Health reform rediscovers the patient - includes related information

Business & Health, Annual, 1997 by Susan Carleton

QMNet will help CONQUEST users by providing technical support (via phone, Internet and mail) and holding annual conferences, starting this year, on searching the database and using the measures it contains. It will also add to CONQUEST's capabilities, expanding information on a number of medical conditions and identifying gaps in the database. Information on disease-specific epidemiology, utilization and costs, potentially preventable adverse outcomes, comorbidities, risk factors and recommended clinical services will also be expanded. Finally, QMNet is charged with developing private support so it can be sustained beyond the three-year AHCPR grant period. "Our hope is that Qmnet ultimately may aid in the creation of a freestanding quality network," says AHCPR administrator Clifton R. Gaus.

How does QMNet fit in with other quality measurement leaders such as FAcct and the NCQA, which accredits health plans and assesses them through its just-revised Health Plan Employer Data and Information Set (HEDIS)? Both these organizations, as well as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have signed on as advisers to QMNet. As Diamond sees it, "QMNet provides the measurement infrastructure to assess clinical quality of health care, as opposed to the use of cost and expenditure measures. The CONQUEST database measures issues that are of clinical relevance: What does the clinical evidence justify from the point of view of service delivery? It's like the third leg of a stool, adding another dimension of understanding to die financial and use measures you already have."

Countervailing forces

Despite these developments, movement toward a more rational, quality-conscious health care system is slow and painful. "Quality assurance and accountability issues have acquired great urgency as a result of several things," says Ellwood. "One, the publicity about HMOs is, I believe, eroding the confidence and trust in managed care, and without that trust there can be no managed care. Two, health plan margins are way down, and they're having to be much more aggressive about cost control. In doing so, they're passing more risk onto providers, which means plans are increasingly losing control [of care]." The result: Providers are accountable mainly for keeping costs down, possibly at the expense of quality, which a remote HMO administration may not monitor closely.

Ellwood decries ham-handed legislative attempts to restrict and control managed care. In the California state legislature alone, more than 100 health care bills had been introduced by last October. If the system is micromanaged by the likes of Congress and state legislatures, he says, we might as well abandon all hope of applying rational standards to health care.

Equally troubling, already strapped health plans may balk at the expense of careful quality monitoring and reporting. "When the health care plans start the measurement process, it will cost them something, and they'll say that there isn't enough money in the premium to cover it," says WBGH's Cole. "Then purchasers will have to tell them it's just the cost of doing business. My feeling, though, is that the plans are going to have to learn quickly that they need to do measurement to stay competitive." Regardless of who winds up bearing the cost, the inevitable standoff between profit-squeezed health plans and tight-fisted buyers will also slow the pace of change.