or improving it."
Treatment changes health status
Some physicians may question how much impact they have on patients’ overall physical and mental health, particularly with those who fail to follow their treatment advice.
But Ware points out that trust and communication can strengthen compliance, and he asserts that specific interventions clearly affect the health status of patients with conditions such as diabetes or hip fracture. "Therapies improve these scores," he says. "There is a link between treatments we know are effective and health improvement."
In the Health of Seniors measure, health plans will be compared based on changes in the overall physical and mental health scores. But the SF-36 also provides scores for subscales, such as pain and vitality, that plans can use to guide quality improvement. "They might look at those processes that are contributing to their [mental and physical health] outcomes," says Chris Haffer, PhD, director of the Health of Seniors-Managed Care Project for HCFA.
The Health of Seniors survey includes additional questions on activities of daily living and medical conditions. The results will be risk-adjusted based on such factors as age and illness. Plans will receive state, national, and regional norms as well as their own scores.
While mental health among this Medicare group should remain stable or even improve slightly, physical health will decline in two years, says Ware. "Probably twice as many seniors will decline each year in physical functioning as will improve," he says.
Such projections are based on studies using the SF-36, such as the massive Medical Outcomes Study that provided the foundation of current knowledge of health status assessment. Yet even one round of the Health of Seniors survey will dwarf the prior research. "They will have almost as many seniors in each of 280 plans as we had in the entire Medical Outcomes Study," says Ware. "This is a much higher degree of precision than we’ve ever had."
The plans each surveyed 1,000 members, and HCFA officials say they hope to receive completed responses for both baseline and follow-up from 500 members per plan. That final number will likely be lower due to variation in response rate. "That would have given us very, very strong statistical power," says Haffer. "We can detect meaningful change if we have 250 people completing both surveys."
In fact, response rate is one statistical aspect that may impact performance on the Health of Seniors measure. The response rate for plans ranged from 29% to 79%, says Haffer.
The first respondents to a health status survey tend to be healthier than those who need many reminders before responding, says James Cooper, MD, a geriatrician and senior medical adviser for the Center for Primary Care Research at the Agency for Health Care Policy and Research in Rockville, MD. "We don’t know if they’re more likely to change, to get better or worse."
Haffer says HCFA will keep a close eye on demographic and other differences among respondents to plans with different response rates. The agency may set a cutoff, excluding plans that don’t have a sufficient response rate for comparison, he says. "So far we haven’t answered that question yet," he says.
Will measure change physician behavior?
Even while the technical details are worked out on the Health of Seniors survey, the project promises to have a broader impact on care. Medical groups, hospitals, and home health agencies are implementing interventions to determine how they can improve health status scores among older people.
Cooper predicts that the Health of Seniors measure will broaden the way physicians and other providers view their jobs. "[The measure] will lead to providers taking more responsibility for broader concerns about health — getting people to exercise, improve their diet, control alcoholic consumption," he says.
Ware says he would like to see more physicians using the SF-36 as a monitoring tool of overall health of individual patients. "My own belief is that they should be doing this [health status assessment] regardless of whether it’s an outcome in an accountability system," he says. "Just as they monitor the organ of the body they’re treating, physicians should be monitoring your entire health. They really need a barometer that tells them overall how you’re doing."
Editor’s note: For more information on the Health of Seniors survey or a copy of the manual ($75 plus $10 shipping and handling), contact the National Committee for Quality Assurance Publications Center, 2000 L. St. NW, Suite 500, Washington, DC 20036. Telephone: (800) 839-6487. World Wide Web: http://www.ncqa.org.
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