Clinically, for-profits lag not-for-profits

MANAGED CARE November 1998. ©1998 Stezzi Communications

A Managed Care magazine analysis of Quality Compass 98 — the National Committee for Quality Assurance's annual compilation of HEDIS data — has blown the dust off of some controversial generalizations about the health plan industry. Our study of Quality Compass data indicates that on the whole, not-for-profit health plans tend to outperform for-profit plans on Health Plan Employer Data and Information Set measures. We also found that large national health plans can have large regional differences in quality of care and that pure HMOs appear to score higher than point-of-service plans.

This year, 447 plans reported HEDIS data to NCQA; 292 agreed to allow NCQA to make their scores public. NCQA offers that plans that publicly report data tend to score higher on HEDIS measures than plans that choose to keep their scores confidential. Similarly, NCQA-accredited plans outperform health plans that do not seek the NCQA seal.

In all charts, the numbers represent the percentage of enrollees eligible for the service who actually received it.

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For-profit vs. not-for-profit

Some not-for-profit health plans have long looked down their noses at their for-profit cousins, claiming superiority of priorities. Quality Compass could give the not-for-profits fuel for their arguments. While generalizations about quality of care are difficult to state definitively, for each of six key HEDIS measures that we checked out, the average score of all not-for-profit plans is higher than that of for-profit plans. (Averages for each measure are calculated for publicly reporting plans that furnished data to NCQA for the specified measure.)

Regional variances

NCQA found significant regional variance within plans and differences from plan to plan. For instance, the average health plan in New England administered beta blockers to heart attack patients 90 percent of the time, while plans in the south central U.S. did so only 60 percent of the time. In general, New England outperforms the nation on HEDIS measures.

Given regions' varying resources and demographics, can these differences be overcome? At an NCQA news conference, Jeffrey Harris, M.D., M.P.H., director of prevention research and analytic measures for the U.S. Centers for Disease Control, related a discussion he had recently with quality-improvement managers from the nation's largest health plans. When some managers told him their plans were "pushing the limit on improvement," Harris replied, "Oh yeah? What about New England? How come they can do so well?" The managers talked about New England "all night long," Harris recalled, "and tried to figure out how they could get to that standard."

It would be little surprise to compare, say, a small health plan in New England to a small plan in another region and find different levels of HEDIS performance. But regional differences appear to extend to large national plans, which generally attempt to standardize care. For the three largest national plans' HMO products, a comparison of six important HEDIS measures by location reveals some profound differences.

HMO vs. POS plans

While point-of-service offerings are rapidly gaining popularity, they tend to lag HMOs on HEDIS performance. Quality Compass reports separate scores for HMOs, point-of-service plans and preferred-provider organizations (though insufficient information exists to make valid comparisons about PPOs).

To report or not to report?

There are reasons, often valid, why some plans participate in HEDIS but do not make their scores public. But in an effort to turn up the heat on nonreporting plans — and as a message to employers to support plans that are gutsy enough to lay their cards on the table — NCQA released data showing that, overall, plans that report publicly outscore plans that do not.

The accreditation correlation

NCQA-accredited plans tend to outscore those that do not seek accreditation. This takes on new significance next year, when HEDIS performance will count toward accreditation scores. "Accountability will drive better performance," says NCQA President Margaret O'Kane, noting that plans that participated in HEDIS two years in a row outperformed the industry as a whole.

MANAGED CARE November 1998. ©1998 Stezzi Communications