The National Committee for Quality Assurance recently released statistics on HMO performance that show a turnaround of sorts: movement toward quality care and, perhaps more important, movement toward acknowledging the value of quality care.
The NCQA's latest report on the quality of HMOs, Quality Compass 1999, was released in late July. The report, which uses scores from the Health Plan Employer Data and Information Set, or HEDIS, permits some global assessments of managed-care quality:
* Plans that deliver the best clinical care enjoy higher member satisfaction.
* Plans that regularly disclose their quality data outperform those that don't.
* Plans are gaining confidence in the accuracy and validity of all plans' data and are more willing to participate in the NCQA's process.
As is known in science, the act of observing something can change its value. If the NCQA's data are correct, the same would seem to be true of measuring health plan quality.
Take the use of beta blockers after heart attacks, an easy indicator that patients are receiving the recognized standard of care. In plans that reported HEDIS results in 1996, the year Quality Compass was launched, an average 62.5% of indicated patients were given beta blockers. The next year, that average hit 74%. And in 1998 it rose to 79.9%. The NCQA estimates that this improvement has saved 2,179 lives and has enhanced the quality of life for many thousands more.
The plans that submitted data for all three years and released them to the public achieved a score of 85% in 1998 for use of beta blockers, the best of their breed.
Adding new clinical measures to the data set can lead to sudden, dramatic improvements in rates. Chicken pox vaccination wasn't part of the data set in 1996. In 1997 the plans vaccinated an average 40.1% of eligible patients. In 1998 that score shot up to 51.9%.
Yet the national averages in a fair number of clinical categories showed only marginal improvement from 1997 to 1998. The rate of diabetic patients who received eye exams barely budged to 40.9% in 1998 from 39% in 1997.
"It's a different universe of plans that report every year," explains Brian Schilling, NCQA spokesman. "It's not an apples-to-apples comparison."
In 1997, 292 plans reported data and made them public. In 1998, 410 did. Because so many plans were reporting for the first time in 1998, their data pushed down the averages.
"It makes it appear the whole industry isn't improving that quickly," Schilling says, "whereas the plans that have been reporting for a while are making some impressive gains." For example, of the plans that reported and published data for all three years, the percent of diabetic patients who received eye exams was 49.4%, a substantial margin above the 1998 mean.
Health plans are allowed to submit data to the NCQA but may refrain from having it published. In 1996, 329 plans allowed their data to be published, but the next year, only 292 published. Of those that published their results in 1996, 158 had cold feet in '97 (Sept. 28, 1998, p. 12).
Many of those plans, however, came back in 1998. Schilling attributes that to two factors. First, the increase in plans reporting audited data "gave other plans that hadn't previously reported a little more confidence that they'd be compared fairly. Now we have close to 90% of data being audited."
Second, the media pressured plans that refused to allow their data to be published. Employers, too, called their nonreporting plans on the carpet.
This year, plans got the message. Of the 447 plans that submitted data, 410 allowed publication.
"It speaks to the power of the media to make the market behave," Schilling says.
In 1996 executives at Cigna HealthCare were disappointed in the company's scores. So the next year they declined to publish numbers, even though they continued to report them for benchmarking and to employer customers.
"This year we felt we had made substantial improvement in our ability to collect the data as well as on the effectiveness-of-care measures," says Cigna spokesman Howard Drescher. "So we have reported all our effectiveness-of-care data publicly in Quality Compass this year."
Those are a lot of data. Quality Compass 1999 lists 26 regional health plans for Cigna.
"We have improved our aggregate performance by 5%," Drescher says. Most of Cigna's plans exceeded the national average for effectiveness of care, but they could improve in other areas. "We're working on it," he says.
Much of the problem lies in the measurement process itself, Drescher says. "The questions are simple, but getting the answers is very complex. It involves the commitment of a lot of resources."
Unlike most of the plans that published their data, Cigna did not allow its member satisfaction rates to be published, because results for HMOs and point-of-service plans are combined. That pushes averages down.
"Members in HMOs are generally more satisfied than members of point-of-service plans," Drescher says. "It has to do with service issues, a hassle factor. When people exercise their out-of-network option, their plan becomes more like a standard insurance plan. Their cost is higher. They have to file claims. They're exposed to potential service issues that they don't have to deal with in the HMO."
Cigna didn't want that information published and used to the company's disadvantage.
Conspicuously absent from the NCQA report was Humana. The company, which operates in 15 regional markets and has 6.1 million enrollees, is the largest HMO that did not participate in the survey.
"We have participated and submitted data in the past," says Stephen Schmaltz, Humana's director of statistics analysis and HEDIS. "The one thing we're concerned about . . . is the public has a tendency to misinterpret the information they see."
Humana thinks it's a problem that Quality Compass includes staff-model and IPA-model HMOs. Staff-model HMOs "are able to capture their data better than HMOs that work with large networks of physicians," Schmaltz says. "A great deal of time is spent by the plans in pulling that data together."
Humana no longer operates any staff-model HMOs, he says.
The company shares its HEDIS data with employer purchasers, and it's preparing to develop a World Wide Web site to offer HEDIS data to its members.
Another plan partially missing in action was PacifiCare Health Systems, which covers 3.6 million people in nine states. Five of its regional plans were listed, but four states-California, Oregon, Texas and Washington-were unaccounted for.
"Pacificare submitted audited data for all its plans," says Alexandra Warnier, spokeswoman for the parent company in Orange County, Calif. "There was a miscommunication with the NCQA, and four states were left out." Those states "will definitely be included" next time, she adds.
How much the public actually uses the information is anybody's guess. "My impression is, members don't really look at it as they should," says William Bennett, senior vice president for marketing at Mercy Health Plans in St. Louis. "I think they don't understand it, because the employers don't understand it."
Bennett says in his market, consumers tend to choose a low-cost plan, regardless of quality indicators. But they're beginning to understand the importance of quality, Bennett says. "It's moving in the right direction."