HMOs posted big improvements in their vigilance against illness and chronic conditions for the second straight year, offering evidence that efforts to identify and manage major diseases can succeed at the hands of health plans.
Some of the biggest gains occurred in management of high-risk and costly ailments such as heart attack, stroke and diabetes, according to a report released last week by the National Committee for Quality Assurance, which accredits managed-care plans. For example, the percentage of patients screened for cholesterol levels after a heart attack increased to 74% in 2000 from 69% in 1999 and 59% in 1998 (See chart).
Buoyed by across-the-board gains in its 60 measures of healthcare quality and service to enrollees, the NCQA unveiled an effort to prove that improvements in HMO track records can translate into quantifiable savings for healthcare purchasers. Implicit in the case for healthcare quality is a message that NCQA-accredited health plans are better than nonaccredited HMOs.
"That's been our plan all along," said NCQA President Margaret O'Kane, harking back to the organization's genesis 10 years ago as a vehicle for major employers to make informed contracting decisions based on the same measures of performance among HMOs. Those measures, known as the Health Plan Employer Data and Information Set, or HEDIS, have evolved through the years to better focus on outcomes of care traceable to the efforts of HMOs and comparable among them. Two years ago the HEDIS program instituted a greater emphasis on diagnosis and treatment of chronic conditions.
The improvements in those measures gave embattled HMOs a chance to crow about their progress in preventing and managing disease on behalf of consumers concerned about quality of life and employers losing productivity to sick workers. The report was particularly welcome because just a week earlier a separate survey gave HMOs poor grades for customer services (See story, p. 17).
"When you watch a health plan's HEDIS results increase from year to year, that plan has done a good job of developing a collaborative relationship with its physicians and members," said Sam Nussbaum, M.D., executive vice president and chief medical officer of Anthem Blue Cross and Blue Shield Plans. "Health plans that work with their physicians, hospitals and members can raise the bar dramatically on quality."
Indianapolis-based Anthem was among health plans reporting significant improvement from 1999 to 2000. Its division in New Hampshire, for example, improved its record for controlling cholesterol after a heart attack to 75% of all patients, nine percentage points better than in 1999 and 22 percentage points above the national average. Anthem's Connecticut plan gave beta-blocker drugs to 98% of heart-attack patients, a proven preventive measure against another attack. That was two percentage points better than a year earlier and 10 points above the rapidly improving national average.
The payoff in the healthcare market for these improvements, however, comes when healthcare purchasers take the differences in quality into account when deciding to add, retain or drop HMOs from consideration for their employees. If quality scores can affect the choice of a health plan, then they can affect a health plan's choice of a provider depending on how a doctor or hospital is adding to or detracting from the plan scores, O'Kane said.
That's part of the agency's plan to prod providers into improving their efforts to manage the care of patients, she said, adding to the pressures building from government and industry sources such as the Institute of Medicine and the employer-run Leapfrog Group.
Among other challenges, health plans have to include broad coverage of providers in a region to be competitive, crimping their ability to hold providers accountable for HEDIS performance.
The NCQA will have to do better than it has in the past to build momentum for quality-based purchasing decisions. Just three years ago, two studies by the New York-based Commonwealth Fund found that only 9% of firms offering managed-care plans required the plans to be accredited by the NCQA.
Ford Motor Co., which requires NCQA accreditation, hasn't dropped a health plan for poor performance, but it has come close, said Vince Kerr, M.D., the automaker's medical director.
The NCQA now is trying to draw distinctions between the performance of the 280 accredited HMOs and those that reported HEDIS results but have not achieved or sought accreditation. A preliminary business model compares the overall results of accredited plans against nonaccredited plans and calculates what the spread means in sick days avoided and dollars saved.
The analysis concludes that a hypothetical firm with 579 diabetics among its 20,000 employees would have 1,528 fewer days lost and $244,000 less in sick-day wages based on the capacity of accredited plans to control 22% more of the workers' diabetes than nonaccredited plans could.