THE NCQA'S PRESIDENT SPEAKS
Can quality in health care be measured? The National Committee for Quality Assurance, the leading HMO accrediting organization, is making an ambitious attempt — and not without controversy. Here the NCQA's president offers views on the measurement effort and what it means for physicians.
Managed Care caught up with NCQA President Margaret O'Kane after the question-and-answer session following her remarks at the National Managed Care Physician Leadership Conference in Washington last month. The tone of the questions from some of the physicians in the audience had verged on hostility, but O'Kane appeared unruffled, and graciously agreed to answer further questions during a taxicab ride back to the NCQA's offices.
MANAGED CARE: Of course, our readers will not have sat in that room and heard the tone of the questions. But how would you explain the attitude some physicians have toward the quality measurement process and the encumbrances it places on them?
Margaret O'Kane: First of all, I think that there is a general anger about managed care in that it's changed physicians' incomes, it's changed their autonomy, it's changed their relationship with their patients, and part of the anger is related to those larger issues. I think there are also issues more specific to NCQA, relating to accountability and evidence-based practice, that are very controversial in the physician community. So the fact that we say to a plan that it has to hold its physicians accountable for quality is offensive to a profession that is not used to being accountable to others. It's used to sort of self-policing.
MC: Since you've used that word "policing," isn't it hard to fault physicians for a certain resistance to an effort of policing or quality management that is fraught with so many difficulties in execution — for example, the fact that you're often dealing with a plan that has contracts with a lot of physician groups who also have contracts with a lot of other plans?
O'Kane: There's no question that this is incredibly complex and that there need to be systems developed to reduce redundancy, to reduce the hassle for doctors, and so forth, and they don't just spring up overnight. There need to be much more efficient ways of getting this information, and I am confident that they will emerge. But you just don't just put something out there and then everything falls into place. You have to sort of work through the problems that are created.
MC: Is it fair to say that there has been some dissatisfaction with NCQA on the part of those involved in the Foundation for Accountability and others in that you're not outcomes-oriented enough?
O'Kane: Well, it's certainly easy to criticize what we do. I mean what we do is very, very difficult and, as you say, it's very easy to say, "Well, if I were doing it, I would do it differently." We don't think we should have a monopoly on performance measurement. We'd like to be the standard setter for performance measurement, but we welcome the work of others. And if FACCT can give us measures that we can move out into the marketplace, we welcome those as well.
MC: But isn't it a hassle for HMOs? You've got NCQA coming one week, and the Joint Commission [on Accreditation of Healthcare Organizations] the next, and —
O'Kane: Well, I don't think that's actually true. The Joint Commission has accredited only a few health plans.
MC: And yet it boasts that it's the one that looks at the actual site of the delivery of care.
O'Kane: There are, in a typical health plan, hundreds of physician offices. First of all, you're not going to get to an adequate sample, and, secondly, looking at the physical cleanliness of the office and the safety issues in the office doesn't really address the core issues of clinical practice.
MC: Are the core issues of clinical practice addressed effectively by looking at what we can measure now? In one of our articles ["NCQA Raises the Quality Bar for Plans — and Physicians," October 1996, p. 14] we quote [NCQA Vice President] Cary Sennett [M.D., Ph.D.] saying — and I thought this was an interesting quote — "No matter how important it is to measure outcomes, if we can't do it yet, we can't do it."
O'Kane: That's right.
MC: Is there pressure to measure more than we can and know more than we can?
O'Kane: Well, we think we've taken a very pragmatic and practical approach to this, and we think we're pushing the boundaries in some areas. The "health of seniors" measure that we have — it's an outcome measure, it's assuming that the plan can have an impact on the health status of seniors. It remains to be seen whether we're going to be able to detect differences among plans, but I don't think anybody can accuse us of being overly conservative. We're attacked on the one hand for scientific issues and on the other hand for not moving quickly enough. What we have to do is choose a sort of balanced posture where we weigh scientific imperfection, which is the reality here, against creating potential damage in the marketplace because of scientific imperfection. The nature of this work is inherently controversial.
