By Rebecca Anwar, Ph.D. & Judy Capko
The pressure is on for managed care organizations (MCOs) to receive high marks in quality performance. In recent years the public, somewhat wary of managed care, have become more vocal in their demands for quality, choice and service. Organizations such as the National Committee for Quality Assurance (NCQA) and the American Medical Association (AMA) are moving into high gear. NCQA is the top credentialing organization for MCOs, with nearly half of the nation’s HMOs seeking NCQA accreditation. Meanwhile, the AMA recently launched a nationwide accreditation program for physicians. The development of new credentialing programs and the continued expansion of existing accreditation programs will define, measure and monitor quality indicators that relate to physician performance. This has a dramatic impact on physicians, who will find patients, employers, government, the media and MCOs demanding quality and increasing their expectations of physicians.
Increasingly, patients will seek physicians who receive high ratings and abandon those that do not. Employers will select MCOs that are accredited and MCOs will scrutinize physician behavior and performance. In addition, you can expect the media, which are already annually reporting on the performance of HMOs, to begin examining and reporting on medical group performance. MCOs, relying on physician performance to achieve NCQA accreditation, closely monitor the performance of their physicians and hold them accountable for achieving superior ratings for quality care and service. Physicians that do not achieve high patient satisfaction scores for access, choice and service risk being deselected by MCOs and managed care insurance plans.
Employers are “value purchasing” when they review the health care options they will select for their employees. Value purchasing means selecting the highest quality health plan at the most affordable price. When the price is the same, quality becomes the differential. To become the preferred choice, physicians must partner with MCOs in meeting standards of quality that differentiate them in the market.
From the patient’s perspective, they have always assumed physicians have the necessary clinical expertise to provide quality care. Patients, generally, do not have the ability to measure or rate clinical performance and technical competence. NCQA, on the other hand, has developed quality indicators that specifically relate to clinical performance.
The new version of the Healthcare Employer Data Information Set (HEDIS) 3.0, refines standard performance measurements in four critical areas: access, effectiveness of care, outcomes and customer satisfaction. MCOs’ ability to meet these performance measures is directly dependent on the service and care provided by the physicians they contract with.
Access to care. Access and availability of care relates to the MCO having a large enough primary care physician (PCP) panel, geographically positioned to adequately meet the needs of the enrollees (member population) covered by the plan. In addition, the ability to access the specialist is monitored. The MCO is required to have a written access plan, but an important component of how well it works is the referral mechanism between the PCP and the specialist, and the appointment availability of all the physicians. The MCO assumes responsibility for collecting and analyzing data that evaluates the physician panel’s performance.
For physicians, it is important to know exactly what the access to care standards are for each MCO contracted with. Your high scores are important to MCOs. Get these standards in writing and then modify your practice’s policies and procedures accordingly. For example, timeliness of care standards include establishing parameters for preventive care appointments, routine primary care appointments, urgent care and emergency services. Beyond this is the key element of telephone service response time, on-hold times and hang-ups.
Effectiveness of care. Appropriateness of care is evaluated through Quality Improvement (QI) activities that include trending measures of care and service and analyzing improvements in both care and service.
Although controversial, developing and implementing practice guidelines is a primary means to accomplish desired results with effectiveness of care. NCQA standards are fairly explicit in promoting the adoption of practice guidelines. Organizations must involve practitioners in the selection and adoption of guidelines, which must then be widely disseminated. Researching guidelines is essential, and each guideline adopted must be measured against a minimum of two other guidelines. Utilization management and clinical decision making must be consistent with guidelines that have been adopted. This requires a commitment from physicians and the leadership of emerging medical groups to examine existing industry practice guidelines to determine guidelines the MCO will approve and implement.
Member satisfaction. NCQA standard for member satisfaction can be met by instituting member satisfaction surveys, evaluating the number and types of member disputes tracked through member complaints and appeals. Other mechanisms to evaluate the MCOs (and physician panel) performance are analyzing members’ requests to change physicians and the number of voluntary disenrollments that are occurring. HEDIS 3.0 requires hiring an outside vendor to conduct the annual member satisfaction survey. This is important to ensure the methodology is consistent with HEDIS guidelines and the assessment is unbiased. Access, availability, communication and service issues are the traditional measures that evaluate physician and staff performance when a satisfaction survey is conducted.
Accountability agencies. Beyond NCQA which is driven primarily by insurers, there are other groups that focus more on physicians per se. Physicians must recognize the impact of these emerging programs that will require them to comply with specific quality standards. AMA predicts their physician accreditation program will involve half the states by the end of 1998 and all 50 by the year 2000. In addition, the Foundation of Accountability (FACCT) focuses on purchaser and consumer needs examining the “experience of care.” The five measures are breast cancer, diabetes, major depression, health plan satisfaction and health risk behavior. FACCT’s approach to examining and measuring includes the steps to good care, level of satisfaction and the result (outcome).
The Agency for Health Care Policy and Research (AHCPR), a government agency affiliated with the Department of Health and Human Services, is involved in formulating policy to evaluate technology and primary care systems. Its most notable achievement is the support of Patient Outcomes Research Teams (PORTs). PORTs are a series of studies on the quality, effectiveness and cost effectiveness of current therapies for the treatment of some of the most common and costly medical conditions in the United States.
Still, it is NCQA that has the most immediate impact on physicians who are providing patient care through managed care contracts, whether they contract directly with the HMO plan, a network, an independent provider association (IPA) or other MCO configurations. NCQA is stimulus for MCOs to structure quality programs to ensure accountability exists among physicians. Selecting qualified medical directors and establishing a solid infrastructure that includes the utilization review (UR) committee and the development of QI standards and programs is essential. When this structure is in place and a commitment to quality exists, physician accountability becomes a reality.
Rebecca Anwar, Ph.D., and Judy Capko are senior consultants with The Sage Group, Inc., a national health care consulting firm.