HMOs have made great strides in improving quality of care and satisfaction of enrollees, but there's still a lot of room for improvement, according to physician executives and other healthcare quality monitors.
But quality will only continue to improve--and HMOs will only be able to survive--if these plans reach a state of enlightenment in their relations with physicians, these industry experts say.
Plans that batter physicians to the bottom line are already on the way out and may soon be gone, according to Salt Lake City surgical oncologist Brent James, M.D., who served on the Institute of Medicine committees that published "To Err Is Human" in 1999 and "Crossing the Quality Chasm" in 2001. "We're going to see a market shakeout in the next few years, with the short-term-focus plans washing out," says James.
Patients are jumping ship to fee-for-service, he says, and the means to stem the tide includes defined benefits, consumer-centrism, equitable partnerships of stakeholders and care that enhances quality by applying physician-generated treatment protocols and a willingness to pay up front for improved outcomes down the road.
A host of managed care organizations have boosted their Health Plan Employer Data and Information Set (HEDIS) scores since 1992, when the National Committee for Quality Assurance, a Washington, D.C., not-for-profit that evaluates HMOs, took over that data-gathering function.
NCQA started issuing report cards on HMOs four years later. Accredited, larger, older health plans are making the greatest advances in quality and satisfaction.
Plans in regions with well-organized physician groups outpace areas where the groups are more loosely structured, says NCQA Executive Vice President Greg Pawlson, M.D.
While some see the glass as half-full and others see it as half-empty, there is wide agreement among stakeholders that further improvement is needed.
More and better data
Parents who revel in their child's math grade might be unaware of his playground misdeeds, and it's those pesky, unmeasured areas of performance that needle internist Gregg Meyer, M.D., director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality in Rockville, Md.
"By and large," he says, "the quality of care through managed care has gotten better in those areas measured, but what about the other areas?" Furthermore, some health plans receive no report card at all: Many states don't require HMOs to divulge clinical outcomes.
Pawlson says 75% of health plans, representing 65 million lives and 90% of enrollees nationwide, report to NCQA, but 20% of those do not permit public airing of their data. The performance of that shrouded 20%--when contrasted with that of the plans allowing disclosure--highlights the virtue of transparency, says Pawlson, who is an internist and geriatrics physician. "Public reporters do better than nonpublic reporters," he says. (See chart, page 18.)
But it's anybody's guess how the 10% of patients enrolled in commercial HMOs that don't report to NCQA--and those receiving care via fee-for-service arrangements and PPOs--are faring, Pawlson says.
"You can't manage what you can't measure," says Gregg Lehman, president and CEO of the Washington, D.C.-based National Business Coalition on Health, a not-for-profit group that coordinates the work of 85 business coalitions to obtain quality, affordable healthcare.
But times are changing. Representatives across the healthcare spectrum say efforts are under way to broaden and standardize tools that measure health plans and publish all resulting data so every player--from the mega-MCO to the individual enrollee--can compare apples to apples.
The healthcare industry is widely committed to achieving that goal, which dovetails with mounting consumer and governmental pressures to curtail runaway costs and return sovereignty to the patient-provider relationship, says Maureen Connors Potter of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, Ill.
"Quality and cost-effectiveness are not mutually exclusive. All stakeholders will benefit from more and better measurements," she says.
But the era of standardized yardsticks and openness is in its "awkward adolescent stage," says Suzanne Delbanco, executive director of The Leapfrog Group, a Washington, D.C.,-based consortium of healthcare purchasers leveraging a collective $52 billion in annual purchasing power to improve patient safety.
"We need to help the healthcare system evolve to a whole new cultural norm of transparency where uniform information about the quality of care is shared freely," she says.
So how exactly can we do this?
"If it was easy," says Lehman, "somebody would've done it a long time ago."
Incentives for quality improvement
Going forward, quality efforts will get a boost from a form of organized system rare today--one in which stakeholder incentives are aligned by dividing the financial pie evenly, says James.
Such systems, he says, shift decisionmaking to clinicians and patients, foster individualized treatment plans founded on evidence-based medicine, relax dictates that prioritize short-term cost and share the long-term savings equitably.
