Competing on quality: Can it be done?
Coalitions struggle over outcomes measurement
The concept is admirable: Remove health plans as an intermediary between doctor and patient, and hold providers directly accountable for their quality of care.
But ambitious programs in Minneapolis/St. Paul, MN, and Des Moines, IA, designed to do that have encountered major stumbling blocks in their development of outcomes measurement.
As consumers choose among care systems of doctors, hospitals, and other medical providers rather than health plans, their selections are based largely on cost.
In Minneapolis and St. Paul, consumers can review charts of patient satisfaction data, including patient sentiments about waiting time and physician advice and explanations. But the purchaser coalitions in both communities have yet to determine how to provide statistically valid information on clinical quality.
"You need a lot of patient volume to do outcomes measures at the [care system] level, as we’d like to report them," says Steve Wetzell, executive director of policy and public affairs for the Buyers Health Care Action Group, an employer coalition based in Minneapolis.
"It’s also expensive to do," he says. "Unless we can get other purchasers to share the cost for that and share data, it’s very difficult for us to do."
Wetzell and his counterparts at the Community Health Purchasing Corp. in Des Moines are trying to develop partnerships with public and private payers to collect and report outcomes data. One problem with that tactic, however, is that the care systems are distinct (physicians may join only one), while patients in other health plans commonly move among a wide mix of providers, making them less directly accountable. (For more information on the Buyers Health Care Action Group, see Patient Satisfaction & Outcomes Management, December 1996, p. 133.)
The Iowa coalition will test a collection of diabetes, depression, breast cancer, and asthma measures developed by the Foundation for Accountability (FACCT) in Portland, OR. Meanwhile, both groups hope for an evolution toward outcomes.
"Our measurement strategy is really our growth strategy, to increase the number of people who are purchasing in this marketplace on this basis," says Patricia Drury, MBA, director of quality for the Minnesota coalition.
Despite the obstacles encountered over outcomes measurement, the consumer choice programs in Minnesota and Iowa have proven to be successful models of reform.
The Minnesota program, which began in January, covers about 120,000 patients in 20 care systems. Primary care physicians can join only one care system, eliminating the typical scenario in which doctors contract with every health plan. In fact, the health plan is out of the picture unless the plan holds a contract to conduct administrative tasks.
Buyers Health Care Action Group, while still relatively small, has gained popularity, says Wetzell. "A number of our employers eliminated other managed care options because this offered so many providers at such a competitive price," he says.
Benefits are the same, but prices vary
All care systems offer the same benefit package, although they may set gatekeeping rules. Care systems also may compete on price, which is generally reflected in the premiums; there is a $37 monthly difference for family coverage between lowest cost and highest cost group of doctors, says Wetzell.
Out of the 23 companies that offer the program, 17 implemented different premiums depending on which group of doctors an employee selects. In those cases, about 5% of the beneficiaries changed providers. Yet when employers set no price differentials, less than 1% of members changed providers, says Wetzell.
"That indicates that there is price sensitivity," he says. "Beneficiaries are willing to shop if there’s a financial incentive to do so."
Program members also sought the patient satisfaction measures, which were provided in a booklet and on the Internet. "Some [people] value the quality information more," says Wetzell. "Some value the price more. Some don’t want to give up their doctors under any circumstances. Individual consumer values are going to determine why consumers make their decisions."
For two years, price differences and provider lists have dominated the choice of members in the Community Health Purchasing Corp. of Iowa, which encompasses 30,000 eligible lives and 30 self-insured corporations. "Consumer information will be the third part of the equation," says Paul Pietzsch, MPH, president of Community Health.
In 1998, the Iowa group will conduct a patient satisfaction survey using the Consumer Assessment of Health Plans tool developed by the federal Agency for Health Care Policy and Research in Rockville, MD. The Iowa group is also collaborating with FACCT and the Buyers Health Care Action Group to resolve outcomes measurement problems.
Pietzsch predicts that the care system model will continue to grow, both in members and in communities willing to try it. In this model, which has received national media attention as a possible next phase of health care delivery, managed care organizations are limited to ancillary administrative roles.
"It solves a lot of the backlash issues of managed care," says Pietzsch. "It’s a return to the provider-patient relationship rather than having the patient and provider separated by some intermediary."
[Editor’s note: For more information about Buyers Health Care Action Group, contact Steve Wetzell, executive director of policy and public affairs. Telephone: (612) 896-5190.
For more information about the Community Health Purchasing Corp., contact Paul Pietzsch, president. Telephone: (515) 277-1210.]
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