NCQA report ranks health plan quality

Poor performers are able to avoid scrutiny

Health plans that publicly report quality data not only perform better, but they show more improvement than those that don’t, according to the State of Managed Care Quality report released by the National Committee for Quality Assurance (NCQA) in Washington, DC.

While that finding bolsters the case for health care accountability, it also reveals a disturbing truth: Plans with poor performance still can avoid scrutiny simply by declining to release their results. And quality experts say these plans aren’t yet likely to face adverse consequences from consumers or purchasers.

While an estimated 90% of the country’s 650 health plans collect at least some quality data, and 447 reported 1997 Health Plan Employer Data and Information Set (HEDIS) results to NCQA for its Quality Compass database, only 292 plans allowed their data to be made public.

"It is important to remember that the lower performers in Quality Compass are not actually the worst plans — far from it, in fact," said NCQA executive vice president Cary Sennett, MD, PhD, in the report released in late September. "There are many plans whose performance is much lower still. The plans that publicly reported their data deserve credit for stepping forward. These are the plans that consumers can expect will get better over time and work to deliver top-quality care."

Patients were more likely to say they were "completely" or "very" satisfied with care from plans that publicly reported data (58.5% vs. 50.4%), and those publicly accountable plans performed better on every HEDIS measure.

The Quality Compass data again showed huge variation between the highest- and lowest-performing plans. For example, rates of beta blocker treatment for patients who had a heart attack ranged from 52% to 92%, with a national average of 74%. Plans publicly reporting their data outperformed their counterparts on that measure by 11%.

New England outperformed other regions in the country, as it did in last year’s report. Other regions shared the bottom spot as low performers in different categories.

Meanwhile, preferred provider organizations and indemnity plans do not participate in HEDIS and report no quality information to NCQA or other national bodies.

"I think purchasers and regulators need to be more aggressive in saying we’re going to get the same information about everyone," says Andrew M. Wiesenthal, MD, associate medical director of Colorado Permanente Medical Group in Denver and a member of the NCQA board of directors. "If you can’t provide the information, [they should say] you can’t provide the services."

We’re still far from value-based purchasing

However, most purchasers and consumers don’t yet seem attuned to quality indicators. That means there is little pressure on poor performers and few advantages accruing to the high performers.

Despite talk about "value-based purchasing," Wiesenthal’s group-model HMO has yet to see benefits from its quality data.

"We have comparable [premium] rates to major competitors in our market and demonstrably better quality on the public measures," says Wiesenthal. "People ought to be beating my door down to become members. Big employers ought to be insisting that we’re one of their offerings."

They’re not, Wiesenthal laments. Still, he remains optimistic that the health care market will become more focused on quality.

"I like to see the good things that appear about us in the press when these reports are released," he says. "I’d like to think it helps [competitively], but there’s no data that it does." Still, he says, "In the long run, it’s going to be what [matters]."

Even fewer independent medical groups collect and report HEDIS data, notes Wiesenthal. The California Cooperative HEDIS Reporting Initiative (CCHRI) will begin public reporting of HEDIS rates by medical group next year.

Leaders of the medical groups involved with CCHRI are committed to accountability, says Alfredo Czerwinski, MD, a principal with Lawson & Associates consulting firm in Sacramento, CA, and a member of the CCHRI executive committee. But those groups currently see little material benefit to their involvement.

"The overarching issue is this: Will the group get 10,000 more covered lives after it goes through all the work of pulling the charts, calculating the measures, and publishing the data?" asks Czerwinski, who specializes in physician organizational development and quality improvement. "Will some economic advantage accrue to those who take the trouble to have and publish good scores?"

Groups move toward physician accountability

NCQA and other organizations are slowly trying to expand the scope of performance assessment. In 1999, all plans that seek accreditation must report HEDIS data that are verified by an approved auditor. Business coalitions such as the Pacific Business Group on Health are reporting information from patient surveys on medical group report cards.

"There is no question that the movement is going toward much more accountability of all segments of health care," says Gary Krieger, MD, a San Pedro, CA, pediatrician and representative on the Performance Measurement Coordinating Council, a collaborative quality assurance group organized by NCQA, the fledgling American Medical Accreditation Program (AMAP) of the American Medical Association, and the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

AMAP is moving toward accreditation of individual physicians, including quality improvement and some form of performance assessment.

"As I’ve had the opportunity to talk to major purchaser and consumer groups, one of the things they say is missing is some understanding of what’s going on in an individual physician level," says Krieger, who also is vice chairman of AMAP.

In fact, many health plans now have physician networks that are virtually identical. But the efforts to assess quality at the physician or medical group level will proceed with caution. "Accountability never hurt anybody, but you have to have the right kind of accountability," says Krieger. "I want to make sure the tools and instruments we’re using, whether for a health plan or doctor, are used in the right way."