Industry needs to improve on chronic care
More sick patients join HMOs
The diagnoses range from asthma to AIDS, from high blood pressure to arthritis. As more chronically ill patients move into managed care plans, providers are searching for ways to treat chronically ill patients in a managed care setting.
So far, the answer has been elusive. Industry insurers and payers continue to fight off criticisms that managed care is more eager to treat the healthy than the sick in order to improve the bottom line.
The advent of Medicare and Medicaid managed care increases the urgency for finding an effective way for managed care providers and insurers to provide cost-effective care to sicker patients.
"We need to start experimenting with different ways to treat this population," says Paul Newacheck, PhD, a professor at the University of California San Francisco’s Institute of Health Policy Studies. "We need to move quickly on this because we’re moving so quickly on managed care in general."
Newacheck, who specializes in children’s health care issues, says the jury is still out on whether managed care is meeting the needs of the chronically ill. But he says enough anecdotal evidence exists to warrant concern, as well as movement toward finding better ways to treat patients who represent the biggest drain on managed care profits. Newacheck is the lead author of a research article in the November issue of Pediatrics that outlines a research strategy for analyzing the effects of managed care on children with chronic health problems.
"Anecdotally, there are arguments for both sides," he tells Physician’s Managed Care Report. "Clearly, managed care offers a great deal of potential. But the downside is that families may have to switch providers; there are questions about whether patients can get specialty care when they need it. And there is the broader economic incentive to cut back to improve the bottom line."
Other studies are pointing to managed care’s shortcomings, as well. A Journal of the American Medical Association study showed that physicians in capitated arrangements focused their quality assurance (QA) efforts on measuring overuse of resources such as cesarean births or angioplasty rates, and focused follow-up services on preventive health, while lacking in follow-up services for chronically ill patients.1
"[A physician practice] needs to have a quality monitoring system that’s uniform and focuses on chronic disease," says Eve Kerr, MD, MPH, a physician with the Ann Arbor (MI) Veterans Affairs Health Services Research and Development Field Program. "It can’t just focus on overuse and preventive services."
Rather than wait for the studies to show whether managed care is doing a poor job of caring for the chronically ill, Newacheck suggests the industry take the following steps:
1. Payers need to ensure reimbursement rates reflect the true cost of caring for those with chronic disease.
This calls for advancements in the field of risk adjustment. There are at least two promising risk-adjustment methods being tested: Ambulatory Care Groups (ACGs), developed by Johns Hopkins University; and Diagnostic Cost Groups (DCGs), developed by the University of Boston and Waltham, MA-based Health Economics Research. Both are designed to risk-adjust payments to providers based on diagnosis. This would allow payers to more accurately estimate the cost of care for chronic illness. While these systems will be better able to estimate costs for the chronically ill, they cannot estimate unforeseen costs, such as injuries caused by automobile accidents, as well as demographically based risk adjusters.
By coming up with an accurate risk-adjustment method, health plans can be held accountable for the care that is delivered, Newacheck says.
"We need to do a lot more work on moving the field of risk adjustment forward, and do it quickly so that we can start building in these rates in the plans," Newacheck says.
2. Reporting systems need to measure care of chronically ill patients.
Reporting systems, such as the Health Plan Employer Data Information Set (HEDIS 3.0), currently measure treatment of acute illness and chronic illness together. Newacheck says reporting systems should measure quality of care for chronic illness separately.
3. Create standards of care that are chronic- illness-friendly.
Health plans should have physician panels that include providers trained to deal with specific diseases or illnesses. If a child with cystic fibrosis or spina bifida enrolls in a plan, there’s nothing that requires the plan to have a specialist familiar with the child’s condition.
Short of enacting legislation that would require an HMO to include a physician on its panel for each chronic illness represented in its patient population, Newacheck says managed care organizations should do this on their own.
"We need to get to a point where [HMOs] feel they have to have those specialty providers so that a child doesn’t have to go to an adult provider or a generalist who doesn’t have much experience with those conditions," he says.
4. Create links to the community.
Only so much care can be delivered in acute care or physician office settings. Newacheck says providers need to reach out to the community to find additional care for their chronically ill patients. For example, look for community aging programs for elderly patients or social workers for mentally retarded patients.
