Managed care reporting: Outcomes, performance improvement bar rising
Managed care reporting: Outcomes, performance improvement bar rising
Meeting challenge now means competitive advantage
Performance improvement, accreditation, and outcomes reporting are increasingly important for private duty providers and health plans alike. Operating in a sharply competitive environment, with employers, consumers, and the government demanding cost and quality substantiation, managed care companies now seek more information from their home care vendors. Private duty providers who supply much-sought data can place themselves at a competitive advantage, sources say.
NCQA drives managed care reportingManaged care organizations continue to seek external quality validation to distinguish themselves competitively and gain new members. More than 300 plans insuring 45 million Americans and representing more than 75% of HMO enrollees now participate in voluntary National Committee for Quality Assurance (NCQA) accreditation.1 Washington, DC-based NCQA, using its Health Plan Employer Data and Information Set (HEDIS 3.0) quality management tool and accreditation surveys, measures and compares health plan performance. (See related story on the state of managed care quality, p. 63.)
HEDIS involves 71 numerical and descriptive measures, which are grouped into these eight domains:
1. effectiveness of care;
2. access or availability of care;
3. satisfaction with the care experience;
4. health plan stability;
5. use of services;
6. cost of care;
7. informed health care choices;
8. health plan descriptive information.2
It is the "industry default" for health plan reporting, explains Brian Schilling, communications specialist for NCQA. More than 90% of the nation's 650 HMOs - including those covering Medicare and Medicaid patients - submit at least some HEDIS data, he adds. But it has little direct applicability to home care. Most measures involve conditions and utilization parameters normally addressed in hospital and physician office settings.
Though not directly impacted by HEDIS, private duty providers still feel its effects as managed care plans generally solicit more advanced quality and outcomes information as their own reporting requirements increase.
"Any vendor's ability to supply data makes it more marketable. It is a huge advantage for the managed care organization, and they will find people that can provide sophisticated data," Schilling says.
What managed care plans wantManaged care reporting requirements vary significantly between regions, payers, and product lines, says Barbara Rosenblum, BSN, MAOM, president of Strategic HealthCare Programs in Santa Barbara, CA, a software development/data management firm.
"There are some areas of the country, such as Seattle, where you can't even show up at the door without outcomes data because all your competitors are doing it, not necessarily because the managed care companies request it. Other areas, [for example], the Midwest where managed care isn't as big, the companies aren't asking for [much] data," she adds.
Payer requests range from allowing providers to submit data they deem appropriate to very specific, structured information for disease state management programs, Rosenblum says. One common thread: patient satisfaction outcomes. They prompt significant "interest all across the board," she adds.
Greenbelt, MD-based NYLCare Plans of the Mid-Atlantic does not mandate standardized outcomes reporting for its home care contrac t- ors but will expect more quality improvement and outcomes information in the future, says Kathleen Milanich, director of communications. The company does require some specialized reporting, however. For example, its home infusion providers must submit summaries indicating the number of patients and admissions per thousand by NYLCare product line - HMO, Medicare, preferred provider organization, and point of service. And it has sought vendors' collaboration in at least one quality improvement study dealing with the length of time between initial referral and case opening.
NYLCare credentials providers every three years, relying on their Medicare certification and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation coupled with routine office visits, which include medical records and quality improvement reviews, Milanich notes. NYLCare separately audits providers without Medicare or JCAHO credentials, utilizing parameters similar to those used by both organizations, she adds.
Requiring both HCFA and JCAHO certificationBlue Cross Blue Shield of Maryland in Owings Mill - which includes the company's FreeState and Delmarva managed care products - also requires Health Care Financing Administration (HCFA) certification and JCAHO accreditation, says Daniel Winn, MD, medical director of care management. In addition, home care contractors must summarize utilization information by major physician group. Blue Cross uses the data to evaluate its overall home care usage and address both under- and over-utilization. For example, the company educates physicians with less-than-expected usage rates about the benefits of home care.
Blue Cross does require outcomes reporting from certain providers. For example, infusion companies must submit infection rate data. Contractors must also meet other performance standards such as service timeliness.
Although not yet required to do so, Sun Home Health Services in Northumberland, PA, reports outcomes data to contracted managed care plans, says Gretchen Wagoner, RN, BSHA, director of quality improvement. A participant in the Medi care Quality Assessment and Quality Improve ment demonstration project, Sun has received two Outcomes Assessment Information Set (OASIS) reports matching its results with other providers.
The statistically sound, case mix-indexed data indicate Sun's wound healing and pain management outcomes compare favorably with other OASIS participants, she adds. While these experimental outcomes involve only Medicare patients, Wagoner notes their importance to managed care organizations is that "we apply the same standards and quality of care to managed care [members]."
While managed care organizations have not yet asked Sun for OASIS-type outcomes, they do require updates on certain disease state management populations. For example, using a quality of life questionnaire, Sun elicits information about different aspects of congestive heart failure patients' daily living.
Do agencies understand the data collected?At least one home care provider is skeptical about managed care's use of more complex data. "Everyone talks about quality and outcomes reporting, but I don't know whether they are looking at it," says Judy Lewis, BSN, president of Creative Health Care Services Inc., a Tempe, AZ, infusion nursing company.
"All want to know that you have certain credentials [such as] a QA facilitator, JCAHO accreditation, [and] performance improvement studies when contracting," but demand little ongoing information.
Creative Health operates in a highly competitive, capitated market with more than 86% of its revenues coming from managed care. Still, Lewis says only one managed care organization requires formal utilization information.
And only recently did a nationwide company ask specifically about Creative Health's outcome studies. "Mostly people ask `how can we get better utilization so patients aren't in the hospital?' And they want to know that you have protocols to do it in the home safely and cost-effectively, but they're not looking [in any more detail]," she adds.
Rosenblum agrees. "Providers are more sophisticated than the people contracting for their services, and it should be that way. It allows them to show contracting managers what they can produce."
No matter what data sophistication shore managed care currently rests on, the tide is turning, sources say. Payers are more interested in and beginning to look more purposefully at data, Lewis notes.
Outcome studies and other performance measures' real value will become more evident when payers and providers link, selling their joint services to employers.
"We can prove your employees will get well sooner" has a lot of impact, she adds.
Regardless of managed care organizations' formal reporting requirements, information can be a real competitive boost, sources say. Outcomes data are a good way for providers to solidify their relationship with payers, Lewis notes. "Good service alone doesn't get it."
References1. National Committee on Quality Assurance. The State of Managed Care Quality. Washington, DC; 1997.
2. National Committee on Quality Assurance. Hedis 3.0 Executive Summary. Washington, DC; 1997.
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