What Congress Can Do To Boost Health Care Quality

Margaret E. O’Kane, president of the National Committee for Quality Assurance (NCQA), an independent, non-profit organization whose mission is to improve the quality of health care, writes about NCQA’s new report, The State of Health Care Quality 2009. You can also read an interview with O’Kane here.

Just as the health care reform process is speeding up, NCQA has found that progress on important measures of health care quality has slowed down. After 12 years of steady and often remarkable progress in performance, the report we released today documented relatively little improvement in most areas of care during the past year by the nation’s health plans. These findings underscore why provisions to improve quality must be part of any health reform package.

Because reform will most certainly bring more individuals into Medicare and Medicaid programs, it was especially disconcerting to see that for the third year in a row, we found that performance of health plans serving these public programs failed to improve on key quality measures. In fact, Medicare Advantage plans made statistically significant improvements on only five of 36 measures (14 percent). The results for Medicaid plans were somewhat better, but still there was a statistically significant gain on only 18 of 50 measures (36 percent), and most of these were small. Results in the commercial plan sector were slightly better, with improvement on 22 of 51 measures (43 percent).

The State of Health Care Quality report is based on an analysis of Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data that was submitted by 979 health plans (702 HMOs, 277 PPOs) across the country that collectively cover 116 million people, or two in five Americans. HEDIS measures assess how often patients receive care that conforms to evidence-based guidelines, such as for diabetes care, cardiac care, cancer screening, immunizations, and smoking. CAHPS looks at patient satisfaction with their plans.

We can be encouraged about progress on some measures including:
• Care for the 30 million Americans living with asthma is consistently exceeding 90 percent;
• Delivery of beta blocker drugs to patients for six months after a heart attack increased 10 percent in Medicare plans; and
• Initiation of smoking cessation treatment jumped 5.5 percent in Medicaid plans.

Nevertheless, there has been disappointing progress on other key measures:
• Only 46.4 percent of people taking anti-depressant drugs are monitored by their physicians;
• Only 34.1 percent of children prescribed medications for attention deficit hyperactivity disorder (ADHD are seeing a doctor for follow-up care;
• Only half of patients previously hospitalized for mental illness see a physician for a follow-up visit; 
• Only 45.3 percent of people are receiving colon cancer screening at the appropriate age; and
• Only 42.6 percent of patients with alcohol or drug dependency are entering into treatment. 

We also observed continued sharp disparities for Americans depending on where they live. People in some parts of the country were far less likely to receive appropriate care than those in other areas. Across key measures in diabetes, cancer screening, behavioral health, and cardiovascular care, high-performing regions outperformed low ones by 14 percent or more. 

Among the biggest reasons the quality world is flat is our failure to link what we pay for to what is actually needed. Though large employers have built performance expectations into their contracts with health plans, small and mid-size companies do not have the market clout to follow suit. In Medicare, where health plans serve one in 5 beneficiaries, there are no payment incentives for those plans to improve performance.

Here’s our view on what Congress can do to assure that we start paying for what is effective and essential – and put the quality curve back on an upward trajectory:

First, create insurance exchanges and require plans that join them to report HEDIS and CAHPS and maintain meaningful accreditation.

Second, reform payment systems by linking pay with performance, allowing providers to share in the savings and, ultimately, provide global payments that focus on the whole patient, not their parts.

Third, invest in quality measurement by setting priorities for improvement, funding measure development, and gaining stakeholder agreement to use the same (or similar) measures across all sectors.

These policies can save lives and money. NCQA estimates that if we can bring the performance of all plans up to that of the 90th percentile, we would save between 49,400 and 115,300 lives every year and save billions in unnecessary costs.

So, this is no time for those of us working in the trenches, advocating for measuring and improving quality, to enter a “quiet period.”  We need to send a strong signal that quality is an essential element of health reform and can’t end up on the cutting room floor.

Comments

[Rick Brush]

The “strong signal” that Margaret O’Kane calls for should also include an insistence on national measures of non-clinical determinants of health. In fact, research tells us that social and environmental factors – such as educational quality, economic and employment opportunity, social cohesion, and access to essential goods and services like food and transportation – account for more than half of what makes us well or sick. So why aren’t these measured and reported as national health indicators?

Through CIGNA's Communities of Health initiative, businesses and communities are coming together in a growing number of cities around the country to uncover and address these broader health influences. In some cases this is aided by a data-modeling process that maps healthful or harmful conditions by neighborhood. The result is a map of community “hotspots” (red zones) that guides business, neighborhood and organizational communities to the most significant and actionable opportunities to improve health. For instance, by overlaying its employee population on the map, an employer can illuminate specific social determinants that matter most to workers living in the red zones.

Improving quality of care must be a national priority – and we also need to bring to light those factors that cause so many more of us to seek care in the first place. The evidence is clear: where we live, work and play; our socioeconomic status; our sense of control, hope and belonging; and how we treat each other…these matter most to health. If we fail to see and act on this our health as a nation will not change.

Rick Brush
http://www.communitiesofhealth.org

[Craig Smith]

How to fix the Health Care Crisis: Growing up around medicine and doctors I have learned a few things about the rise of the health care cost problem. It is not what many think…fat cats increasing rates. For effective control of costs and a re-emergence of the grandeur of the US Health system, ten steps must be taken immediately. They are not cruel suggestions, rather real solutions for the problems we face.
1. Standardize Prices for procedures – Equalizing the cost Hospitals and Medical Groups may charge for a similar procedure allows insurance to budget expected costs.
2. Limit Liability for Malpractice – For any mistake including Gross Negligence, neither person nor family affected by the malpractice claim may capture more than 1 Million in damages.
3. Force all Medical Malpractice to Arbitration – Less expensive for the hospital, medical group and easier access for consumer to file a complaint / claim.
4. Nationalize a Government Healthcare System – Provide government Health Insurance for Government Hospitals– Consumers can opt to have free insurance via the government (funded by taxes) to be insured. Government run Health (like VA system) will be longer lines but less expensive health care and focus more on acute care rather than preventative. Care is first come first serve basis, as socialized medicine.
5. Incent the taxpayer to have private health insurance instead of the free one by giving them a $8,000 direct tax write-off.
6. Force Pharmaceuticals to offer name brand meds as generics to Government Health System at 50% off.
7. Repeal any laws requiring private hospitals and private practice to care for uninsured. Instead refer them to Government Health System.
8. Set a max threshold payment any insurance (private or government) would pay, whereby anything beyond 1M within 10 years is not covered for any reason. The unhealthy will die anyway and should not bankrupt the system.
9. Employers may at their option, choose the least expensive option for employees, even no insurance (Government Health System).
10. Give additional yearly tax credits for every member of the family for obesity body fat measurements that can be certified and filed online by any healthcare provider. Severe / High – no credit, Mild / Elevated - $200, Normal / Low $500.
11. Health Care Database – Based on Social Security Numbers, a facility treating a patient may request and receive secure electronic medical records from a previous treatment or facility.
We face a certain break in our health care system within the next 1 to 5 years unless significant change occurs. The rise of health care costs is because the system is ineffective at treating and communicating together. The changes above all or partial will help lower the costs of healthcare to the individuals, allow for coverage for everyone and incentivize better health and private insurance.