Quality assurance programs can help
In physician practices, doctors need to be mindful of the quality of care they are delivering those with chronic illness. Improving QA programs to include measuring care for chronic illness can get practices moving in the right direction.
At Carle Clinic in Urbana, IL, practice guidelines, disease management, and physician education play important roles in the organization’s QA efforts. But the approach the clinic takes with its physicians has changed to adapt to today’s health care industry.
"The difference between quality assurance of years ago which was, Let’s look at the bad apples and tell them they’re doing a bad job and maybe they’ll change’ and today is that now you have to be proactive," says Sandra Reifsteck, RN, MS, associate administrator of Outreach and Development at Carle Clinic. "You need to look at what you need to be doing, what diagnoses you have, how you can do things better, and what tools to give your physicians to do better."
Many health plans require quality assurance, but only offer general guidelines rather than specific requirements. In the end, QA programs may end up focusing more on prevention than on the chronically ill. Also, practices may avoid formal QA measures such as outcomes and patient satisfaction measurement because of the cost associated with them. Experts warn that this may prove to be poor judgment, because a sound QA program can actually save money and improve patient care.
Outcomes measurement more complex
Although physician groups have fallen short of their QA responsibilities, the reason isn’t irresponsibility, but rather the complexity and expense of running a comprehensive QA program, says Julie Sanderson-Austin, vice president of quality management and research at the Alexandria, VA-based American Medical Group Association, formerly the American Group Practice Association.
"Measuring preventive care is just like measuring widgets," Sanderson-Austin says. "You just count how many mammograms you did or how many immunizations you gave. When you begin to get into measuring the quality of care in chronic disease, you’re not measuring widgets anymore. You’re measuring how patients are doing. It’s difficult to get into that arena unless you really want to dedicate yourself to measuring long-term outcomes."
A sound QA program should consist of the following elements, according to Sanderson-Austin:
1. Health Plan Employer Data Information Set.
HEDIS 3.0, which went into effect this month, offers a good QA program starting point. Used to evaluate the quality of health plans, HEDIS measures quality of care through preventive care measures, pregnancy care, acute and chronic illness care, mental health care, access to care, and patient satisfaction.
These are items physician groups should be measuring. For instance, comparing the childhood immunization and breast cancer screening rate to national and state averages, or the number of diabetic retinal exams delivered annually, allows physician groups to benchmark their quality.
2. Peer review.
This isn’t anything new to physician groups; professional collaboration is commonplace. "Act together as a team," Sanderson-Austin says. "No one can judge the technical quality of care except the professional." This can be accomplished formally or informally. Peer review can be accomplished with impromptu meetings in the hallway or weekly meetings, she says.
3. Measure patient satisfaction and outcomes.
Here is where it starts to get complicated. Measurement of patient satisfaction and outcomes is an emerging discipline in the health care industry, and will require additional resources. These measurements are vital for a physician practice to move toward tracking quality of care for the chronically ill.
"People with chronic illness get sick very slowly," Sanderson-Austin says. "Trying to measure medical care’s impact on the illness process, whether it’s slowing it or halting it, is very different from measuring preventive care."
Measuring outcomes through tracking vital signs and other markers will allow providers to gauge the progress of the patient’s health against the course of treatment.
Carle Clinic took the disease management and preventive care approach. It started by analyzing patient encounter data and determining the most prevalent diagnoses. Then, two physician committees were formed, one for disease management and one for preventive care.
The committees were responsible for developing clinical practice guidelines for specific diagnoses such as heart failure, depression, and low back pain. Using outcomes data, the guidelines are constantly updated to incorporate care that improves patient health and highlights efficiency.
But the key to success doesn’t lie strictly in the measurement tools a practice uses. Physician support is important, as well. "What we’ve done is seek the support of key physicians," Reifsteck says. "To start without it is almost a waste of effort. You need a committee of physicians that are committed to implementing a [QA] program."
Reference
1. Kerr E, Mittman B, Hays R, et al. Quality assurance in capitated physician groups. JAMA 1997; 276(15):1336-1239.
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