As Congress prepares for an historic floor debate over health care reform, those of us who have worked in the trenches to measure and improve the quality of care are watching with a mix of anticipation and concern. Reform has the potential to significantly improve the transparency and, ultimately, the quality of our system of care. But I worry that the provisions needed to achieve a transparent, high quality system could end up on the cutting room floor as lawmakers strive to finish the picture.
The unique perspective of the National Committee for Quality Assurance (NCQA) on the status of health care quality in the U.S. is based on rigorously audited data submitted annually by health plans according to specifications laid out in the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) information. Today, we publish the 13th in a series of annual reports known as the State of Health Care Quality and, for the first time, the results leave us little room to celebrate. In fact, performance across all three sectors of health care – commercial insurance, Medicare and Medicaid – was nearly flat, with only a few bright spots.
The report is based on an analysis of HEDIS® and CAHPS, data that was submitted by 979 health plans (702 HMOs, 277 PPOs) across the country that collectively cover 116 million, or 2 in 5, Americans. HEDIS® measures assess how often patients receive care that conforms to evidence-based guidelines, such as for diabetes care, cardiac care, cancer screening, immunizations, and smoking. CAHPS® looks at patient perceptions of access, timeliness, and satisfaction.
The flat-line results of this year’s report are most striking in the public sector, where we have seen little progress for three consecutive years. Among Medicare Advantage plans, we saw statistically significant gains in only 5 out of 36 measures (14%). Among Medicaid plans, the results were slightly better, with improvements in 18 of 50 measures (36%). Among commercial plans, 22 of 51 measures (43%) showed such improvements.
There were a few reasons to celebrate. Delivery of beta blocker drugs to patients within 6 months of a heart attack was up 10 percentage points in Medicare plans. Initiation of smoking cessation treatment jumped 5.5 points in Medicaid plans. And care for the 30 million Americans living with asthma is consistently exceeding 90 percent. Also, in 2009, we saw a 9 percent increase in the number of people enrolled in health plans reporting HEDIS data to NCQA, and a 127 percent jump in transparency since 2000. With nearly 300 PPOs now reporting audited HEDIS data to us we are able to get a more complete picture of care quality.
On the flip side, there has been no progress on a series of behavioral health measures that are hovering at an unacceptably low level. These include monitoring of adults on anti-depressants and children on ADHD medications as well as initiation of treatment for people with alcohol or drug dependencies.
Why Is Quality Flat And How Can We Reverse The Trend?
Why is the quality world flat? The biggest reason is the failure to link what we pay to what we want. Major employers – including many in the Fortune 500 – have built performance expectations into their plan contracts. But small and mid-size firms do not have the market clout to follow suit. While many states have instituted pay-for-performance systems in their Medicaid managed care programs, half the people in that program are in a form of fee-for-service care. In Medicare, where plans serve 1 in 5 beneficiaries, there are no payment incentives for plans to improve performance. We simply pay for health care piecemeal. And experience shows, that sort of payment system results in us buying more care than we really need. By some estimates, a lot more.
So what do Members of Congress and President Obama need to do to reverse these troubling trends? How about these three steps:
1. Create insurance exchanges and require plans that join them to report HEDIS and CAHPS and maintain meaningful accreditation.
2. Reform payment systems by linking pay with performance, allowing providers to share in the savings and, ultimately, provide global payments that focus on the whole patient not their parts.
3. Invest in quality measurement by setting priorities for improvement, funding measure development and gaining stakeholder agreement to use the same (or similar) measures across all sectors.
These steps won’t cost very much to implement and, in fact, will save money. NCQA estimates that if we can bring the performance of all plans up to that of the 90th percentile, we would save between 49,400 and 115,300 lives every year and save billions in unnecessary costs. Who can be against that?