MC: Without any criticism intended of NCQA or anyone else, is there a danger to health care from everyone's getting obsessed with what can be measured? Like a high school teacher who teaches the test and lets the rest of the curriculum go?
O'Kane: Yes, there is. Definitely.
MC: How would you characterize that danger?
O'Kane: Well, the problem is the underlying problem of not knowing what we're doing in the medical care in many cases. And my belief is that that situation is going to change rapidly, particularly as we have better data systems and we're able to do better studies of what works and what doesn't work. You know, let's talk about an absence of accountability for quality. What are the dangers in that? The dangers are a price-driven marketplace where you are punished for investment in quality infrastructure and quality management. I mean, isn't that equally dangerous or more dangerous?
MC: Is there something, though, to the contention that medicine is an art as well as a science, and the claim by some physicians that "What I do cannot be reduced to a series of quantitative measures"?
O'Kane: Well, I don't know. I guess I feel a little funny about that, and I know a lot of corporate purchasers also say, "If we wanted art, why would we send people to medical schools?" There is a strong interest in evidence-based medicine in the purchasing community, and it's not just knowing what you're doing but, where you know that something works, making sure you have the systems to deliver it.
MC: I hope you don't feel ambushed by the issue of Managed Care that this comes out in, because our cover story is about what "falls through the cracks," potentially, when quality is measured.
O'Kane: Clearly there are many things that fall through the cracks. The problem is, if you wait for a grand unified field theory, you will not have anything. So you can either have something and work to improve it — I mean we are working like crazy to improve this. I think the fact that we've moved from HEDIS [Health Plan Employer Data and Information Set] 2.0 to 3.0 demonstrates that we're able to make a lot of progress on these fronts. But if we're all going to sit around and wait until we have the perfect, then the market will be price-driven and quality will be punished.
MC: Do you think it's been too price-driven?
O'Kane: Yes. Managed care has been, I believe, mostly a price-driven product.
MC: It is said that the way you standardize care, to get the best care — find out what's the best and then get everybody doing it — is by implementing practice guidelines as well as looking at the other end and testing what has happened.
MC: I keep reading that with practice guidelines you've got to have physician "buy-in," so physicians should be part of the development of practice guidelines in a given locality. Isn't that inconsistent with standardization?
O'Kane: I think it's a struggle. You know, to me, when we have science that demonstrates that women over 50 ought to have mammograms, it's indefensible that somebody would have a different philosophy that's not based on science. When the science is clear, then practice ought to be standardized. When the science is not clear, we ought to be experimenting with what works and moving the ball forward.
MC: To some degree is it a kind of sop to physicians to talk about their participation in the development of guidelines in a given locale?
O'Kane: I don't think so. They are the scientists there.
MC: But a given group of physicians in a given care delivery location won't really have that much to say about the optimal treatment of a condition that we know about nationally, will they — aside from a few climatic differences?
O'Kane: Then am I, as a patient, supposed to be indulging the wishes or whims of local physicians, or am I supposed to get the best that science has to offer? I believe physicians are smart. If you show them good evidence, if you let them debate the evidence, I believe they will choose the right pathway.
MC: O.K., but they will not necessarily — in a given institution, say — have played a part in creating the guidelines that describe the care they're giving.
O'Kane: No, and that's not the way it should work, because it's a very sophisticated process that requires the most highly technical science. But that doesn't mean that it's not absolutely translatable to physicians, understandable by physicians, and even criticizable. There are things out there that physicians rightfully criticize, and not all practice guidelines are created equal. So I think there is a very important role for physicians. Physicians are the experts, right? To have them have to obey practice guidelines that they haven't had some role in developing — that doesn't mean every little local group has to modify them. To me that wastes a resource.
MC: Is there another danger from an undue stress on patient satisfaction, trying to please people? There's a point where satisfaction is one thing and good health care is another, isn't there?
