AHCPR's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of State, local, and Federal policymakers and other health services research users, such as purchasers and health plans.
This workshop was designed to address the information needs of State and local health officials from both the executive and legislative branches of government responsible for the design, conduct, or regulation of health care quality-related activities. It was held in North Charleston, South Carolina, June 4-6, 1997.
In recent years, tremendous changes have taken place within our Nation's health care delivery system. With these changes, not the least of which has been the shift of significant portions of the population into integrated managed care delivery systems, has come a greater emphasis on measuring the quality of care provided by our health care systems, a notion often discussed but very difficult to operationalize.
A number of reasons can be put forward to explain this increased emphasis on quality of care, including:
As the shift to managed care has increased the demand for quality of care information, the health services research community has been pursuing a wide range of initiatives designed to increase or measure the effectiveness of alternative treatment interventions and assess the performance of different delivery systems. Many of these initiatives have been funded by the Agency for Health Care Policy and Research (AHCPR). Although the progress in these areas to date has been impressive, many questions remain to be answered.
In this continually changing health care environment with its evolving health care delivery systems, State and local governments find themselves faced with responsibilities in a number of key areas that could have an important influence on the quality of care provided by these systems. For example, State licensure requirements could influence the quality of care provided by health plans that must meet those requirements. Both State and local governments acting as purchasers can significantly influence the quality of care provided to their entrusted populations through their contracting efforts. In addition, there is the potential for them to play very important leadership and oversight roles in promoting quality improvements that can benefit all members of the communities they serve.
To effectively carry out their responsibilities, it is necessary that State and local officials address many challenging, and often technically complex, issues and questions, including:
This workshop was designed to help State and local health officials address these and other pressing questions related to health care quality. While the purpose of the workshop was not to prescribe what policies these officials should adopt in this area, it was intended to enable the officials who attended to make more informed decisions with respect to health care quality-related policies and programs.
Participants were health officials from a broad range of organizations, including: State legislatures; State Medicaid agencies; State departments of insurance; State data organizations; maternal and child health bureaus; workers' compensation programs; Federal, State, and local health departments; and national associations.
Overview of Quality Measurement Issues and Challenges
Licensure, Accreditation, and Systems Standards
Quality/Performance Measures
Quality: Considering the Consumer
Private and Public Purchaser Strategies to Obtain Quality Health Care
Quality Assurance for Special Populations
Efforts to Ensure Quality Care: The Health Plan Perspective
Broadening the Focus: Quality-Related Initiatives to Improve Community Health Status
Roundtable: The State as Leaders—Developing Integrated Strategies to Ensure High Quality Care
Presenter:
Helen Smits, M.D., President, HealthRight, Inc., Meriden, Connecticut
This session established a foundation for the workshop by providing a common understanding among the participants concerning the basic concepts and issues associated with health care quality measurement and related policy issues. Helen Smits, M.D., President of HealthRight, Inc., and a former public official responsible for quality-related policy development, began the session with a discussion of recent changes in the health care marketplace, such as the shift towards managed care, that have resulted in an increased emphasis on health care quality.
She also explained that to tackle complex quality issues requires an understanding of the often misunderstood word "quality". She suggested that "quality" can be considered through several different perspectives:
Other areas explored in this session were the role of the States in the regulation of managed care organizations, and the States' ability as purchasers to demand quality through their own Medicaid programs. A specific concern noted with respect to Medicaid is that, due to a lack of true market pressures from consumers, quality problems—especially for special and vulnerable populations—could occur. To promote quality care, the presenter identified several steps that States could pursue, including creating consistency across and between States and other purchasers in terms of measuring quality, and publicly reporting outcomes of care.
Reference:
Health Care Quality Improvement Studies in Managed Care Settings: A Guide for State Medicaid Directors, prepared for the Health Care Financing Administration by the National Committee for Quality Assurance.
