Quality review sponsored by independent organizations, most agree, is the best way to inculcate quality measurement into the culture of healthcare providers. So it's not encouraging when one of those accreditation agencies goes belly up.
On Dec. 8, 1997, the Seal Beach, Calif.-based Medical Quality Commission, a not-for-profit accreditor of capitated medical groups and independent practice associations, announced it was giving up the fight. It will cease operations March 31.
The MQC took the step, it says, because of "financial constraints imposed by decreasing educational and research grants and flat demand for medical group and IPA accreditation." In other words, it was offering a product hardly anybody wanted.
This should give pause to all those who project a rosy future for the medical quality movement.
"You can't fight the economic reality," says Alan Zwerner, M.D., MQC president and chief executive officer. "Right now, the market is not there. Plans are not demanding it; purchasers are not demanding it. We do more in the capitated medical arena than anyone else, and we do very little."
The MQC has accredited 30 capitated medical groups and IPAs since it began operations in 1987 as part of the Unified Medical Group Association. It broke off from the UMGA, which represented capitated medical groups, in late 1990 because of conflict-of-interest issues.
Zwerner says the MQC's failure raises questions that ought to be seriously pursued by anyone interested in outcomes measurement. "When and where and how and who will be the organizations that end up scrutinizing the provider organization sector?" he wonders. "We had hoped it would come from within the industry." The MQC was created by a variety of stakeholders -- purchasers, providers, plans and policymakers. Its successor could be a single external stakeholder, like a business purchasing group or the government.
"It was a band of brothers that were trying to self-regulate, to defend against the skepticism of the public and employers that at-risk capitated medical groups were not performing quality care," says Ian Morrison, a California healthcare consultant. "That's what really spawned the need for this in the minds of the medical groups."
This model was particularly applicable in California, where most of the population is enrolled in HMOs that contract with physician groups to care for enrollees. Most clinical management occurs at the provider group or IPA level. A typical health plan in California will offer 130 or 140 medical groups or IPAs to subscribers. The MQC wanted to accredit those medical groups.
"They were ahead of their time," says Robert Brown, president of the Kansas City, Mo.-based Mid-America Coalition on Healthcare, an alliance of employers and healthcare organizations that examines quality issues. "This is a function that will return shortly because there's a need for this. We're talking about a way to establish some objective standards."
Wayne Burton, M.D., corporate medical director at First Chicago/NBD Corp. in Chicago, agrees with that assessment. "I believe the time will come, and there will be a national accrediting organization for quality at the group level," Burton says. "I think it's just a little premature."
For the time being, however, it's not on employers' radar screen, he says. That's not because of any lack of interest in quality, but because in the Midwest at least, the focus is on contracting with managed-care organizations accredited by the National Committee for Quality Assurance. Once that quality standard is attained, then you can drill down to the next level, the provider group, Burton says.
The NCQA accredits HMOs and also has developed a new physician organization certification program. This is not accreditation but a certification that the medical office is in compliance with specific standards. Once the office is certified by the NCQA, the various HMOs the medical group contracts with can accept that evaluation and skip doing their own survey.
Margaret O'Kane, NCQA*president, says employers aren't ready to make purchasing decisions based on accreditation of medical groups. "Awareness is high, but there's not really much of a push on this at this point," she says. "Everybody agrees this needs to happen. We're just at the beginning of the demand for information."
For the time being, O'Kane doesn't see any market advantage to medical groups from accreditation. "I don't think the market forces are aligned yet."
The MQC's failure exposes some of the dilemmas in managed care, Morrison says.
"We want to pretend we're in a world of managed competition, where people compete on cost and quality," he says. But in fact, HMOs in the California model are little more than "long-distance telephone service" driven by marketing. They all have to contract with the same large medical groups, and "it's not in their structural interest to expose the fact that they have the same networks."
Although people are accustomed to ranking HMOs by quality, "the variation within an HMO is greater than the variation between HMOs" in terms of medical performance, Morrison says. The MQC "was trying to expose that differentiation. The reason it failed is the world is not ready for the truth." And that truth costs money, which neither the medical groups nor the payers are willing to shell out.
An actual survey costs $10,000 to $15,000, Zwerner says, but the real cost to an organization is in the preparation, creating the systems and documentation.
"These are expensive processes to go through," Burton says. "They depend on sophisticated computer systems to get the data out, which the plans generally don't have." The medical groups have computers designed to generate bills. They need an expensive upgrade before they can measure quality.
The MQC's Zwerner agrees: "Until there is a marketplace advantage, or disadvantage, then few players will come to the table. No one rewards them for being accredited or punishes those who aren't. It's an idea whose time has not yet come."