Health Care
Evaluating quality care
How health plans recognize providers who offer quality care
By Meredyth McKenzie
Smart Business Detroit | June 2009
Dr. Bruce Niebylski, Associate vice president of medical affairs, Priority Health
As an employer, you want your health plan to provide the best care possible for your employees. Working together with your health plan and its physicians can help you do that, as can services such as quality health programs, physician report cards and physician incentive programs that emphasize patient care.
“If a quality program is in place, the health plan is trying to reduce barriers to good care for members and trying to increase the incentives for the different variables that go into that patient getting good care,” says Dr. Bruce Niebylski, associate vice president of medical affairs with Priority Health.
Smart Business spoke with Niebylski about how using physician rankings and report cards can help ensure that patients are receiving proper care, how physician incentive programs work and how they can benefit you as an employer.
How did quality health programs get their start?
Quality health programs were initiated by employer groups years ago when they realized certain diseases were costing them a lot of money and were keeping employees away from work for long periods of time.
Employers realized they were spending a lot of money on health care for people with diabetes, heart failure and asthma.
Employers then went to health plans to see how plans could provide those patients with disease management. The programs help the sickest people navigate their condition through information and care. And if they begin to take better care of themselves, it will cost employers less in health care.
It’s a lot like AAA sending driving and safety tips to members.
How can employers use physician rankings and report cards to make sure their employees are getting the best care?
The physician ranking system and report cards are pretty much the same thing. The ranking system started about eight years ago when employers wanted to make sure their employees were seeing the best doctors.
A list of questions was generated about what makes a good doctor, and it has evolved from there. The original report cards gave stars to doctors who had board certification and no stars to those who didn’t.
The ranking system is typically an annual thing, because there are seasonal differences in what doctors do, and there are delays in collecting data. The ranking system is then updated once a year.
There have been a lot of questions over the years about physician report cards, and they’re still evolving as we’re learning what the best measures are that reflect a physician’s behavior. Because every doctor’s patients are different, in terms of their age, gender and life habits, all their demographics are different.
I may be doing an incredible job with my patients who are 70-year-old smokers with heart failure, but I may not have as high of a ranking as somebody caring for healthy 25-year-old joggers.
How do these ranking programs benefit employers and patients?
Physician report cards do change behaviors. Physicians, no matter where they rank, are always trying to improve their patient care. For example, if someone with asthma uses a steroid inhaler for care, he or she will prevent problems of the disease.
Health plans started measuring a doctor’s asthma population in the report card to see what percentage of patients used steroid inhalers. When it first started, about 50 percent of the patients were on steroid inhalers. But now, it’s up more than 90 percent, because doctors know it’s included in the report card.
Asthmatics are now receiving the right treatment and medication, and doctors are also persistent to get them to continue treatment. Some health plans have even gone as far as to reduce co-pays for steroid inhalers so it’s easier for patients to get.
It’s a concentrated effort to take responsibility for improving patients’ awareness and care of their disease or condition. For example, a patient may be motivated to take care of his or her asthma, but if the doctor is not available, he or she becomes unmotivated.
If the cost of the medication is too expensive for the patient, he or she may be motivated but unable to get treatment because of the price. Disease management programs try to reduce the barriers to people getting good care.
Health plans try to make sure medication is affordable, physicians are motivated, and many times members receive incentives when they achieve certain quality measures.
What is the incentive for physicians to participate in quality health programs?
It typically varies between health plans — some use a lot of incentives, some use a few, and some don’t use any at all. Many incentive programs are based on quality measures — things like asthmatics getting their steroid inhalers, diabetics getting their disease under control, women getting their mammograms and pap smears, and children getting their immunizations.
If a physician has a high percentage of members getting these preventive services, plans will give them incentives or extra money for achieving that rate. For example, if a physician has a 90 percent rate of children receiving immunizations, he or she will receive an additional $175 for each child in the plan.
Dr. bruce niebylski is the associate vice president of medical affairs at Priority Health. Reach him at (248) 324-2763 or bruce.niebylski@priorityhealth.com.
