Quality-Measurement Organizations Look Beyond HMO and POS Plans


Now that the hard part — forging quality-measurement systems for HMOs and point-of-service plans — has been done, the next step is to adapt these programs to the rest of the health care industry.

Margaret E. O’Kane

Twenty years ago, when fee-for-service practice was dominant, medicine was unlike any business. There was no oversight to assure customers that service was of high quality. Today, this has changed. More employers demand proof that they’re getting value for their health care dollars. Even patients want the ability to judge the quality of their care in much the same way they would consider the quality of any major product before buying it.

To its credit, the managed health care industry has, at least in part, embraced this trend; half of all HMOs have earned NCQA accreditation, and about 90 percent collect HEDIS data. We’re proud of having succeeded at making a large share of HMOs take ownership of the quality of care and service they deliver.

But there is more work to be done. Accountability must become the norm for the entire health care industry. That means adapting our current measuring tools — accreditation and HEDIS — to PPOs and medical groups.

We should not expect wholesale changes overnight. It will take time to fine-tune oversight efforts, such as our new PPO-specific consumer survey, before they are adopted by more than a few leading PPOs. PPO accreditation, which will be pilot-tested next July, likely will also attract only a handful of leading PPOs at first, much as our HMO accreditation program did when introduced in 1991. But the effort will be worth it. PPOs cover 89 million Americans, and we need to know the same things about them that we know about HMOs and point-of-service plans.

Physicians who actually deliver care should be held accountable in the same way HMOs are. It may not be the same kind of information used to evaluate HMO quality, but nonetheless, this kind of information is the best way to hold medical groups accountable for quality.

It can be done

Some suggest that measuring medical-group quality of care will be much more difficult than measuring health plan quality. Truth be told, I don’t see it as complex. There are barriers, but basically we’re talking about evaluating two things: clinical systems and the functions they perform. We’ve shown that’s possible and that it can pay dividends in terms of improved care. The reason 80 percent of people in managed care now get beta blockers after a heart attack instead of 62 percent, as was true three years ago, is due to HEDIS.

We already evaluate functions relevant to medical groups in our health plan standards: Are credible practice guidelines in place? What patient education programs exist? What outreach and follow-up systems are there? The devil is in the details, as we have learned through the development of health plan accreditation standards and of HEDIS. Adapting this to medical groups will present challenges, but we’re up to the task.

Quality measurement has turned out to be both more challenging and more straightforward than I expected. Challenging, because you need to question your assumptions constantly as you go forward — “Do we really need to have plans report every HEDIS measure every year?” and so on. But on the other hand, the concept is fairly simple: Measure something, work to improve it, and it will get better. It’s a simple formula, but it has had a profound effect on health care in this country.

Margaret E. O’Kane is president of the National Committee for Quality Assurance. NCQA accredits HMOs and manages the evolution of HEDIS.

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