Dissatisfied with HEDIS, employers say, ‘Give us the outcome FACCTS’

NCQA standards don’t measure up for MCOs

With large purchasers voicing doubts about the usefulness of "process-oriented" outcomes such as HEDIS, hospital systems and disease management companies are turning to patient-centered measurement sets published by the Portland, OR-based Foundation for Accountability (FACCT). The employer-sponsored quality measurements could become de facto requirements for providers competing for managed care contracts.

A coalition of Fortune 500 companies, government agencies, and consumer organizations representing more than 70 million Americans, FACCT has published a number of measurement sets — including sets for breast cancer, diabetes, and, most recently, asthma — that have been adopted by managed care plans across the country. (See related story on the asthma measurement set, p. 67.)

While large corporate employers dissatisfied with the National Center for Quality Assurance’s (NCQA) HEDIS 3.0 data sets have been compelling some plans to use the FACCT measures, other plans have begun using them voluntarily, as a means of evaluating the performance of physician groups and disease management companies.

"There are a number of business coalitions around the country now that are just beginning to implement the FACCT measures," says Louise Dunn, director of accountability projects at FACCT. "We also have hospitals and plans that would obviously be interested in complying with business purchasers’ requirements." Dunn adds that some plans and other health care providers have begun using the FACCT data sets "because they think they’re a good set of measures to judge how to do quality of care."

Unlike NCQA, which uses its report for certification purposes, FACCT does not take cost into account in its measurement sets. "The financial stuff doesn’t have anything to do with our mission," says Dunn. "We’re really working on patient-centered outcomes and results. So, how the organization is financed and those types of things aren’t really of interest to us."

Nevertheless, FACCT’s outcomes data can be used as one indicator of cost, says Dwight McNeill, manager of health care for GTE Corp. in Boston. "According to our data on health plans, quality costs less." In examining premium costs for the various health care plans with which it contracts, GTE found that premium costs for high-quality HMOs were less than premium costs for lower-quality HMOs. "I’m delighted to be in a position to push for quality in health care and get costs down at the same time," McNeill adds.

Purchasers want audited data

McNeill says because purchasers are placing greater emphasis on quality as opposed to price alone, health care plans could find it in their financial best interest to disclose their clinical outcomes and patient satisfaction rates.

GTE, a Stamford, CT-based telecommunications company, contracts with 139 health plans nationwide and covers more than 300,000 employees, family members, and retirees. A founding member of FACCT, GTE has long required plans to provide information on health care quality and outcomes. The company defines quality as accessibility to health care, adequacy of benefits provided, cost-effectiveness, and patient satisfaction.

GTE and its employees use this data to make plan selections. In turn, plans are increasingly using outcomes data to evaluate physician groups and disease management companies when assigning contracts, McNeill adds.

GTE used to use HEDIS 2.0 data to analyze and compare costs and quality at the HMOs with which GTE contracted. It stopped, McNeill says, because the company considered HEDIS’ process-outcomes focus "insufficient in helping consumers make meaningful choices about the type of care they want to receive."

"NCQA, via the HEDIS measures and accreditation, have defined what quality is in this country for health plans," says Daniel Malloy, PhD, senior director for HCIA-Response, an outcomes technology firm based in Boston. "But people comment that that’s not really quality or outcomes. It’s not what they’re experiencing. It’s a question now of whether plans are willing to embrace types of performance measures that don’t meet a regulatory requirement or an accreditation requirement but are what the consumers ultimately want and need. And actually, what the plans themselves need to understand if patients’ experiences are positive within their systems."

While Malloy supports NCQA’s work with its Health Plan Employer Data Information Set (HEDIS), Malloy points out that HEDIS data is not intended primarily for the general public, and it doesn’t help consumers anticipate the events that are likely to occur in their interactions with health plans.

Nevertheless, NCQA claims that, with the advent of HEDIS 3.0, the committee is moving toward a better mixture of process and outcomes measures in an effort to "give the public ever more comprehensive and meaningful information on plan performance." An NCQA spokesman points out that, unlike previous versions, HEDIS 3.0 includes a member satisfaction survey and selected FACCT measurements. NCQA maintains that it, too, is moving toward a more patient-centered measurement set, and in recent months, has been actively working with FACCT.

NCQA’s attempts to become more consumer-friendly represent one more reason health care providers should get away from the idea that outcomes are relevant only "to your own group for your own self-improvement," McNeill says. "In market competition, we want disclosure; we want the market to recognize the best providers and to make that public. If you really think you’re doing good work, then stand behind it."

Malloy claims that performance measurement is at a crossroads, "where the industry is trying to format and present information that they think consumers need. To some degree, they’re realizing that they may not be specifying things that patients and purchasers care about."

Indeed, a study called "Employers and Individual Consumers Want Additional Information on Quality," prepared last year by the federal Government Accounting Office in Washington, DC, showed that individual health care consumers did not trust the quality data provided to them by managed care companies, calling it "self-serving" and "one-sided." It concluded that managed care organizations should ensure their data are independently audited and compared to benchmarks to enhance its credibility.

To be an effective decision-support tool both for providers and consumers, performance measurement must shift away from "this continued overemphasis on process measures and start looking at what patients’ experiences are," Malloy says. "The fact is that consumers have very little information that will help them understand what they will probably experience when they begin some disease state management program, or they have a disease and have to seek treatment through a health plan," says Malloy.

By relying primarily on patient survey data, FACCT’s work "is probably more pertinent and useful for consumers as well as providers who have to channel people through a system," says Malloy. "For example, FACCT’s breast cancer tools open the door to actually look at some of the experiences of people with breast cancer, not just at whether certain events have occurred on certain dates that can be verified against billing records," says Malloy. "It’s actually, what did someone experience in their treatment process?"