Red flags are being raised about the value and utility of the popular healthcare "quality report cards" comparing managed-care plans.
That's because the "grades" have been based on the plans' own internal measures of quality and efficiency. As a result, employers are putting pressure on the managed-care industry to develop acceptable standards for auditing the performances of HMOs and PPOs to make sure their claims are credible.
The report cards one day may be used by consumers to shop for the best health plans in much the same way many people shop for new cars and appliances.
But even their proponents worry that the report card claims described in breezy press releases and glitzy ads in newspapers and magazines around the country may be more hype than help.
So far, four managed-care insurers-United Healthcare Corp., Minnetonka, Minn.; Blue Cross of California, Woodland Hills; U.S. Healthcare, Blue Bell, Pa.; and the northern region of Kaiser Permanente, Oakland, Calif.-have published report cards describing their performances. The self-evaluations focus on such categories as the frequency of mammography screening, Pap smears, pediatric immunizations and hospitalizations for chronic conditions such as asthma (See chart). More HMOs are expected to publish similar report cards in the months ahead.
"We've moved from a dearth of information into a rush of accountability," said Carol Cronin, executive director of the Managed Health Care Association. "That makes me a little bit nervous" because it may be premature, she said.
MHCA is a Washington-based education, research and lobbying group representing 110 private employers nationwide. It's become one of the chief sponsors of the Health Plan Employer Data and Information Set (known as HEDIS 2.0), which is intended to spell out for HMOs a standard method of identifying, calculating and reporting 60 performance measures covering quality, enrollee satisfaction, utilization and financial data (Dec. 20/27, 1993, p. 62).
HEDIS has been under development since 1989 by the National Committee for Quality Assurance, a Washington-based HMO accreditation agency, in association with several HMOs and a handful of large employers.
Because of the widespread support of large private employers, HEDIS 2.0 is likely to become the managed-care industry's standard for measuring the future performances of the nation's health plans.
Putting standards in place.Alreadysome two dozen employers have said they will require their health plans to begin using HEDIS standards in all their quality reports this year.
The California Public Employees' Retirement System also has begun requesting information based on the HEDIS model from some 20 health plans serving nearly 1 million state employees and their dependents.
In addition, 21 HMOs have agreed to spend a total of $2.1 million to fund a pilot project they hope will produce a standard report card based on NCQA's research. If successful, that report card eventually will be used nationally by purchasers as well as HMOs to rate providers, perhaps as early as 1995.
So far, few hospitals have been affected by the drive to develop a standard report card. The most prominent example involves 30 hospitals in Cleveland, which are experimenting with a system that attempts to uniformly assess the institutions' quality of care (Dec. 20/27, 1993, p. 6; April 12, 1993, p. 43).
As the idea catches on, however, more hospitals can expect to be involved in the development of similar uniform rating systems that will be used to judge how well they and their competitors provide various services on a local and national basis.
For employers battling rising healthcare costs, it's "absolutely crucial" to hold health plans accountable for their performance, "especially when they're given money every month to do so," said Helen Darling, manager of healthcare strategy and programs for Xerox Corp. "There's tremendous room for improvement," said Ms. Darling, whose department oversees more than 200 contracted HMOs around the country.
"We need HEDIS to feel confident that our health plans are specifying, calculating and repeating performance data in the same way," said Alan Peres, manager for benefits planning at Chicago-based Ameritech. HEDIS also incorporates a "user's guide" for help in interpreting the data in much the same way business people have learned to read financial statements, he said.
The report card of U.S. Healthcare is the only one to be based on HEDIS 2.0 standards, which were unveiled in September 1991. Those ratings were based on the HMO's performance covering 600,000 Pennsylvania enrollees (See chart). Collection of the data can be expensive and time-consuming for many of the provider groups responsible for producing the reports, which may delay the release of other report cards until agreement can be reached on uniform standards.
HMOs may collect and use some of the same data for purposes other than for developing self-rated performance reports. Blue Cross of California's "quality scorecard," for example, is used by the company to rate its outside network of physician groups. Those groups that score well will receive monetary bonuses in 1994, Blue Cross said.
A degree of risk also is involved in this process to establish uniform standards. "We're really just starting down this road (of standardization)," said Janet Corrigan, NCQA's vice president of planning and development. "We don't know yet how good these performance measures are."
Despite the unknowns, HMOs are moving quickly to develop a uniform method of reporting before "the battle of the report cards" has a chance to sour the public on the usefulness of their claims.
Marketing scores.In some markets,
managed-care plans are using newspaper advertising to trumpet their high quality marks and paint their competitors as inferior alternatives.
"In terms of substance, what's the contribution (of the ads)?" asked Allan Baumgarten, a Minneapolis-based healthcare consultant and former associate director of the Citizens League, a public affairs research and education organization in Minneapolis.
He said Medica, a unit of United Healthcare, and Group Health, another Minneapolis-based HMO, have been waging a report card "war" in newspaper ads in the Twin Cities comparing their performances in various categories.
"The HMOs deserve some credit because they're testing new methods of reporting," Mr. Baumgarten said. "But you don't know what methods or standards they followed to come up with those numbers."
"You want to get that kind of information into employees' hands, but you don't want to mislead them," said Fran Bastien, national health program manager for Digital Equipment Corp., Maynard, Mass., one of the founders of the HEDIS project.
Such marketing may "work on Madison Avenue, but I'm not sure it plays the same way on Main Street," said Martin I. Schneider, publisher and editor of Health Pages, a consumer-oriented glossy magazine that debuted recently in St. Louis to provide comparative performance data on local managed-care organizations.
Although he believes "most people take ads for what they're worth, if you're going to have competition, it's going to have to be audited," Mr. Schneider said.
The Managed Health Care Association's Ms. Cronin acknowledged that "there's value in starting the process of publicizing the information. There's a difference if you're using it for marketing purposes," she said. "Ultimately what you need is some third party in control of more complete information."
Toward that end, MHCA and several business coalitions are backing Mr. Schneider's efforts to develop Health Pages into a "forum of comparability" that will help consumers choose from a panel of local providers based on uniform standards of performance.
The first effort of the New York-based publisher, who owned and managed several outpatient medical clinics before he embarked on his latest endeavor, focuses on 20 managed-care plans in St. Louis. The 40-member St. Louis Area Business Health Coalition guaranteed distribution of 60,000 copies of the 64-page magazine to employees and retirees of such companies as McDonnell Douglas, Union Electric and Union Pacific.
The magazine compares the health plans in eight categories: pediatric immunization, mammography, Pap smears, eye exams for diabetics, prenatal care, low-birth-weight babies, asthma and deliveries by Caesarean section. The magazine also compared the plans' rate of disenrollment and frequency of patient complaints. It also included a guide to St. Louis-area physicians that provides consumers with basic information about fees, services and backgrounds in various specialties.
None of the information about the 20 HMOs and PPOs was audited, which means the magazine was unable to say whether the health plans used the same methods of collecting data for comparison.
Mr. Schneider described the first edition as "a first step." He said he's working with NCQA to come up with a method of checking the data that will be submitted by the plans before the magazine's next edition in St. Louis, which is expected to be published later this year.
"The goal is not to allow managed-care plans just to provide any information they care to and not have them be accountable," he said. "It certainly wouldn't serve the readers' interests."
He said with that strong employer-based support, he'll publish more editions of Health Pages in several other cities in the next 18 months. Cities or regions tentatively targeted include Pittsburgh, Washington, southern Florida and northern California.