Scholle S, Mardon R, Pawlson G; AcademyHealth. Meeting (2004 : San Diego, Calif.).
Abstr AcademyHealth Meet. 2004; 21: abstract no. 1317.
National Committee for Quality Assurance, Research & Analysis, 2000 L Street, N.W., Suite 500, Washington , DC 20036 Tel. 202.955.1726 Fax 202.955.3599
RESEARCH OBJECTIVE: Previous studies of Medicare data show that large regional and local differences in health care spending are unrelated to access to care, quality of care, health outcomes and satisfaction. As health care spending rises, it is unclear whether the purchasers and consumers of care are getting value for their health care dollar. The purpose of this study was to examine correlations of commercial health plan performance on HEDIS effectiveness of care with access to care, outpatient use, and hospital use, as a proxy for cost. STUDY DESIGN: Health care utilization and quality measures reported by 316 commercial managed care plans in the 2003 HEDIS data were analyzed. Plans report on a standardized set of performance measures using detailed specifications. To be considered in the HEDIS data set, an independent audit of data collection procedures is required. This study used data from all reporting plans (including unaccredited plans that do not allow public reporting of their data). Utilization measures include Access to care (the proportion of adults with at least one primary care or preventive visit) and the rate of outpatient visits. As a proxy for potentially avoidable hospitalization, the rate of hospitalization (excluding surgical and obstetric care) examined. Quality measures include all the measures available in the HEDIS Effectiveness of Care domain, such as the diabetes measurement set, anti-depressant medication management, follow-up after hospitalization for mental illness, use appropriate medication for people with asthma, breast cancer screening, cervical cancer screening, cholesterol management after acute cardiovascular event, beta blocker treatment after a heart attack, controlling high blood pressure, Chlamydia screening, childhood immunizations and adolescent immunizations. POPULATION STUDIED: Three hundred sixteen plans representing 63% of MCOs in the US and representing 87% of individuals enrolled in commercial MCOs. Average number of enrollees per plan is 211,635.The commercial enrollee population is 52% female and less than 2% are ages 65 years or older. Plan product types include HMOs (36%), HMO/POS combined (61%), and POS (3%). PRINCIPAL FINDINGS: Rates of medical hospitalizations and outpatient visits vary by more than six-fold between the highest and lowest utilization plans. For example, the average annual number of medical Hospitalizations among adults age 45-64 ranged from 11.5 to 76.5 per 1000 members, with a mean of 48.4. Access to care (defined as at least one primary or preventive care visit) was not as variable, with a mean of 94.2 and range of 67.7 to 98.4 for this age group. Higher rates of access to primary and preventive visits were associated with higher performance on HEDIS measures. For example, access to care for adults age 45-64 was correlated 0.31 with the plans average performance on diabetes control, 0.31 with acute phase depression management, 0.39 with appropriate asthma medication use, 0.45 with breast cancer screening, and 0.30 with childhood immunizations. In contrast, higher rates of hospital care were associated with lower quality performance with performance on HEDIS quality of care measures: -0.27 for Diabetes control, -0.32 for acute phase anti-depressant medication management, -0.11 for appropriate asthma medication use, -0.22 for breast cancer screening, and -0.11 with childhood immunizations. Quality was only slightly, if any amount, correlated with outpatient visit utilization rates:0.00 for diabetes HbA1c control, 0.09 for acute phase depression management, 0.03 for asthma medication, 0.04 for breast cancer screening, and 0.00 with childhood immunizations. CONCLUSIONS: High quality health plans may reduce hospitalization care, while increasing access to primary care services. Some plans may achieve high quality more efficiently than others, given the lack of correlation between quality and utilization. Further research should examine whether potential differences in patient populations, health plan characteristics and provider supply factors account for these correlations. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: With health care costs rising and placing greater burdens on purchasers and consumers, there is a critical need to learn more about ways to identify and reward efficient provision of high quality care. Initiatives to identify health plans that achieve higher performance while minimizing costs are needed.
Publication Types:
Keywords:
- Adolescent
- Adult
- Female
- Health Maintenance Organizations
- Health Services for the Aged
- Humans
- Managed Care Programs
- Mass Screening
- Medicare
- economics
- methods
- utilization
- hsrmtgs
UI: 103624351
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