Consumers provide the FACCTs on how well provider systems address chronic conditions

A coalition of public and private Iowa employers is going straight to the patient to measure providers’ effectiveness in treating asthma, diabetes, and coronary artery disease. The survey will use a self-reporting methodology, bypassing the traditional medical records review, to determine whether there is any difference in care between public and private patients.

The effort, facilitated by the Portland, OR-based Foundation for Accountability (FACCT), is part of a growing effort by purchasers to look beyond a plan’s reported clinical outcomes to what the patient actually thought the care did for him or her. FACCT, a standards organization sponsored by large employers representing more than 70 million employees, has become one of the nation’s leading advocate groups for analyzing such care at the level of the provider, rather than by health plan.

"In a lot of situations, the health plan is simply an administrative agent," says Ted von Glahn, a consultant for FACCT. "The action, in terms of how people are doing with regard to their health and management of disease, is at the care system level."

FACCT is conducting the survey for a coalition of purchasers in Iowa consisting of the state of Iowa, the Iowa Medicaid program, and the Community Health Purchasing Corporation, a sophisticated group of 30 self-insured employers. The collaboration makes it possible for the survey to find out if the performance of a given set of providers varies by whether the person has public or private insurance.

"We’ve been doing consumer satisfaction surveys for ages," says Harry Gill, MD, PhD, a physician consultant for the Iowa Medicaid program. "It will be interesting for us to find out how we compare to commercial plans."

FACCT is spearheading a national effort to integrate patient-based information with more traditional reporting methods. Over the past two years, FACCT has worked in concert with the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations and the Skokie, IL-based National Committee on Healthcare Quality to incorporate FACCT measures into the clinical outcomes reporting systems of those two organizations. This coordination of reporting standards acknowledges the push by consumers through their employers for more responsive systems that take into account how consumers feel about the care they receive.

The survey is possible only because of the unusual structure of Des Moines’ providers and purchasers. The Des Moines provider systems in the survey are comprehensive, fully integrated, and—most significantly—tend to have exclusive affiliations with their primary care physicians. By identifying an enrollee’s primary care physician, it is possible to know the full range of providers who serve that person.

It’s no longer enough to measure just plan performance, particularly when providers belong to multiple plans, says Community Health Purchasing Corporation president Paul Pietzsch. "Our hypothesis is that when you have plans that have all the providers in a community, what you’re measuring is just averages," he says.

Several separate areas will be explored in the survey:

The Basics: Information on how well plans ensure access to care, communicate with enrollees, and ensure providers are responsive will come from existing and ongoing data collection using Consumer Assessment of Health Plans Study surveys.

Staying Healthy: Information on how providers and plans help people avoid illness and maintain their health will come from existing and ongoing data collection from the Health Plan Employer Data and Information Set (HEDIS). HEDIS is a set of standardized measures developed by the Washington, DC-based National Committee for Quality Assurance.

Getting Better/Living with Illness: The survey for the final area covered by the Iowa initiative has been developed by FACCT. It addresses how the plans or care systems operate when enrollees have either an acute or chronic illness.

The survey will zero in on finding out how the care systems work for people with asthma, diabetes, and coronary artery diseases. Purchasers have a slew of questions about how well the systems are educating patients to take control of these chronic diseases, says Mr. von Glahn of FACCT.

"Did the patients even get the education? No. 2, did they understand it? Did they have a degree of confidence that they can use it? No. 3 is, what are their actual behaviors? What are their outcomes? What are their symptoms? How much work or activities of daily living are they missing?"

Chronic conditions only now are coming into the forefront of quality assessment efforts because, up to now, there has been "fairly poor agreement" among providers on how they should be managed, Mr. Gill says.

Another factor piquing the interest of researchers is the literature suggesting some chronically ill populations, such as asthmatics, fare better in a managed care environment than in fee-for-service plans.

The survey will compare the performance for three care systems—Iowa Health System, the Secure Care/Mercy Health System, and the McFarland Clinic—and the two administrative agents that serve them, Principal Health Care of Iowa and the Medicaid program.

"It’s exciting to us to slice it both ways," Mr. von Glahn says.

The so-called FACCT/One surveys are different from previous efforts by the company in that they will rely on self-reported survey data for clinical information, bypassing the cost, confidentiality, and coding issues posed by medical records review, says Mr. von Glahn.

"Part of what we’re learning about is whether you can use a patient self-report instrument here in Iowa to do a nice job of reporting on quality."

For Mr. Gill, relying on self-reported data for clinical information is a concern "to some extent," but he is willing to explore how it can be used for quality assessment. Separate University of Iowa analyses of Medicaid care for the chronically ill will be stacked up against the FACCT/One data for a fuller understanding of the program, he says.

Contact Mr. von Glahn at (503) 223-2228, Mr. Pietzsch at (515) 277-1210, and Mr. Gill at (515) 281-5394.