More transparency in quality of care performance might be needed

November 1, 2005

Managed care executives should be making delivery of high-quality care a higher priority and marketing themselves based upon their clinical performance, according to industry experts.

NATIONAL REPORTS- Managed care executives should be making delivery of high-quality care a higher priority and marketing themselves based upon their clinical performance, according to industry experts.

According to Earl Steinberg, MD, MPP, president and CEO of Resolution Health, a healthcare data analysis company that provides quality improvement and cost reduction services to health plans, employers, PBMs and DM companies, executives should be asking their medical director:

According to NCQA's annual State of Health Care Quality report, only about 21.5% of the industry now reports publicly on its performance. "The takeaway lesson here is that the quality improvement [QI] model of measure, analyze, report, intervene and repeat measurement is a good model for the entire healthcare system, not just HMOs and point-of-service plans," says Greg Pawlson, MD, NCQA executive vice president.

Among the 289 commercial health plans that reported their data, average performance improved on 18 of 22 clinical measures. Medicare and Medicaid plans reported smaller gains. "That's great news for people who are enrolled in the plans that give us performance data, and it provides yet more evidence that public accountability drives improvement," Dr. Pawlson says.

Second, there has been a shift in enrollment to plans that don't report on their performance. The HMO and point-of-service sectors are shrinking while the PPO and high-deductible/consumer-directed health plan sectors are growing. "The latter don't yet report on their performance," Dr. Pawlson says. "To say that that's troubling is an understatement, because it strongly suggests that the level of accountability is slipping rather than improving. If there is no reporting, care could actually be getting worse, and we would not know it. In a time of growing consumerism, it's imperative that all types of plans report their performance data publicly or the positive trend we've seen over the past six years may evaporate, or even reverse itself."

Just as airlines focus on "on-time" departures and arrivals, health plans focus quality improvement efforts on things on which they are being measured, Dr. Steinberg says. "Since, from a practical perspective, health plan performance is defined in terms of HEDIS scores, plans focus their quality improvement efforts on HEDIS measures. That said, the magnitude of improvement overall was not very high. There is, thus, a lot more work to be done," he says.