Quality Talk

This month, Keith Moore discusses the future of quality in health care. He describes developments such as the on-line purchasing of health care benefits and the growth of consumer assertiveness in health care decisions. Moore is president of McManis Associates, a Denver-based research and management consulting firm. One of the firm’s subsidiaries offers medical malpractice insurance. Moore shares some provocative insights into the relationship between quality measures of clinical practice and malpractice claims. He has worked with health care clients including VHA Inc., as well as health plans, government agencies, and companies in the financial industry. His latest book Beyond Managed Care (Jossey-Bass) is due out in June.

Q. You’ve stated in other interviews and in your writing that a growing number of health benefit buyers base their decisions on outcomes of care rather than merely settling on the lowest bid. Can you give us examples?

A. There is a group of buyers that is highly focused on outcomes. It’s best to give an example of a specific market — just one of many. In the Orlando market, there is a large group of buyers led by the Walt Disney Co. Disney will openly tell you that its average employee is going to be there about three years. What Disney would like in a health plan is simply very, very low cost. They’ll say, "We don’t want wellness; we don’t want psych [psychiatric care]. We want a very, very inexpensive plan, targeted primarily toward young people who can smile." They don’t want more psychiatric coverage than is mandated by law.

Then there is a second segment in the marketplace. The best example of that segment would be a large local school district that wants the best plan it can get. It is very concerned about quality, and is constantly seeking any measures of quality it can find. The Orange County (FL) School District, is one example of that assertive, quality-focused segment.

The third group, led by companies such as Marriott International and 7-Eleven Inc., are most concerned that their employees are spread all over the place. When they describe what they would like, they say, "First, I certainly do not want to talk to you about buying a health plan for Orlando. My employees are spread all over, and one of my biggest problems is how to aggregate them." This third segment falls between the first two, in emphasis on quality.

There are different quality-demanding segments among today’s employers. There are those that are not nearly as concerned about quality as they are about price. And some are in between.

We take the position in our new book, and elsewhere, that a major shift is taking place. It’s about to accelerate in pace, and it’s going to produce some fundamental changes in the health care marketplace. That shift is the increasing role of the consumer. Consumers, when they get sick, are going to play a larger role in the decision-making process, as the employer is playing a smaller role.

Several factors will cause that change. For one example, a number of employers are basically trying to back out of the health care choice process. It’s similar to what has taken place with retirement plans. Employers are thinking about paying a certain amount of money and telling employees, "Here are three plans we have screened. You’ll get the same contribution from us no matter which you choose, and you can pay the difference." That’s one example by which consumers are playing a much more active role.

Another example is that in many markets, including Denver, you’ll hear ads for Internet sites where you can buy your health care coverage. And in the Pacific Northwest, you can go on the Internet to Costco, the value shopping store, and buy your health care! Costco has made arrangements with physicians and hospitals and others to form its own provider network, and it’s acting as a wholesaler of health care directly to the consumer.

In this emerging marketplace, quality is about to become a far more dominant factor. It’s always been highly important, but our difficulty is in measuring it. If you think employers have an interest in quality, you have to multiply that manifold when the consumer is in the driver’s seat. Buyers are going to evaluate quality against other factors: Contractual access — how hard is it to get access to that provider today? Physical access — are they close to me? What kind of service do I get? Then, there’s something a little more abstract; we call it customer affinity. It’s more than service. It’s whether providers seem to empathize with you and connect with you in some way. And, of course, cost is an important factor.

All those factors, in addition to quality as we might measure it in outcomes, are part of the marketbasket that a consumer or an employer evaluates. But when a consumer is evaluating — trust me on this — quality goes to the top of the list even faster than with the employer. So, we are about to see even more emphasis on quality than we have in the past.

Q. In that consumer-driven scenario, will health care organizations still have quality specialists and designated departments responsible for managing the quality programs? Or will that function be distributed throughout the organization?

A. I believe that the whole organization has to take a more emphasized approach to quality. And that means someone does have to be responsible overall.

On the other hand, if the consumer is going to play a stronger role in the health care decision-making process, we’re talking about a more assertive and knowledgeable consumer than in the past. The number of consumers who access health care information over the Internet is growing monthly. And in some places, 40% of elderly households report that they are accessing health care information over the Internet, and playing a more active role in their own care.

The widespread embracing of new technology suggests that quality improvement will have to be a distributed function within the health system. Every service line will need to evaluate how to become more customer-friendly, more accessible from a consumer’s point of view. And the service line probably will need to know how to involve the consumer more in the decision-making process, because that’s part of what consumers want.

Q. Are the definitions of quality of care and quality of service going to change?

A. Increased consumer involvement could change the definitions, but I think the two will also become more intertwined.

Q. Could you describe a health care package containing high-quality service as well as care?

A. Here’s one example: The protocols we have now, to a great degree, are clinical diagnostic protocols. They say, "We’ll take this step, then this step, then this step."

I have to believe that the protocols of the future are also going to identify, and put in place, points at which the consumer is given more choices. Most of us who have protocols are basically measuring the degree to which we follow them. But there’s more to it than that.

The quality-malpractice claim connection

The company and its subsidiaries with which I’m associated have a 12-year study of the causes of medical malpractice claims. It’s an empirical study that looks at past claims and how they correlate with decision-making processes. Those data suggest to us that, in addition to the clinical protocol, there are a number of factors that play a key role in providing a higher probability of good outcomes.

I think the outcome measures of the future are going to combine that sort of empirically-based analysis with clinical protocols and patient satisfaction information. They will analyze those pieces of information together. Our studies have done something else, also. In several instances, we’ve looked at the patient record. We started with the emergency room. We looked at the records from three perspectives:

1. legal and regulatory compliance;

2. utilization;

3. efficiency.

We’ve learned from this process we call "trialysis," that when you have a potential outcomes-related (malpractice) exposure, it’s amazing how often you also have a compliance problem and a utilization review problem. All three tend to occur together. It suggests that when we identify outcomes issues, we’re likely to find the other three as well.

Q. Where does patient satisfaction figure in?

A. We’re about to correlate patient satisfaction with that. I’m assuming it will correlate as well, but I can’t prove it yet.

[For more information, contact Keith Moore, McManis Associates, 2000 S. Colorado Blvd., Suite 2-900, Denver, CO 80222. Telephone: (303) 300-1515. E-mail: kmoore@mminet.com.]