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Patricia Drury, MBA, joins us this month. Drury is senior consultant for Buyers Health Care Action Group (BHCAG) in Minneapolis. Renowned as the boldest health care delivery innovation of recent years, BHCAG is a coalition of 28 self-insured employers who purchase their health benefits directly from providers. Altogether, the coalition insures roughly 130,000 individuals. Providers set their own fees and practice guidelines. BHCAG bestows Excellence in Quality awards annually. Last year, $100,000 went to the Gold Award winner, St. Croix Valley HealthCare of Stillwater, MN. Three systems won Silver Awards of $50,000 each. BHCAG received a 1999 Ellwood Award from the Foundation for Accountability (FACCT) of Portland, OR. FACCT praised it as "the major health care experiment in the country." (For details on BHCAG, see related stories, QI/TQM, November 1998, pp. 145, 148, 150, 151.)
Q. How does the patient care outcomes agenda of an employer purchasing group such as BHCAG differ from that of other third-party payers like HMOs or commercial insurance plans?
A. First, it should be said that the outcomes we are interested in are quite similar, but with some important differences. HMOs’ agendas are, in part, driven by the HEDIS measures. We are interested in some of the same things, plus outcomes in other areas — as are they. But they have to focus where their accreditation criteria demand. The difference is that we are interested in seeing those measures at a unit-of-analysis level. We are interested in what we call "care systems." Care systems are what other people might call clinic groups, medical groups, or medical systems.
Q. Will you define care systems as the term is used by BHCAG?
A. We have a legal definition. A care system, for us, is an entity that is able either, in-house or through its contractual relationships, to deliver the whole range of benefits that our member companies provide to their employees (from primary care to specialty and inpatient care). Care systems can take any corporate structure, but they must be entities that can provide the whole range of care. One of the rules in our contractual relationships is no overlap. In other words, to contract with BHCAG, primary providers may only participate in one care system.
Q. When you say no overlap, do you mean that when they contract with BHCAG, they forfeit the option of contracting with other health plans?
A. No. They can contract with anybody they want to. But under BHCAG, if Dr. X is part of care system A, he cannot also be a part of care system B. Some specialists may be a part of A and B, but a primary care doctor has to pick the system through which he or she is going to practice for us. We think it’s important, for accountability, for physicians to have an organization they feel loyal to. I don’t know of anybody else who does it. Although it’s terribly important for accountability, it’s hard for political reasons. It doesn’t tend to be the norm.
Q. How does the no overlap requirement ensure accountability?
A. It doesn’t. It just focuses attention on the individual care system level. By contrast, what happens at the health plan level is that when all the health plans have all the same doctors and you measure the quality of care, you just measure the same doctors’ care from different angles. And it’s not clear who is accountable for what.
In our market (Minneapolis-St. Paul) for example, all the health plans are huge networks with multiple medical groups. If one group gets really good at certain kinds of care, that will be averaged against everyone else in town. Nobody realizes the excellence in that medical group. But if you want the medical group to get excited and committed to the hard work of re-engineering and serious quality improvement, that group has to be recognized for its achievements. They cannot just be averaged in with everybody else in a huge health plan network.
Q. What contributions have employer purchasing groups made to QI measurement and outcomes measurement?
A. Although we are not doing original research, we have taken the application down to the care system level. When we do that, we see greater variability. So the measures get much more interesting in our world than they do in the HEDIS world. Things are not averaged out. Once you get variability, the interest level for consumers goes way up. We have actually started to bring consumers this information because now it has some fire to it.
Q. Do the quality improvement managers in the care systems do special data gathering and reporting to meet BHCAG contract requirements?
A. We do not impose any new reporting requirements. While we require our care systems to engage in formal, continuous quality improvement efforts, we don’t tell them what areas to focus on. Most of them are engaging in improvement efforts anyway. We accept what they’re doing — they just have to be doing it. We expect them to identify projects with goals. We also expect them to establish and conduct measures of progress toward the goals. They are required to create a feedback loop to the providers or systems producing those results. And we expect them to do continuous rounds of improvement.
Q. Do you rely on the care systems to validate their measures and make severity adjustments?
A. Right now we do because we are not reporting those measures to the public. We look to see that they have articulated a goal, have actual measures, and the feedback wheel. Now if they apply for our quality award, we scrutinize their measures more closely.
The health care field, as a whole, has higher sophistication in measurement methods than BHCAG, but the measures have such a high level of aggregation that their usefulness to purchasers and consumers is low. We would like to bring that level of sophistication down to the care system level. But we have two problems:
1. We don’t have the legal approval to look at the records, which is what it takes to construct a lot of the HEDIS measures.
2. We also only have jurisdiction over our members, and the numbers are small in any given care system. Our population is spread over 24 care systems in the Twin Cities and a five-state area. We’re still trying to figure out a solution to that.
We choose not to publicly report our measures because we have both an "n" (total numbers) problem and a validation problem. First, we are not imposing the same projects on everybody. Second, we don’t have the ability to go in and audit their records to verify their improvement reports. Until we have the structure to do external audits of measures at the care system level, we won’t be able to report our outcomes. It’s just going to take some development time.
Q. Do you see any signs that this type of direct purchasing from the providers might eventually replace the go-between of the insurance plan?
A. Great question. Health plans firmly believe that this cannot possibly go anywhere, that it’s only a flash in the pan. And then there are others who say it’s a fragile movement, but it still can grow.
There are purchasers around the country who express a very high degree of interest in our model. We have national companies with a presence in Minnesota joining us. We have other coalitions looking at how it would apply in their markets — and they are looking hard. It’s no longer "Come and tell us about it." They are saying, "Let’s talk about how we would go about it; let’s get some real numbers." There are advisors to various congressional committees and others in the political parties who are very interested in this model as a possibility for HCFA, under certain circumstances. No one has made any commitments, but there is a high degree of appreciation of the possibilities in significant places. Of course, there are enormous difficulties to overcome. We have an entire industry that says this cannot grow, and they will work to make sure that’s true.
For coalitions to work, all the employers have to be prepared to take a long-term view. This doesn’t pay off in six months. It’s something you have to invest in and understand. Do it for the principle, not just for the quick fix. It’s a whole restructuring of a market.
Q. What kind of feedback are you getting from the providers and support staff in BHCAG’s care systems?
A. Everything we get is very positive. If they are not happy, they’re telling somebody else. I have been on the podium with one doctor who said, "This is the best deal in town for us. It allows us to do the right thing and be compensated for it." This is a system that supports preventive care and allows care systems to develop excellence in caring for a chronic illness. We look at the illness burden of the people who actually select each care system, and we adjust payments accordingly. They are not penalized as they could be under non-risk-adjusted capitation. It’s a climate that nurtures excellence; it doesn’t guarantee it, but it nurtures it.
[For further information, contact BHCAG, 7900 Xerxes Ave. S., Suite 2420, Bloomington, MN 55431. Telephone: (612) 896-5186. Web site: www. choice plus.com.]