Presenter:
Janet Olsezewski, M.S.W., Chief, Managed Care Quality Assessment and Improvement Division, Michigan Department of Community Health and Member, Quality of Care Group for Quality Improvement Systems for Managed Care Initiatives (QISMC), Health Care Financing Administration
This session examined State governments' efforts to ensure quality in health care through their licensure activities. Specifically, discussed were State licensure requirements for managed care organizations, including a description of what is involved in the licensure of these entities, and an explanation of upon what aspects of health care quality these requirements focused. Following a discussion of the strengths and weaknesses of States' approaches to the licensing of managed care organizations—which are often based on frameworks that are 10 to 20 years old and no longer reflect today's marketplace—options for developing more appropriate regulation of new care models were described. These options included the expansion of current HMO regulations, the creation of new licensure categories, and a more sweeping overhaul of a State's health insurance/managed care regulatory structure. In this context, model regulations and statutes being developed by the National Association of Insurance Commissioners (NAIC), and the issues associated with linking public licensure and private accreditation efforts, were also discussed.
References:
A Report to the Governor on State Regulation of Health Maintenance Organizations, Aspen Systems Corporation, 1993.
Berger, D. Playing the Accreditation Game: Strategies for Networks. Health Care Innovations, March/April 1996, 828.
Health Care Professional Credentialing Verification Model Act, NAIC 1996, 70-1 70-6.
Quality Assessment and Improvement Model Act, NAIC 1996, 71-1 71-8.
States' Roles in Monitoring Quality is Evolving, NCQA, Winter 1995-96, Vol. II, No. 3.
Presenter:
Irma Arispe, Ph.D., Director of Evaluation Research, Department of Care Management and Outcomes Research, Johns Hopkins University-Bayview Medical Center, Baltimore, Maryland
An important element of any quality assessment process is the development of accurate and appropriate measures of quality. Discussed were the key issues and challenges associated with the development of clinical performance measures used to assess the extent to which a provider delivers appropriate medical services.
Among the key questions discussed were the following:
In discussing this last point, performance measure development efforts were described that are being undertaken by key quality measurement organizations, such as the National Committee on Quality Assurance (NCQA), the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the Foundation for Accountability (FACCT), and AHCPR. CONQUEST, a software tool developed with support from AHCPR, can assist policymakers and program administrators in identifying clinical performance measures developed by different organizations that might be adopted or adapted for use in public programs.
References:
Schoenbaum, S.C. et. al. Using Clinical Practice Guidelines to Evaluate Quality of Care: Issues and Methods. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. (AHCPR Publication Number 95-0045 and 95-0046); Attachment B, March 1995.
Palmer, R.H. et. al., CONQUEST 1.0: COmputerized Needs-Oriented Quality Measurement Evaluation System. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. (AHCPR Publication Number 96-N009), 1996.
Presenter:
Charles Darby, M.A., Expert Appointment, Center for Quality Measurement and Improvement, Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Rockville, Maryland
Many of the efforts to disseminate the results of performance measurements are designed to help consumers make informed choices about health care providers and plans. In turn, customer input is an important part of measuring quality. Charles Darby, M.A., from the AHCPR's Center for Quality Measurement and Improvement, provided an overview of the research on consumers' views of quality. He explained that, in general, consumers are not interested in highly technical measures of quality. When considering quality, they think of covered benefits, access to preferred providers, and ease of access to care and costs. Certain subpopulations, like Medicaid patients, have some additional concerns, such as cultural sensitivity.
Consumer satisfaction surveys have been found to be an important sources of information on how consumers feel about their health care providers and plans. AHCPR, through contracts with several research organizations, is sponsoring the Consumer Assessment of Health Plans (CAHPS®) project, which is seeking to develop several survey methods for obtaining information from consumers. The team developing the CAHPS® survey made an effort to gather important information that consumers are interested in, while keeping the instrument short and at a low literacy level to ensure maximum participant response and comprehension. In addition to a core instrument, they developed a supplementary set of survey items to address the specific needs of special populations.
