New definitions up the ante for health plans

What is quality and how do you measure it? Those core questions are the focus of constant study and debate. Meanwhile, health plans and purchasers are measuring performance based on their own definitions.

Clearly the Health Plan Employer Data and Information Set (HEDIS 3.0), developed by the National Committee for Quality Assurance in Washington, DC, has become a national standard. Quality improvement based on HEDIS, such as cesarean rates, immunizations, or mammograms, enables medical groups or health plans to tout their performance and compare it to others.

But plans and purchasers are experimenting with new ways to calculate outcomes. Increasingly, comparisons include non-HEDIS measures, such as glycosylated hemoglobin rates among diabetics or breast cancer stage at detection.

"HEDIS is really the entry fee for anybody to be in the [health care] business," says Antonio Legorreta, MD, MPH. Legorreta is vice president of quality initiatives for Woodland Hills, CA-based Foundation Health Systems, the parent company of Health Net. "If you don’t have HEDIS [measures], it’s hard to comprehend how you can be in the business of providing access to medical care."

Even patient satisfaction goes beyond the baseline question, "How satisfied were you overall with your care?" Purchasers and plans want to know whether patients think their doctors are competent and concerned.

"Patient satisfaction is very telling about the communications skills of providers," says Suzanne Mercure, healthcare plan manager at Southern California Edison in Rosemead, CA. "It isn’t about the clinical quality of the care; it’s about the quality of the caring."

Mercure knows that physicians often view patient satisfaction as a marketing gimmick. But she sees a direct connection to outcomes.

"If the patient has a better relationship with you, they’ll rate you higher," says Mercure. "Do you think they’ll be more likely to comply [with an advised treatment]? Yes. Then you’re likely to get a better outcome."

With each new outcomes measure comes debate about the validity of the data collected. For example, patients may refuse to obtain some of the preventive care required by HEDIS.

Alfredo Czerwinski, MD, senior vice president for clinical resources of Sutter Health in Sacramento, CA, predicts that physicians increasingly will be held accountable for following evidence-based guidelines or protocols. That would avoid some of the difficult issues about comorbidities, patient compliance, and severity adjustment, he says.

While physicians often bristle at the idea of protocols and "cookbook medicine," Czerwinski notes that airline pilots never complain about following a preflight checklist each time they enter a cockpit.

"They may have been flying a Boeing 747 a thousand times before," he says. "We still expect them to follow a protocol."