Questing for quality: QISMC-ly cutting the QAPI - quality improvement system for managed care; quality assessment and performance improvement

Healthcare Financial Management, Oct, 1998 by Jeanne Schulte Scott

"[T]he market will reward those providers that can truly manage care by finding innovative ways of delivering consistent quality at a reasonable price."

- HFMA President and CEO Richard C. Clarke, FHFMA, commenting on HFMA's survey of providers and employers and their attitudes toward continuing quality improvement in managed care.

"Unless the regulations are carefully modulated for different types of healthcare products, they will limit beneficiaries' options to tightly managed HMOs and deny access to popular PPO products."

- Dr. Daniel Lestage, vice president of professional and organizational relations for Blue Cross-Blue Shield of Florida, commenting on the industry's concerns that new Medicare and Medicaid rules for quality will prove to be too costly for many managed care plans.

While managed care has gained in popularity among employers in one market after another as a means to help control rising healthcare costs, a question that has haunted healthcare policy-makers since the advent of managed care has taken on new urgency: In the quest to save money, has quality been sacrificed? Both employers and managed care plans have tried to convince the public that managed care is quality care. There is, however, considerable skepticism among healthcare consumers about the quest for quality in managed care.

Employers and managed care plans established the National Committee on Quality Assurance (NCQA) to address quality issues. Through NCQA, employers and plans have, to their great credit, fostered and funded the expanded use of quality reporting indicators, primarily the Health Plan Employer Data and Information Set (HEDIS). HEDIS measures now are used widely in managed care and form the basis for the NCQA accreditation program so important to many employers in deciding which managed care plans to make available to their employees.

On January 1, 1999, the nation's largest healthcare program, Medicare, and its regulatory agency, HCFA, will begin something new - Medicare Choice. This experiment in direct contracting between provider-sponsored managed care plans and Medicare will include continuous quality improvement requirements, which HCFA has dubbed a "quality improvement system for managed care" (QISMC).

QISMC goes beyond the HEDIS quality assessment process by attempting to make continuous quality improvement a standard for participation in Medicare Choice. Plans will have to demonstrate that they have a quality system in place that actually enhances performance and results in systemic quality improvement. Furthermore, HCFA intends to make QISMC mandatory for Medicaid managed care plans and to impose the new standards on the states.

Provisions of QISMC include requirements that plans:

* Operate an internal program of quality assessment and performance improvement that achieves demonstrable improvements in enrollee health, functional status, or satisfaction across a broad spectrum of care and services;

* Collect and report data reflecting their performance on standardized measures of health outcomes and enrollee satisfaction, and meet such minimum performance levels on these measures as may be established under their contracts with HCFA or the state Medicaid agency; and

* Demonstrate compliance with basic requirements for administrative structures and processes that promote quality of care and beneficiary protection.

Immediately after the QISMC initiative was launched, it came under attack. The initiative demands too much, too soon, said its critics, and places very heavy demands on plans, especially smaller ones. As a result, critics charged, QISMC could divert needed resources from patient care. In addition, because of the new reporting systems demanded by QISMC, some critics felt that new contractors would be effectively barred from entry into the program and that existing ones would be driven out of participation. Critics argued further that the costs of QISMC compliance would end up limiting consumer choices. Others suggested QISMC encourages plans to address areas where improvement is easiest to effect, regardless of their relative importance. Finally, state governments objected to the fact that the burden of enforcing compliance among Medicaid managed care plans would fall on them.

Taken aback, HCFA convened a panel of quality experts to address these concerns and, based on their recommendations, agreed to make some basic changes in the initiative. For example, plans will be required to complete three projects in clinical focus areas during a set three-year period. Two projects are to be selected by the plan from a limited list of project topics developed by HCFA and/or state Medicaid agencies. A third topic will be identified by the plan itself. These projects will be selected to foster meaningful quality improvement and simultaneously promote sophisticated management information systems.

Plans also will be required to complete projects in three nonclinical areas in each three-year period. Topics all are to be selected by the plan, although HCFA and the states reserve the right to direct plans to focus on specific concerns.