O'Kane: I don't think so. I don't see any conflict between satisfaction and good health care. There are different dimensions, and you can be a technically excellent doctor who offends patients, but why shouldn't patients know that? There's no reason that a technically excellent doctor has to offend patients, right? Is there some conflict between technical excellence and being nice to people?
I think giving doctors this kind of information enables them to see how they stack up compared with their peers. Ultimately, doctors are high achievers. They want to be excellent in what they do. We know from science that the bond between a doctor and a patient affects the outcome, and if doctors are given information that their patients are unhappy with their interpersonal skills, I believe it's going to change them. Some it won't, of course. So it's really just trying to figure out how are we doing both at the physician level and at the delivery system level. And having information, in my view, will improve performance.
MC: Is being a doctor a less creative occupation than it was?
O'Kane: I think there's still a great need for creativity in terms of interpersonal aspects of care and trying to motivate the patients to do things that are good for them. There's a tremendous opportunity for physicians. We know from the science, over and over again, that physicians are the best motivators of patients for healthier behaviors, for compliance, and so forth, and, as physicians are able to see how effective they are in having a positive impact on patient behaviors, I think they'll be more and more creative about that. So I think having the information is really critical to the practitioners in evolving the way they practice medicine.
MC: Are we in any danger, in your view, of lapsing into a kind of fascistic "blame the victim" approach to health care, given that we're finding that behavior contributes far more to health status than we previously knew in a lot of areas?
O'Kane: I don't know. I think it's always a spectrum. You could have a fascist system where you get punished if you overeat and such. But look at what's going on in certain trends. Smoking rates are rising among teenagers. Obesity rates are rising among children. These are things that are going to have a tremendous and lifelong impact on their health, and for us to say, "Well, that's not our business. That's only the problem of the individual," in the face of a society that's marketing cigarettes to children, that's causing people to eat unhealthy foods — you know, I can't buy it. I think there is obviously a line beyond which the practitioner or the system cannot go in terms of invasion of patients' prerogatives to abuse their own health if they so choose. But at least give them the information, and develop support systems for them. I mean, I go to Weight Watchers, O.K.? Weight Watchers is fantastic.
MC: [Surprised look.]
O'Kane: Well, that's why I'm not fat! It's a wonderful system. There are ways the health care system can provide that kind of support and reinforcement and self-monitoring for patients, I believe, that are not explored.
MC: In your speech you mentioned NCQA's plans to begin accrediting medical groups as well as HMOs. What kind of a future do you foresee for direct contracting between provider groups and employers or other purchasers?
O'Kane: I think it remains unclear. Certainly for large medical groups there is no reason why they couldn't be directly contracting if they are providing a full range of services and they have the administrative talent they need. For many medical groups, they're too small to make it cost-effective, to have that kind of infrastructure within their plan, so it may be that they would need to be part of a network. But whether they are contracting directly or not, I imagine that physicians want a bigger piece of the pie and are unsatisfied with having intermediaries that are taking large profits out of the system. So I expect there will be more physicians at the helm of multiple-physician groups, and so forth. It may be that there are different organizational models. But whatever entites provide health care should also be held accountable for quality.
MC: Of course, there have been a couple of instances, both with physician-owned HMOs and with attempts at direct contracting, where physicians have discovered that there's something the HMO does after all.
O'Kane: Oh, I think there is no question that the HMOs add a tremendous amount of value in terms of services such as marketing, and even quality management in many cases, but it depends. It varies by your health plan. And if physicians have a large enough entity, there's no reason they can't just hire the people and do these things themselves. I don't care whether my health plan is an HMO or a medical group as long as I'm getting consistently high quality and good service.
MC: What is your personal health coverage, if you don't mind my asking?
O'Kane: I belong to an IPA-model HMO.
MC: Are you pretty satisfied with it?
O'Kane: Uh, I have my issues with it.
MC: And you're well equipped to bring them up, I would imagine.
O'Kane: I don't call up and say, "I'm the president of NCQA and I want this." But I've complained about a couple of things that have happened, and they've been pretty responsive.
MC: Thank you.