PHC4 | Buying a Health Plan

Quality

Quality is difficult to define and even harder to measure. Yet organizations, including health care organizations, strive continuously to measure and improve the quality of their products and services. The Institute of Medicine defines health care quality as care to individuals and populations which increases the likelihood of a desired outcome and is consistent with the current state of professional knowledge. Experts tend to describe three dimensions of quality: structure, process, and outcome. No single dimension alone is sufficient to describe quality.

Structure - Structure comprises properties of personnel and facilities and are used as indicators of the expected quality of care. It can include such items as safety, organizational structure and staffing of health care providers.
Process - Process describes what is done for patients and by patients and includes the content of care and the skill with which care was executed. The process of care is critical to the delivery of quality care. An example of a process indicator is the frequency of cholesterol screening for the at-risk population.
Outcome - Outcome is the end result of care. Is cholesterol reduced? Is the patient restored to health and full functional status? Is the patient satisfied with the health care services? Some outcomes like functional status are difficult to measure. Others, which may be easier to measure, such as mortality, are sometimes difficult to link to a specific process of care.

Accreditation

Accreditation agencies like the National Committee for Quality Assurance (NCQA) focus primarily on structure and process. Accreditation by the NCQA is strictly voluntary. How to define and measure health plan performance is still a new concept, and there is no clear consensus on the best way to approach the issue. As a purchaser, it is important that you understand basic concepts and not be reluctant to ask questions about quality.

The Pennsylvania Department of Health requires HMOs in Pennsylvania to undergo an independent quality review to ensure progress in quality assurance and to identify quality improvement opportunities. Accreditation is one way of satisfying this requirement. Accreditation by NCQA is not limited to HMOs. Other types of managed care organizations can receive accreditation. Accreditation involves an intensive on-site review of the following plan activities:

Quality Management and Improvement;
Members' Rights and Responsibilities;
Preventive Health Services;
Utilization Management; and
Medical Records.

The status of accreditation is available from the Pennsylvania Department of Health, Bureau of Health Care Financing at 717-787-5193 or the NCQA at 202-955-3500.

What Is a Managed Care "Report Card"?

Efforts to define, measure, and report on managed care organizations including health maintenance organizations are continually evolving. Currently, the leading effort is the Healthplan Employer Data and Information Set (HEDIS). HEDIS is a voluntary effort to measure and report on the performance of health plans. It has developed measures in the following categories:

Quality of Care;
Member Access and Satisfaction;
Membership and Utilization;
Finances; and
Health Plan Management.

How Does HEDIS Measure Quality?

HEDIS (currently V 2.5) reports the rates of utilization for a number of preventive services as its quality indicators. Many of these measures are an indirect measure of outreach to at-risk populations. A newer version of HEDIS is expected in early 1997 and may include a number of additional measures. Some of the quality indicators in the current version of HEDIS are:

Childhood immunization rate measures the percentage of children who have received a complete set of immunizations.
Cervical cancer screening rate measures the percentages of women between ages 21 and 64 who have been screened for cervical cancer.
Percentage of low and very low birthweight babies measures the number of live births weighing less than 2500 or 1500 grams (5.5 and 3.3 lbs.) to mothers who were continuously enrolled in the plan for 12 months prior to delivery.
Asthma inpatient admission rate measures admission rates for asthma. Low admission rates are regarded as an indicator of the plan's ability to manage this chronic disease.

Is HEDIS alone an Adequate Measure of Quality?

The process of defining, measuring, and reporting the quality of health plans is an evolving discipline. Currently, HEDIS addresses issues for quality improvement and remains the measurement of choice by many plans and employers. NCQA is in the process of updating HEDIS, which may include up to 80 additional measures and several new categories by the time the new version is released in 1997. Some consulting firms have developed their own measures. Some items that have been proposed include long term survival rates for cervical cancer and functional status of asthma patients. These outcomes are difficult to measure and interpret, especially when members change plans frequently during a lifetime.

Clinical outcomes measures can be used to supplement or replace the HEDIS measures. An outcome measure is a performance measure which assesses patient health status resulting from health care treatment. An example of a clinical outcome measure is mortality. A comparison of clinical outcomes of different provider networks can be meaningful. The Pennsylvania Health Care Cost Containment Council has demonstrated an ability to compare risk-adjusted mortality rates of hospitals and physician groups in its Consumer Guide to Coronary Artery Bypass Graft (CABG) Surgery reports and the recently released Focus on Heart Attack report. The Council has also aggregated the performance of providers to analyze outcome measure by payor classification.

Some questions to ask your health plan representative about clinical outcomes include:

What are the referral hospitals?
What is their risk adjusted mortality rate?
How well does that rate compare with state and national norms?