Better health plans report quality data

Poor performers still able to avoid scrutiny

Here’s evidence that health care accountability works: Health plans that publicly report quality data not only perform better, but they show more improvement than those that don’t, according to a recent report from the National Committee for Quality Assurance (NCQA) in Washington, DC.

Unfortunately, plans with poor performance can still avoid scrutiny simply by declining to release their results. And so far, better performance on quality indicators hasn’t guaranteed plans or medical groups a competitive advantage.

While an estimated 90% of the country’s 650 health plans collect at least some Health Plan Employer Data and Information Set (HEDIS) data and 447 reported 1997 HEDIS results to NCQA, only 330 pursue accreditation, and only 292 allowed their data to be made public. Meanwhile, preferred provider organizations and indemnity plans do not participate in HEDIS and report no quality information to NCQA or other national bodies.

"I think purchasers and regulators need to be more aggressive in saying we’re going to get the same information about everyone," says Andrew M. Wiesenthal, MD, associate medical director of Colorado Permanente Medical Group in Denver and a member of the NCQA board of directors. "If you can’t provide the information, [regulators should say] you can’t provide the services."

George Isham, MD, medical director and chief health officer of HealthPartners, a managed care organization based in Minneapolis, believes the trend is moving toward greater accountability. He notes that 121 plans allowed their data to be released for the first time this year. "I think people are paying attention to these numbers," he says. "I think this is a matter of momentum and building. It’s moving in the right direction."

Variation remains high

As in last year’s report, the 1998 Quality Compass data again showed a huge variation between the highest and lowest performing plans. For example, rates of beta blocker treatment for patients experiencing a heart attack ranged from 52% to 92%, with a national average of 74%. On average, plans publicly reporting their data outperformed their counterparts by more than 10%. Overall, New England outperformed other regions in the country.

Patients were more likely to say they were "completely" or "very" satisfied with care from plans that publicly reported data (58.5% vs. 50.4%) and those publicly accountable plans performed better on every HEDIS measure. (See chart, at left. For more information on the study, see related story, p. 145.)

Physicians often find fault with HEDIS as an assessment of quality care, pointing out that most indicators measure a process of care, such as screening patients for breast cancer, rather than an outcome, such as lower stage of cancer at diagnosis and better survival rates. NCQA points out that better cancer screening and beta blocker treatment can save lives. And at the same time, NCQA acknowledges that HEDIS is a work in progress.

"This is a beginning step, an exceedingly important step," says Gary Krieger, MD, a San Pedro, CA, pediatrician and representative on the PMCC, commenting on the Quality Compass results. "We must refine it so the consumer and the purchaser of health care can make informed decisions."

"You can point up many fallacies in what’s being reported," acknowledges Krieger. "But we are constantly improving."

In fact, overall, plans showed little progress on 10 effectiveness of care measures, including mammograms, immunizations, cervical cancer screening, and prenatal care. But plans that publicly reported their data for the past two years did show significant improvement. For example, plans that report data improved their adolescent immunization status from 53.6% to 57.8%.

Unfortunately, most purchasers and consumers aren’t yet attuned to the quality indicators. That means there is little pressure on poor performers and few advantages accruing to the high performers. Isham notes that some large employers, such as General Motors and Xerox, are rewarding better-performing health plans. But that trend is far from widespread.

"I think purchasers and regulators need to be more aggressive in saying, We’re going to get the same [quality] information about everyone,’" says Wiesenthal.

Despite talk about "value-based purchasing," he says his group model HMO has yet to see marketplace benefits from its quality data.

"We have comparable [premium] rates to major competitors in our market and demonstrably better quality on the public measures," says Wiesenthal. "People ought to be beating my door down to become members. Big employers ought to be insisting that we’re one of their offerings."

They’re not, he adds. But Wiesenthal remains optimistic that the health care market will become more focused on quality. "I like to see the good things that appear about us in the press when these reports are released," he says. "I’d like to think it helps [competitively], but there are no data that it does." Still, he says, "In the long run, it’s going to be what [matters]."

Medical groups need incentives

Even fewer independent medical groups collect and report HEDIS data, notes Wiesenthal. The California Cooperative HEDIS Reporting Initiative (CCHRI) will begin public reporting of HEDIS rates by medical groups next year.

Leaders of the medical groups involved with CCHRI are committed to accountability, says Alfredo Czerwinski, MD, a principal with Lawson & Assoc. consulting firm in Sacramento and a member of the executive committee of CCHRI. But currently those groups see little material benefit to their involvement.

"The overarching issue is this: Will the group end up getting 10,000 more covered lives after it goes through all the work of pulling the charts, calculating the measures, and publishing the data?" says Czerwinski, who specializes in physician organizational development and quality improvement. "Will some economic advantage accrue to those who take the trouble to publish and have good scores?"

Slowly, NCQA and other organizations are trying to expand the scope of performance assessment. In 1999, all plans that seek accreditation must report HEDIS data that are verified by an approved auditor. Business coalitions such as the Pacific Business Group on Health are reporting information from patient surveys on medical group report cards.

"There is no question that the movement is going toward much more accountability of all segments of health care," says Krieger.