'Managed competition': Can it improve quality?
Managed competition’: Can it improve quality?
One outcomes expert says it doesn’t work
In the concept of "managed competition," employers and consumers purchase health care based on comparative information about both cost and quality. But one leading outcomes expert cautions that public dissemination of outcomes data doesn’t necessarily lead to the positive market response that health care reformers have touted.
In New York state, publication of physician- and hospital-specific mortality rates from coronary artery bypass graft surgery led to improvements because of peer pressure and targeted quality efforts of the health department, says Mark R. Chassin, MD, MPH, MPP, chairman and professor in the department of health policy at Mt. Sinai School of Medicine in New York City and former commissioner of the New York state Department of Health.
Employers, consumers, and even managed care organizations did not use the qualitative information as many had hoped, he says. "Hospitals [that are] graded the best have not attracted an increased number of patients," he says. "[Patients] have not shied away from those rated the worst. They are not interested in playing that kind of role [as health care consumers]."
Chassin also asserts that managed care organizations still are competing based on cost, rather than quality.
Outcomes programs could expand to include numerous measures on a variety of medical diagnoses. But consumers would find their decision-making even more difficult, he notes. "If we had four or five measures for each of the 50 top reasons why people go to the hospital, the chance that a single hospital would turn up at the top [as the best] is nil," he says.
Instead, patients would need to consider their specific condition. "If you’re pregnant with diabetes, you go to Hospital X, but if you’re pregnant with hypertension, you go to Hospital Y. Are patients really going to choose that way?" he says. "The next year, when we reproduce the data, 75% of the numbers would shift just by chance."
In fact, patients already have failed to use much simpler information the mortality rates linked to specific surgeons, Chassin says. The percentage of patients undergoing bypass surgery at hospitals with higher-than-average risk-adjusted mortality rates was virtually unchanged from 1989 to 1993, a time when data were publicly reported.1
While Chassin asserts that managed competition can’t work the way it is envisioned, he says outcomes reporting can led to better care. "The positive impact depends on the publication of the data and the linkage of publication with local quality improvement," he says.
For example, from 1989 to 1992, 27 low- volume surgeons in New York state stopped performing bypass surgery. In some cases, hospitals restricted privileges of low-volume surgeons based on the results of the health department reports. Those low-volume surgeons who quit performing bypass surgery had risk-adjusted death rates that were 2.5 to 5 times the state average.1
The state Department of Health also worked with St. Peter’s Hospital in Albany, which in 1991 had a risk-adjusted mortality rate that was significantly higher than the state average. The hospital discovered that not enough time had been spent stabilizing patients before emergency bypass procedures. It was also discovered that other treatments, such as intra-aortic balloon pumping, had been used less frequently than at other facilities.1
With changes in its treatment processes, the hospital improved its care. In 1993, 54 patients received an emergency bypass and none died; in 1992, 11 of 42 similar emergency bypass patients died.
Simply reporting the outcomes data without helping the hospital analyze and restructure its treatment would not have led to the significant changes, Chassin says. "I think we need lots more of these [outcomes reporting efforts], but they need to be targeted on improvement," he says.
Reference
1. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med 1996; 334:394-398.
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