Salt Lake City-based Intermountain Health Care already has accomplished this, says James, who is president for medical research and executive director of IHC's Institute for Healthcare Delivery Research. IHC is an integrated, not-for-profit system in Utah, Nevada and Idaho with an HMO, 22 hospitals, 100 clinics and 2,500 affiliated physicians.
"We've been able to show a substantial improvement in medical outcomes associated with significant reductions in cost," he says. "And we have a three-way split where purchasers, IHC and physicians each get a third of the savings."
Lehman of the NBCH says that HMOs "across markets" are beginning to build withholds into contracts that are passed on to providers who meet specified performance benchmarks. His business coalition is aggregating 2002 data from 120 health plans that will be used to develop the benchmarks.
In California, six plans recently implemented Pay for Performance, a program that awards bonuses to medical groups that ramp up quality (see February, page 8). Similar payment schemes, in which purchasers reward providers "through the vehicle of managed care" for quality gains, are popping up across the country, says Delbanco. "I think we're at the beginning of a trend."
Delbanco points to New York's Empire Blue Cross and Blue Shield as one example.
Empire has teamed with IBM, PepsiCo, Verizon Communications and Xerox to offer a 4% bonus this year to hospitals that implement two patient-safety standards recommended by Leapfrog: computerized prescribing linked to error-prevention software and ICUs staffed with critical care physicians.
Another organization, Louisville, Ky.-based Humana, provides nursing scholarships to Baptist Memorial Health Care of Memphis, Tenn., for meeting quality criteria based on Leapfrog recommendations, says forensic pathologist Jack Lord, M.D. Lord is Humana's senior vice president and chief of clinical strategies and innovations, as well as current president of The Disease Management Association of America.
Humana is addressing quality on several fronts, says Lord. Drug decisions are based on effectiveness rather than cost alone; enrollees can rate their physicians via a public Web site; and patients are empowered through redesigned benefit offerings and increased transparency of data, he says.
The role of disease management
Lord and others say that, as baby boomers age and the ranks of Americans with at least one chronic condition swell beyond the current 100 million, disease management will take center stage in the quest for quality.
DM is a focus of JCAHO, where Potter is executive director of Disease-Specific Care Certification, launched on Feb. 14. The program certifies MCOs, integrated healthcare delivery systems, provider groups and DM services companies that promote "the highest quality of care" for people with chronic conditions such as asthma and diabetes, says Potter.
Certification hinges on uniform application of evidence-based medicine, engaging patients in decisionmaking and factoring age, language, culture and any co-existing disabilities into individualized treatment plans.
HMOs are embracing DM--but with an eye on the bottom line, says Jim Hartel, publisher of the Colorado Managed Care Newsletter and its Arizona counterpart.
"They want to demonstrate their effectiveness to employers with these programs as part of their marketing pitch and are angling for exclusive multiyear contracts in which to prove reduced cost and increased productivity," he says.
Everybody wins when quality goes up, and the managed care industry is way ahead of the game in the DM arena, says Susan Pisano, vice president for communications at the American Association of Health Plans, Washington, D.C.
As systems, HMOs can broadly implement proven treatment guidelines, and HEDIS scores are rising as a result, says Pisano. The "fee-for-service world" is not structured enough to apply standards widely and is not rated on performance, she says. Still, clinical behaviors that reap better results, like checking diabetics' feet for ulcers, are not applied evenly in all HMO exam rooms, she admits.
MCOs would do well to take a page from the playbooks of the few HMOs abandoning "the big stick" approach to physicians, says Les Meyer, senior director for business development at the Broomfield, Colo., office of McKesson Health Solutions, which provides DM services to health plans. These HMOs, he says, have returned control of clinical decisions to doctors and nurses and have sloughed their "silo mentality," which allowed little coordination between payers, physicians and hospitals.
"The smart health plans are breaking bread with physicians, paying them for achieving certain quality indicators, developing their confidence and trust that are currently lacking, and lightening their caseload," he says.
Health plans that remain "unenlightened," engaging in "old tricks of the trade" like capitation-style pricing structures that transfer risk to physicians, are withering on the vine, he warns.
"No existing healthcare models--whether fee-for-service, HMO or PPO--are working," Meyer says.
"All stakeholders need to band together and collaboratively generate new organized systems of care."
Linda Boone Hunt is a Prescott, Ariz.-based investigative reporter and feature writer.