Quality with teeth: Washington medical groups join with Premera Blue Cross to quantitatively measure quality and quality improvement

Health Management Technology, March, 2005 by Robin Blair

Talk is cheap. It's easy to banter through a healthcare IT discussion inserting the occasional "patient safety" or "quality improvement" phrase when it enhances the discussion. It's harder to take constructive, targeted action--and to put enough teeth behind it to make a measurable improvement in the quality of care delivered, and also in the patient's compliance with medical recommendations.

But no one does data like health plans. On the nation's West Coast, Premera Blue Cross and a respectable number of physician practices have teamed up in a way that gives new meaning to the word "collaboration." In fact, while this health plan/physician collective has used data and IT to develop an impressive best-practice and quality-improvement tool, it's the coming together of health plan with physician practices that they all herald first.

Mark Sollek, M.D., is Premera's medical director. As a nephrologist, he says he grew up in a world of collaboration and teamwork, so spearheading Premera's effort on a Quality Score Card was a natural. The Quality Score Card represents a three-year effort by Premera and several prominent Washington medical groups to manipulate and analyze data in a way that favorably influences the specific delivery of healthcare services based on best practices, patient compliance with medical recommendations (and hence, improved health status), office efficiency and patient satisfaction.

Don't Reinvent the Wheel

Premera Blue Cross is headquartered in Mountlake Terrace, Wash., with operations and offices in Seattle, Spokane and Anchorage, Alaska. The health plan serves more than 1.2 million members in Washington and another 108,000 in Alaska. More than 21,000 providers are affiliated with Premera, and more than 3,000 employees support its work.

In the beginning, Sollek joined with medical directors from the six largest medical practices in Washington for preliminary discussions. "Health plans are health plans, not just claim-payment shops," he says. The claims data they own is an excellent source for identifying patients who could benefit from the application of accepted and proven treatment methods for specific diseases such as asthma and diabetes, and also for the prevention or early identification of other diseases such as breast cancer or cervical cancer. Health plans, he says, are also great vehicles to help benchmark and measure areas such as well-child screenings, patient satisfaction with provider services and improvements in healthcare delivery efficiency.

The initial group examined available national standards, the types of metrics the Quality Score Card project might produce and the kinds of outcomes the project could expect. Then, says Sollek, "We worked through that, honed it down, and then went to a few clinics to try it out."

Try what out? Sollek's initial group determined that the project's focus must include areas that were clinically significant and areas where specific and changed medical interventions could deliver a measurable improvement in a patient's health status. That was critical to the physicians involved. They also felt that patient satisfaction was an important metric, as was efficiency. As such, they started with 17 specific indicators. (Editor's note: For an in-depth look at the 2004 Premera Quality Score Card, logan to www.premera.com.)

Members of the initial Quality Score Card team considered carefully what standards to use at baseline, and decided against an attempt to develop their own standards. Instead, the group itself strove for efficiency by adopting national standards from respected bodies such as the U.S. Centers for Disease Control and Prevention, the American Heart Association, the American Diabetes Association, the American Academy of Pediatrics and the National Institutes of Health, among many prominent organizations.

Private Data Stays Private

From the start, the project team was aware of the strengths and limitations of claims data, which is, of course, the foundation of health plan data. Claims data may identify patients who have been treated for conditions such as diabetes, asthma or acute bronchitis, and more by exception than anything else, it can be manipulated to determine who has not received specific, chargeable treatment for those conditions. But because it doesn't include lab or imaging results, it doesn't necessarily show an improvement in healthcare quality achieved because a patient did follow the recommended medical regimen for his condition. That's where physicians' data comes in.

Measuring improvement "involved the medical groups and their IT systems," says Sollek. "They had IT systems that could pull numbers for us" to demonstrate positive changes in patients' health status based on their return visits.

Because physicians' data would be involved, the Quality Score Card team agreed not only on the standards of care to be initially measured, but also that participating doctors would control the use of the data. As such, the group set out to measure performance in the 17 areas against national standards, but agreed that the participating physician practices wouldn't share their results, not even with each other.