How managed care measures up: few managed care plans link procedures to health outcomes, despite some efforts to measure the level of preventive screening - includes related information on quality and patient satisfaction

Business & Health, Jan, 1994 by Judith A. Hale, Robin B. Weiner

One of the public's greatest concerns about health care reform is that quality might suffer as pressure increases to control costs. President Clinton addresses these concerns in his health care reform proposal, the Health Security Act of 1993, which calls for developing a set of national measures of quality performance. The measures would be defined by a newly created panel of experts, the National Quality Management Council (NQMC). Each health plan would have to publish its results annually in a standard format, referred to as a quality "report card." The report cards are intended to give consumers the information they would need to reward high quality plans with their business.

The concept of a report card isn't new. Many plans voluntarily prepare report cards on their services. In November, the Kaiser Permanente plan's Northern California Region released a quality report card covering 90 quality indicators. And the National Council on Quality Assurance (NCQA), in Washington, has developed the Health Plan/Employer Data and Information Set (HEDIS), a set of standard performance measures to help employers request quality data from health plans. Twenty-one managed care plans are working with NCQA to develop a report card by 1994 based on the HEDIS standards. Current report cards include only limited data on appropriateness and outcomes of health care services, however.

The Clinton plan would require the NQMC to develop practice guidelines, with assistance from the federal Agency for Health Care Policy and Research. Practice guidelines that have already been developed by other organizations would be evaluated and certified. And support would increase generally for broad-based research on outcomes of health care services, dissemination of guidelines, and methods for measuring quality.

Under the president's vision of health care reform, health plans would have to report on access to care, the appropriateness and outcomes of health care services, health promotion, prevention, and consumer satisfaction. The measures plans use would have to be "reliable and valid," and data would have to be obtained "without undue burden on the entity or individual," the proposal specifies. When a measure is the frequency with which a procedure is performed, that procedure would have to be linked to a specific health outcome.

PLANS AREN'T PREPARED

Results of a recent survey of 102 large managed care plans by A. Foster Higgins & Co. Inc. suggest that managed care organizations are not well prepared to take on the burden of collecting and disseminating data on quality and outcomes.

More than one-fourth (26%) of responding health plans say they are "not at all active" in outcomes research, and the most common response (44%) is "somewhat active." (See chart, page 36.) Plans that are active in outcomes measurement say they focus their research on measuring the incidence of preventive screening, such as mammography and Pap smears. A few large, very active organizations (with more than 700,000 members) are most involved measuring the effectiveness of various treatment methods and establishing practice guidelines.

Although the majority of plans involved in outcomes research are collecting data on preventive measures, the survey makes no distinction between preventive measures and measuring the effect of care on clinical status.

Survey respondents that collect outcomes data restrict the data to internal use, primarily as feedback to their own providers. Many organizations are uncomfortable disseminating this information to the public and few have used it to market their plans. Problems with data availability and validity also suggest that reporting performance data linked to outcomes--as the Clinton plan would require--can't be achieved swiftly.

PRICE VS. QUALITY

Supporters of health care reform expect to create a system based on demonstrated indicators of quality and cost effectiveness. Published reports on medical outcomes and managed care report cards are expected to help force providers to compete for the first time on quality as well as cost. Although some employers already insist that health care providers be accountable for both factors, the survey shows that managed care organizations aren't convinced those factors are important.

Responding organizations were asked to rank seven factors in order of importance to their marketplace success over the next three to five years (see chart, page 38). More than two-thirds (69%) ranked price first or second, followed by patient satisfaction (50%), and provider access (31%). Managed care plans apparently believe their customers are more concerned about price and employee reactions than specific quality measures. For most plans, published outcomes was last on the list; only 9% ranked it one or two in importance.

Surveyed plans believe outcomes research will improve quality, but they disagree about its ability to reduce costs. More than three-fourths (78%) say outcomes research will improve quality over the next three to five years, while only 30% say it will lower costs. Respondents' beliefs that outcomes research will improve quality are unrelated to their outcomes activity. But the majority (67%) of managed care plans that say they are "extremely active" in outcomes research are convinced it will lower costs; only 15% of organizations that are "not at all active" hold this belief. In fact, extremely active managed care organizations are researching a broader range of diagnoses and procedures, some with much higher cost implications (cardiac catheterization and coronary artery bypass surgery, for example).