Consumer-based quality measures gain support from buyers, accreditors

Reporting framework rates care at each point of need from birth to death

Self-insured employers aren’t bargain hunters; they look for value at market-driven prices. The quest has turned an ever larger audience of buyers to the Foundation for Accountability (FACCT) of Portland, OR, whose consumer-based outcomes measures are on a rapid rise to star status.

A newcomer to the quality measurement scene, FACCT began its work in 1995 as a not-for-profit entity. Its trustees from consumer organizations, as well as corporate and government health care purchasers, represent 80 million Americans.

Ted von Glahn, FACCT consultant, says he wouldn’t want anybody to misunderstand the foundation’s role in quality measurement, however. Quality has different dimensions — some are critical to providers, some to accreditors, and some to insurance plans.

"Ours are intended to be put into consumers’ hands for their use in health care decision making," he adds. Although the data might pass through intermediaries like purchasing groups, the consumer is the end user.

FACCT’s work is about accountability, insists von Glahn. As an industry, health care has not publicly disclosed enough information to benefit consumers in their decision making. What are needed are outcomes reports that drill down to the medical group level. That’s what will help employees figure out which names to highlight as they sit around the kitchen table and decide which doctors to choose from their company’s list of options, he adds.

Several purchasing groups, such as the Buyers Health Care Action Group of Minneapolis (see QI/TQM, November 1998, p. 145), currently provide this kind of detail based on available, albeit incomplete, measures. Another is the Community Health Purchasing Corporation of Iowa. The Des Moines-based group consists of 30 self-insured employers in Iowa, state employees as well as the Iowa Medicaid population. Paul Pietzsch, the corporation’s president, says that FACCT goes beyond the others in its measures of value, service, and quality. "This is the best measure we’ve seen."

Does this mean that FACCT’s measures will replace others such as the National Committee on Quality Assurance’s HEDIS (Health Employer Data Information Set), or the Agency for Health Care Policy and Research’s CAHPS (Consumer Assessment Health Plan Study)? In a word — no.

(For a summary of FACCT’s measures framework or template, see "FACCT brings consumers’ wish list to QI table," above.)

FACCT measures are designed toward a singular objective: to reflect what consumers define as their needs and expectations from the health care system. To find the data, the researchers go to the best information source available. "It makes all the sense in the world to reach into patient records for an immunization count from a medical group," von Glahn explains. "But it makes [more] sense to ask consumers with diabetes whether they got a foot exam lately because you can’t find that information reliably in the patient records."

He cites reasons to cross-check data if multiple sources exist: It mitigates errors of omission in reporting sources as well as measurement errors in even the best statistical models. "When we can draw information from both the consumer and from the medical record, it gives us higher confidence, but FACCT believes that good outcomes measures have to have input from consumers," Von Glahn adds.

"But there are different audiences and different needs for health care measures. They should be aligned, but they aren’t yet. At some future date, maybe we could have one set of measures for consumer and provider audiences, but we have a ways to go," he explains.

While the FACCT model measures the consumer’s perspective of health care as no other does, "it’s not the end all," says Greg Larkin, MD, director of Corporate Health Services at Eli Lilly and Co., the global pharmaceutical firm based in Indianapolis. "When taken together, the leading measures of quality in health care make up a fair mix."

Instead of starting from scratch, FACCT is creating measures to plug the holes in the existing measures from accreditors and government agencies. Consumer-relevant information will be captured and pegged to the five categories of the template. The map shows what exists and what’s missing. (See graphic "From quality measures to consumer information," above.)

Also due for testing later this year is a prototype consumer quality report card. It will be streamlined — no data drawn from medical records or clinical systems. Instead the information will come from:

    • CAHPS satisfaction data;
    • selected HEDIS quality indicators;
    • FACCT condition-specific surveys on quality of care for chronically ill patients with asthma, diabetes, and coronary artery disease.

One of the test sites is Pietzsch’s Community Health Purchasing Corp. "From day one, we have worked with provider systems on continuous quality improvement," he explains. "When the mapped measures are accessible, they will be the best we have had so far." In the short term, he adds, the corporation plans to use the FACCT framework as its main QI feedback model: to providers, regarding best practice and clinical guidelines; to employers and health plan purchasing groups, for buying decisions; and to employees and consumers for decision making.

Lilly will continue to participate in FACCT’s pilots. The company uses the measures for corporate buying decisions and disseminates them to employees as aids to choosing providers. Additionally, the company is an ideal test site for one of the big holes in quality measurement. Of Lilly’s 12,000 U.S. employees, 7,200 are using indemnity coverage and 4,800 opt for managed care.

"If FACCT’s template proves to be a useful tool on the indemnity side of health care delivery, we would advocate for wider use of it because we have so few quality measures in indemnity populations," Larkin notes.

Given FACCT’s 4-year history, its progress is amazing. "We have tested whether these questions are measuring what we intend to measure," von Glahn says. "We’ve validated them in various settings and populations — and there’s still a big but’ hanging out there. Remember, our focus is consumers." Thus, FACCT’s next research push: Once the measures are on the street, how will consumers use them?