Reasons why employers should focus on the quality of health care

1. There are numerous errors in the delivery of health care services
1. Adds unnecessary cost to the health care system
2. There is substantial evidence of overuse and underuse of health care services
1. Appropriate care is rarely received
3. Failure to exercise due diligence in evaluating quality of care may impact an employer's liability for a bad outcome of care
1. Recent trend is for insurer to be liable
4. Lack of attention to quality can have negative consequences in relationships with employees, providers and others in the community
5. Poor quality of care erodes the value of health care purchases

Components of quality care

1. Appropriateness - given the current state of the art of medicine (evidence-based guidelines)
2. Excellence - in the execution of care
3. Patient satisfaction

* Quality must be measurable to improve it

Structural issues in the U.S. healthcare system

1. Decentralized nature of the system
2. Poorly-aligned payment structures and incentives
3. Widely varying roles of hospitals and physicians in the delivery of health care services

Considerations in assessing physician quality

1. Assess the physician's training, experience and professional certifications (e.g. state licenses and hospital staff privileges)
2. Review the physician's history of malpractice claims
1. Questions remain whether malpractice experience accurately depicts physician quality
3. For physicians performing specialty procedures, consider advanced training received; volume of procedures performed; complication, mortality and success rates; and ALOS following the procedure
4. NCQA has developed some programs to recognize high quality physicians
5. For physicians in managed care plans, review performance report cards provided by some MCOs
6. Schedule an office visit to evaluate the physician's communication skills
1. Physician-patient communication is very important

Considerations in assessing hospital quality

1. The hospital should have the appropriate accreditations (from the state, CMS and JCAHO)
2. Consider the results of JCAHO on-site surveys
3. The American Hospital Association publishes information on hospital facilities, staff and services
4. Consider government data sources on hospital performance (e.g. CMS, Medicaid)
5. For specific procedures or conditions of interest, consider questioning the hospital directly regarding the volume of admissions; complication, mortality and success rates; ALOS; and whether it is a center of excellence
6. Consider whether the hospital is a major teaching hospital
1. Teaching hospitals have lower mortality rates for certain conditions
7. Review hospital satisfaction survey results
8. Review hospital quality ratings provided by HealthGrades.com and The Leapfrog Group

Considerations in assessing MCO quality

1. Accreditation by the NCQA (see card 7)
2. Accreditation by JCAHO (see card 8)
3. Information may be available from the state department of public health or the state department of insurance
4. Review the MCOs credentialing criteria, quality assurance plan and preventive care programs
5. Review the MCOs reimbursement mechanisms
1. Are there substantial financial incentives for providers to withhold care?
6. Consider performing a site visit

MCO Accreditation by the NCQA

1. Review of quality-related processes including medical care authorizations and review; provider network quality; and member rights and responsibilities
2. Site survey is conducted as part of review
3. Standardized measurement and reporting a) NCQA developed the Health Plan Employer Data and Information Set (HEDIS) to score health plans based on effectiveness of care, access and availability of care and patient satisfaction
4. Levels of accreditation
1. Excellent - meets or exceeds NCQA requirements with high HEDIS scores
2. Commendable - meets or exceeds NCQA requirements
3. Accredited - meets most NCQA requirements
4. Provisional - meets some NCQA requirements
5. Denied - failure to meet NCQA requirements
6. Suspended - accreditation withdrawn to investigate and implement corrective action
7. Under Review - health plan has requested review of accreditation
8. Discretionary Review - accreditation status is being assessed

MCO Accreditation by JCAHO

1. Accreditation process is very similar to the approach used by the NCQA
2. Levels of accreditation
1. Provisional accreditation
2. Accreditation with recommendation
3. Accreditation with or without recommendation
4. Conditional accreditation
5. Nonaccreditation

Provider approaches for improving quality (supply management)

1. Use a hospital database to identify deficiencies in quality and monitor quality improvements
2. Provide feedback on hospital and medical staff performance - can have a significant impact on quality
3. Use quality care data to selectively contract with providers
4. Use care guidelines
5. Promote continuous quality improvement (CQI) plans

Consumer approaches for improving quality (demand management)

1. Provide preventive services
2. Use shared decision-making programs to get the consumer involved
3. Disseminate information about provider quality
1. Must be easily accessible and understood
4. Offer telephonic nurse counseling services
1. Improves care appropriateness
5. Offer telephonic disease management
6. Offer "minute clinics"
1. Provide same services as telephonic nurse counseling services as well as routine clinical services (such as vaccines)
7. Encourage use of reliable internet sources (such as HHS and NCQA)

Primary sources of data for measuring health plan performance

1. Claims and utilization data
1. Least costly and readily available
2. Data quality depends on examiners and providers
2. Medical records
1. Accurate
2. Costly and only includes information on care provided by that provider
3. Patient-reported data
1. Information on services from all sources
2. Responses influenced by the form of survey, question wording and responses available
4. Population exposure data
1. Unreliable and incomplete