International Journal for Quality in Health Care 16:7-8 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Editorial |
Should health plans be accountable for clinical performance measures?
The concept of managed care is pretty straightforward: maximize value of economic resources assembled to provide services for a population of patients. In addition to prudent management of financial capital, managed care companies need to develop networks of providers and coordinate benefits to facilitate effective and efficient health care for its enrollees. These tasks, in and of themselves, are not always guaranteed to run efficiently and effectively when a company opens up for new business. Clearly, some managed care companies may simply be more effective at structuring its programs than competitors.Because managed care programs in the United States are frequently connected with employer health insurance programs, purchasers of health insurance have pressed the industry to develop benchmarks to document effective care of patients whose employment related premiums sustain the economic enterprise. Thus, formal measurement systems such as HEDIS from the National Committee on Quality Assurance have evolved to provide benchmarks of performance to compare plans. Increasingly, such performance measurement is made publicly available to all participants and stakeholders in the health care system [1].
Nevertheless, it remains an open question as to whether health plans themselves have a real impact upon these performance measures. Since the plans, for the most part, contract with the same population of doctors in a region, most physicians participate in multiple health plans. Care for a handful of patients in several insurance products can result in skewed data that is hard for the average clinician to interpret or take seriously. As a result, it is not uncommon for a physician to receive glowing and disastrous performance report cards from different managed care companies for identical time periods.
Nevertheless, managed care companies spend large amounts of money educating providers and patients about good health practices and the preferred management of chronic diseases that are subsequently profiled by public performance measures. This issue of the International Journal for Quality in Health Care has published a useful study which indicates that, for at least a few measures, managed care companies can make a difference in performance measures by their own actions [2]. This finding is of considerable interest and has a number of public policy implications.
Clinical performance measures do not always focus on the same health care processes. For example, the prescription of beta blockers for patients after heart attack is pretty much determined by the pen of the physician. Educational materials developed by a health plan directed at a clinical provider could increase the appropriate delivery of a service to a specific patient population but, if successful, would be unlikely to affect only the patients covered by that plan. That is to say, most clinical offices do not distinguish the insurance status of a patient other than the presence or absence of a pharmaceutical benefit, when designing treatment plans. Thus, a successful program by a managed care company to improve physician prescribing would likely be a tide that raises all boats and not result in better performance by the educating plan in comparison to its competitors. Rates for the receipt of mammography, on the other hand, represents a much more complex equation reflecting referral by the health provider, patient motivation, and access to services. Thus, effective use of an enrollee database with targeted reminders to patients about the value of preventive services could augment information received at a physician’s office and result in greater compliance with recommended screening behaviors. Other activities such as working to enhance access for its enrolled population to preventive services could also result in outcomes that would distinguish one plan from another.
The paper by Baker et al. [2] appropriately examines the impact of health plan efforts in the receipt of certain preventive services. Using claims databases, plans can identify patients who have or have not received certain targeted care and use their central resources to motivate new behaviors by patients in a fashion that is independent of the patient’s primary clinical care site. Indeed, many clinical care sites cannot afford the kind of reminder system and social marketing activities that can be beneficial for enhancing compliance for the receipt of preventive services. The positive outcomes in this study, therefore, make sense and potentially identify a subset of performance measures that health plan behavior can impact observed rates of clinical care of its enrollees. It is not as certain, however, that plans have similar impact on measures such as ace inhibitors for heart failure, control of blood pressure, or use of anti-inflammatory medications in patients with asthma. Perhaps targeted attention to prescription refills could augment care rendered in the office and reflect an independent contribution by a plan to the care of at-risk patients that can result in superior outcomes. Subsequent studies like the one in this issue of the Journal could offer important insight as to how to best leverage the resources of a managed care corporation to improve the performance of the health care system.
American managed care is complicated by its dominance by large corporations that seek economic returns to benefit the company, its employees, and shareholders in the context of providing patient health benefits while serving as an intermediary for provider reimbursement. The sensitive nature of personal health care has resulted in charges against private managed care firms of profiteering at the expense of the welfare of its beneficiaries. Regardless of the validity of this claim, managed care in the United States continues to struggle with this incendiary allegation. Demonstration that plan investment in activities to enhance patient outcome actually work could become a useful element to enhance the reputation of managed care and an effective marketing tool for a specific commercial enterprise.
Thus, it appears that plans can have an impact upon services received by their beneficiary population. Future work should begin to tease apart how measures influence different elements in the health care system and how to best leverage financial resources devoted to measurement to maximize health system performance.
University of Arkansas for Medical Science, Little Rock, AR, USA, Editorial Committee Member, The International Journal for Quality in Health Care
References
- Berwick DM, Public Performance Reports and the fiill for Change. JAMA 2002; 288: 1523–1524.
[Free Full Text] - Baker LC, Hopkins D, Dixon R, Rideout J, Geppert J. Do health plans influence quality of care? Int J Qual Health Care 2004; 16: 19–30.
[Abstract/Free Full Text]
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