References:
Consumer Assessment of Health Plans (CAHPS®), Agency for Health Care Policy and Research. http://www.ahrq.gov/qual/qual/cahpsix.htm)
McGee J., Excerpt from Information Interests, Needs, and Concerns of Medicaid Beneficiaries: A Preliminary Report on the Medicaid Consumer Information Project, submitted to the National Committee for Quality Assurance, April 4, 1996.
McGee J., Sofaer S., Kreling B. Findings from Focus Groups Conducted for the National Committee for Quality Assurance (NCQA) Medicare and Medicaid Consumer Information Projects, July 1996.
Presenters:
Michael Bailit, M.B.A., President, Bailit Health Purchasing, LLC, Needham, Massachusetts, and former Assistant Commissioner for Benefit Plans for the Commonwealth of Massachusetts
Patricia Drury, M.B.A., Director of Quality Measurement and Consumer Information, Buyers Health Care Action Group, Bloomington, Minnesota
This session provided examples of innovative strategies that health care purchasers have pursued in an effort to obtain quality health care services. The first example focused on Massachusetts Medicaid, describing Medicaid's approach to contracting with managed care organizations as data driven and placing a heavy emphasis on quality improvement. Among the tools that the Commonwealth used to implement this approach were:
Also discussed was the Commonwealth's involvement with the Massachusetts Health Care Purchaser Group, emphasizing that the common interest that private and public purchasers had in working together was to ensure that they received value for their health care dollar.
The second example focused on the Buyers Health Care Action Group (BHCAG), a coalition of large purchasers in the Minneapolis/St. Paul area, which is a market dominated by a small number of very large managed care organizations. Described were BHCAG's efforts to increase value, choice, and accountability in that marketplace by bypassing the managed care organizations and contracting directly with care systems established by groups of providers. The rationale behind this strategy and its anticipated benefits were presented, as well as the initiatives' features with respect to reimbursement, risk adjustment, and ERISA-related issues. Also discussed were a number of quality-related measures—including providing financial incentives for strong performance in certain areas—and BHCAG's plans for expanding the initiative into rural areas.
Reference:
Effective Health Plan Purchasing and Management Strategies, Bailit Health Purchasing, LLC, 1996.
Presenter:
Trish Riley, Executive Director, National Academy for State Health Policy, Portland, Maine
This session discussed both the importance of, and the challenges associated with, the development of measures to assess the quality of care provided by managed care organizations to special populations, such as Medicaid recipients, children with special health needs, people with chronic illnesses and the disabled. There are several reasons why these and other special populations are likely to encounter greater obstacles in receiving appropriate care, and as a result, will require system performance measures beyond those of the general population. These reasons include the diversity and complexity of the health and social needs of these populations, as well as the difficulties of coordinating care for those dually eligible for Medicare and Medicaid.
The building blocks for a sound quality management approach that addresses the needs of these special populations were discussed. These key features included the development of:
References:
National Academy for State Health Policy. Quality Improvement Strategies for Risk-Based Contracting, Attachment B, January 1997.
National Academy for State Health Policy. Quality Improvement Strategies Primary Care Case Management Programs (PCCM), Attachment C, January 1997.
National Academy for State Health Policy. Federal Barriers to Managed Care for Dually Eligible Persons: Differences in Federal Risk Contracting Requirements for Medicaid and Medicare, Attachment D, Page 1, August 1997.
National Academy for State Health Policy. The Quality Improvement System for Medicaid and Medicare Managed Care (QISMC), Fact Sheet and Mission Statement, 1997.
Presenter:
Michael F. Montijo, M.D., M.P.H., F.A.C.P., Chief Medical Officer and Vice President for Medical Services, Prudential HealthCare, Iselin, New Jersey
Many of the sessions in this workshop have addressed the necessity of making the health plans an integral part of the quality assessment and improvement process. This session discussed the issues concerning quality from the health plan perspective.
