A consortium of California doctors and hospitals formed to capture managed-care contracts has launched a project to demonstrate improvements in patient care.
The quality-management program at PrimeHealth of Southern California, a Pasadena-based network of 26 hospitals and 18 medical groups and independent practice associations, is unique because it was designed and is being implemented by providers.
"It's not a health plan orchestrating this, but the actual providers of care," says Jeff Borenstein, M.D., PrimeHealth's consulting associate medical director.
"It's a relatively new approach to have a network demonstrate how it can improve clinical care," he says.
The project received approximately $40,000 in research funds from VHA in Irving, Texas, because of its unique character, says Scott Weingarten, M.D., director of health services research at Los Angeles-based Cedars-Sinai Health System. Weingarten and Borenstein are in charge of the quality program.
"The part I think is relatively unique is it's a bunch of different physician organizations, with different information systems," yet they are coming together to collect and share data to improve quality, Weingarten says.
PrimeHealth was formed in 1994 to create "a countervailing force on behalf of the provider community to effectively negotiate contracts (with HMOs) and to assist in the development of new products," says Tom Maloof, president and chief executive officer.
The network's objective is "to secure long-term contracts on a preferred relationship basis," he says.
PrimeHealth is being funded through the sale of stock to its member shareholders-the hospitals and medical groups in the network. The organization aims to secure six to eight HMO contracts over the next four to six years. PrimeHealth's members also do separate contracting with HMOs.
PrimeHealth is in final negotiations for two commercial HMO contracts. The first, a product offered by a small HMO for individuals and small groups, would be launched this summer. PrimeHealth would be the product's exclusive provider network, and the enrollee could self-refer throughout the network without going through a gatekeeper.
The second contract, with a larger HMO, would be launched in the summer of 1998. PrimeHealth would provide administrative functions "that we as providers can perform much more effectively and efficiently" than the HMO, Maloof says. These include claims payment, utilization review, quality reporting and credentialing.
One way the network seeks to snag contracts is "to develop common policies and procedures to create efficiencies that could be passed on to HMOs," he says. Another is to show the network's ability to deliver superior care.
That's where the quality-management project comes in.
The project managers decided to start by using patient encounter data to measure quality of care based on a number of Health Plan Employer Data and Information Set, or HEDIS, indicators: mammography, Pap smears, cholesterol levels, childhood immunizations and retinal exams for diabetics. Physician groups reported data to Borenstein and Weingarten on a quarterly basis. They, in turn, passed it on to Optimatrix, a data-processing business owned by Cedars-Sinai.
Optimatrix processed the raw data and Borenstein and Weingarten sent it back to the physician organizations as "meaningful reports so they could better understand how they were doing," Borenstein says.
"Then we said, 'Gee, wouldn't it be exciting as a network if we could focus on mammography and see if we couldn't put together a quality-improvement program and demonstrate that we can improve mammography rates," Weingarten says.
There's a direct correlation between increased mammography rates and lives saved, he says.
Borenstein and Weingarten gave a number of presentations to physicians in the network to educate them on the importance of preventive care and patient interventions.
Then the project managers redesigned the patient encounter form to both facilitate data collection and remind doctors to perform preventive screening.
"Instead of a paper just having little boxes, we made them huge boxes with the different HEDIS indicators," Borenstein says.
Information from the encounter forms was then used to determine which women had not gotten a mammogram (about 7,000), and letters were sent to them informing them of the benefits of mammography.
As a result of these efforts, mammography rates, which Weingarten described as respectable before the effort, rose in the groups that participated in this project. The improvements ranged from 5% to 15% depending on how the outliers were analyzed. Rates were measured every quarter and then projected over a two-year period, Weingarten says.
The project managers sent the results around to all the doctor groups "to try to get the organizations to compete with each other to give the best care," Borenstein says.
The quality-improvement project at PrimeHealth is also helping the physician groups learn how to collect data using HEDIS measures, as required by HMOs. There's also a big push from large employers to report medical group data, so the experience will expose doctor groups to participation in the HEDIS process, Borenstein says.
In addition, "health plans are now beginning to require not only HEDIS measurements, but they also want to see that you're involved in a program of quality improvement. At least one group was able to use this project to satisfy that requirement," Weingarten says.
The next project the groups will tackle is improving the care of patients with stroke and bridging the gap between inpatient and outpatient quality-improvement programs. "Typically the quality-measurement programs of hospitals are absolutely separate," Borenstein says.
The biggest obstacle faced by the program is the limitations in some of the information systems, which are set up to collect data for administrative and not clinical purposes, Weingarten says.
Another challenge, Borenstein says, was explaining to the physicians that they were being asked to collect data to improve patient care, "that it wasn't a mindless administrative thing. Once they got that, most people said, 'Yeah."'