For the first time, enrollees in Texas HMOs this year will see how their health plans measure up.
Pressure from employers, doctors and consumers has pushed Texas into joining a growing number of states that require HMOs to disclose data on how well they perform.
But the resulting "report cards," due out July 1, already are stirring controversy because the data they contain will be gathered by the HMOs. And, accordingly, the gathering process will likely be different for each group, which may make it difficult to make useful comparisons.
"The concern is whether it will be a comparison of apples to apples," says John Seidenfeld, M.D., vice president and medical director of Cigna HealthCare of Texas.
The HMOs will send the state data related to 26 tasks, such as how long it takes patients to see a doctor, and how often eye exams are performed, young children are immunized or breast cancer and diabetes screenings are performed.
The 26 items are being culled from a list of 70 performance measures known as the Health Employer Data Information Set, or HEDIS. HEDIS was created by the National Committee for Quality Assurance, a quasi-trade group based in Washington, for use in accrediting HMOs. Although using the standards is voluntary, many HMOs do use them because of pressure from employers to provide performance information.
"The impetus for the legislation requiring HMOs to do report cards came from chambers of commerce, employers, the Consumers Union and physicians," says Jim Lloyd, executive director of the Texas Health Care Information Council, the state agency that collects the data from HMOs. "All wanted more data so consumers could make more informed choices."
Although larger HMOs in Texas have already been collecting and reporting HEDIS data -- including Cigna -- the new legislation will be costly to smaller plans because of the need for auditing, says Geoffrey Wurzel, executive director of the Texas HMO Association.
In addition, physicians will likely view the data-collection process as intrusive, he says, because it involves reviewing charts and medical records.
Yet, despite the cost and intrusion, the 35,000-member Texas Medical Association pushed hard for passage of the HMO-report card legislation as well as for another new state law that makes HMOs liable for malpractice. "Managed care is a major concern for physicians today," says association spokesman Ken Ortolan.
Some see the interest of Texas and other states in making the HMO report cards public as a bow to political pressure from the increasing number of people who have been pushed by their cost-conscious employers into health plans that limit their provider choices.
"There's a real hunger for information as consumers are forced into plans that seek to limit access to services," says Barry Scholl, an NCQA spokesman.
The demand has come particularly from large employers, he says. In Texas, the number of people in HMOs has risen to 4.3 million from 338,000 in 1983, Wurzel says.
Although all are agreed on the need for a reporting system, the method for gathering and distributing data is still unresolved.
"How healthcare data is collected, how it is interpreted and made available are political hot potatoes," Lloyd says. "Any listing would have to have a first place and a last place. From a business point of view, no one wants to be seen as being last."
Once the data is gathered and interpreted, it will be grouped according to geographic areas, he says. Obviously, it wouldn't do a consumer in Houston or Dallas much good to know an HMO is 43% effective in getting children immunized statewide without knowing the rates in those specific cities, he says.
Using an instrument known as the Consumer Assessment of Health Plan study, the Texas Insurance Department will survey 10,800 state residents to measure their satisfaction with their health plans. Survey analysis will be conducted by University of Texas researchers, and results will be reported to the state by September 1.
Under the new law, Sept. 1 is also the deadline for Texas HMOs to submit their data to the Health Care Information Council. The reported data must be audited by a company or individual certified by the NCQA to verify its accuracy.
"It's very important that the data have a high level of credibility," Lloyd says. "You know, they say liars figure and figures lie. All information is subject to interpretation."
Even the NCQA has had to contend with different methods of arriving at figures when trying to compare HMO data to that of fee-for-service plans, Scholl says, because there is no comparable reporting of data by indemnity plans. In a recent comparison of HEDIS figures, the NCQA had to rely on estimates, he says.
John Seidenfeld of Cigna adds: "Right now, HMOs are collecting the HEDIS data differently. We would like to see data collected by a third party, not by HMOs themselves." Getting the data standardized and collected by outsiders "will take a few years, but this is a start down the road," he says.
The HMO report cards mirror a trend toward more analytical data that has been fueled by the growth in managed care, Seidenfeld says. For example, research linking ZIP codes and medical practices has shown residents of Lubbock, Texas, with heart problems are more likely than residents of other areas to have heart surgery.
New York and Maryland also require public disclosure of HMOs' performance, says Don White, a spokesman for the American Association of Health Plans, a Washington-based trade group representing 1,000 HMOs and PPOs.
White says the group has drafted its own Consumer Bill of Rights and Responsibilities to address the issue of disclosure. Texas is just one of several states where access to data on health plans and the liability of the plans are issues that have sparked interest, he says.
"Texas is on the cutting edge of requiring the reporting of data; New York, Maryland and Colorado also require some version of reporting data," he says.
New York, for example, releases physician-by-physician comparisons on cardiology procedures, which has led to improvement in overall cardiac outcomes for patients there.