Even before managed care became prevalent, quality of care problems existed, such as the over utilization of certain treatments and the under utilization of others. A number of important issues that health plans must address in improving quality were discussed. These issues included: measurement issues and related data problems; the identification, assessment, and application of potentially effective interventions; and the challenges associated with dealing with factors such as mobile populations and inconsistent regulatory requirements across jurisdictions. A number of areas in which health plans have made progress in improving quality were described, such as: preventative care (e.g., identifying children requiring immunizations); acute care (e.g., treating peptic ulcer disease effectively); chronic care (e.g., intensive case management for diabetes patients); and service (e.g., telephone help lines).
Factors were presented that would promote continued quality improvements, including: improved information systems and data standards; purchasers placing an emphasis on quality; increased regulatory responsibility; and the development of appropriate risk adjustment measures.
References:
Siberman P. Ensuring Quality and Access in Managed Care: How Well Are We Doing? Quality Management in Health Care 5(2), 1997:44-54.
Bodenheimer T. The HMO Backlash-Righteous or Reactionary? The New England Journal of Medicine, 335, No. 21, 1996:1601-1604.
Mariner W.K. State Regulation of Managed Care and the Employee Retirement Income Security Act. The New England Journal of Medicine, 335, No. 26, 1996:1986-1990.
Jewitt J.H., and Hibbard J.H. Comprehension of Quality of Care Indicators: Differences among the Privately Insured, the Publicly Insured, and the Uninsured. Health Care Financing Review 18, No. 1, 1996:75-94.
Young G.J. Bridging Public and Public Sector Quality Assurance. Quality Management in Health Care 5(2), 1997:65-72.
Presenter:
Michael Stoto, Ph.D., Director, Division of Health Promotion and Disease Prevention, Institute of Medicine, Washington, D.C.
While the focus of previous workshop sessions was on efforts to measure and improve the quality of care provided by health plans, this session sought to place health plan activities in the context of broader efforts to improve overall community health status. Two Institute of Medicine (IOM) committees that examined this issue were described, one of which explored the potential of developing performance measures to promote improvements in the public's health.
Recognizing that health status is influenced by a broad range of factors, the committee's recommendations to develop performance measures were described in the context of a broad-based community health assessment, prioritization, and improvement process. The health of the community must be a shared responsibility, which is best served by forming partnerships across a wide range of organizations, including health plans and public health agencies. Also noted was the importance of establishing both specific objectives in a collaborative way for each of the entities involved, and measures to assess their progress in meeting these objectives. To illustrate the types of measures that might relate to the activities of health plans, the presenter shared several examples of prototype measures developed by the IOM committee partnerships in different areas (e.g., infant health, immunizations, and breast and cervical cancer), but stressed that the priority health areas and measures for a given community should be developed in the context of a broad-based, community-specific process.
References:
Durch J.S., Bailey L.A., and Stoto M.A. Improving Health in the Community A Role for Performance Monitoring. Washington, D.C. National Academy Press, 1997.
Stoto M.A., Abel C., and Dievler A. Healthy Communities: New Partnerships for the Future of Public Health. Washington, D.C. National Academy Press, 1996.
Moderator:
Lawrence Bartlett, Ph.D., Director, Health Systems Research, Inc., Washington, D.C.
In this session participants discussed ways in which States and communities can apply some of the lessons learned in this workshop to create and refine their own quality initiatives. Among the points raised in this roundtable discussion were the following:
Under contract to the Agency for Health Care Policy and Research, Health Systems Research, Inc. assisted in planning and conducting this workshop.
Internet Citation:
Ensuring Quality Health Care: The Challenges of Measuring Performance and Consumer Satisfaction. Workshop Summary, June 4-6, 1997, User Liaison Program. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/news/ulp/ulpqual.htm
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