By any other name Featured

10:04am EDT July 22, 2002
If you want to know how sturdy your insurance carrier is, call your state department of insurance. To find out how well your local hospital stacks up, check their status with the Joint Commission on Accreditation of Healthcare Organizations. You can learn your personal physician's history in part from the local medical society or, in even greater detail, from a new set of consumer guides to the nation's best and worst doctors.

However, if you're looking for a national, comprehensive, standard and generally accepted measure of how your managed-care provider compares to others in the market, you have nowhere to go. But that's about to change.

"I think it would be a great thing if we came closer to a national report card, with some good science behind it, available on the Internet, that small employers could just pull down and compare," says Tom Cragg, manager of managed-care plans for General Motors Corp., in Detroit. "We're trying to move toward a national consensus on quality measurements, though we have a long way to go."

Cragg's office of six, along with outside consultants, reviews, negotiates with, selects-and sometimes rejects-managed-care providers for some 1.5 million eligible GM employees and dependents in 30 states.

Cragg works with approximately 100 HMOs at any given time. While he has resources at hand that no small business could hope to command, he says, "There is more information on which refrigerator to pick than there is on how to pick a doctor or how to pick a health plan."

Managed-care companies and their watchdogs in government, industry and the public interest groups have been lurching toward a nationally standard set of quality measures since the managed-care concept caught on with employers about 15 years ago. Since then, managed care's share of the health-care market has ballooned from 5 percent to 80 percent of insured Americans. And quality concerns and consumer complaints have lately drawn congressional scrutiny, including a federal government mandate in the 1997 balanced-budget agreement for a national quality standard.

Yet employers searching for comparable quality measures on managed-care plans are confronted by a bewildering array of partial, developing and sometimes dated statistics-when they can make sense of anything they find. Following are some of the better, more readily available measures to help select a quality HMO.

"I think we're recognized as the standard," says Brian Schilling, spokesman for the National Committee for Quality Assurance, or NCQA. The 8-year-old private, not-for-profit organization is based in Washington, D.C.

For now, and probably for the future, NCQA is the gold standard for quality measurement of managed-care plans. "We are very comfortable with NCQA as a strong indicator of quality," says GM's Cragg. His staff insists the managed-care plans either be NCQA accredited or in the process of earning accreditation before they can be offered to GM employees.

To date, NCQA's work concentrated on two areas. Accreditation involves sending a team of physician and administrative surveyors into the managed-care organization to review six key areas:

  • Quality management and improvement. (Does the company have in place an effective quality-assurance program tailored to the needs of its customers?)
  • Credentialing (For example, do physicians have appropriate licenses and malpractice insurance?)

  • Utilization management. (Denial of benefits must be sound. If a cardiologist says surgery is needed, only another cardiologist reviewing the case may deny the surgery).

  • Preventive health. (Immunizations, etc.)

  • Members' rights. (24-hour customer phone service in appropriate languages, grievance processes, etc.)

  • Medical records, (especially coordination of inpatient and outpatient care, and various diagnostic and treatment regimes).

NCQA offers three levels of accreditation. Full accreditation lasts three years, and to date, 61 percent of plans reviewed have received that highest approval. About 30 percent of plans qualified for one-year accreditation, while 5 percent earned provisional (one-year) accreditation and 5 percent were denied. Somewhat more than half the nation's HMOs have participated in the NCQA accreditation process.

The other side of NCQA involves health-plan performance measurement through HEDIS-the Health Plan Employer Data and Information Set. If a health plan were a car, accreditation would tell you how safe the car is, while HEDIS would tell you how fast it goes. More than 50 standard indicators measure effectiveness of care (stop-smoking programs, immunization rates, chemical dependency treatment); access (availability of primary care providers, dentists, obstetrical and prenatal services); satisfaction (including "disenrollment," that is, insurance dropouts); rate trends, board certification and other statistics. "The idea of HEDIS is really pretty simple," Schilling says. Instead of employers approaching NCQA with innumerable subjective questions about quality issues, HEDIS offers an evolving but objective set of standard measures that allow comparison between competing plans.

HEDIS data is provided voluntarily to NCQA for review. In 1999, NCQA will require that the data conform to audit standards and be performed by certified auditors. Some 330 health plans participated last year in the group's "Quality Compass" program, which makes accreditation status and HEDIS available to employers. Most NCQA data is freely available on the Web at

Starting next year, NCQA will integrate accreditation with selected performance measures (including member satisfaction, quality of care, access, service) into a new program called "Accreditation '99." The organization promises the new standard will be more complete and consumer-friendly.

Observers agree that NCQA accreditation and HEDIS data are the industry standard for quality measurement at this time. But there's still room for improvement, notes Dr. William E. Golden, president of the American Health Quality Association, which recently completed an audit of HEDIS reporting measures.

By making HEDIS data public, Golden says, "You're forced to be much more precise," because its very openness changes the dynamic of data gathering, consumer demands for particular measures, and HMO responses to inquiries. Yet the "science of performance measurement in 1998 does meet that kind of standard for patients or purchasers," he says. "I would say the HEDIS measures are better than nothing. But they are more of an indirect grade than they are a black-and-white measure of performance."

NCQA is likely to respond to this critique, if for no other reason than it now has competition in managed-care comparison business. Schilling estimates there are no fewer than a dozen institutions and businesses vying to join the accreditation industry. "It's hard to know what to make of a health plan that says, 'We're accredited by Joe's Accrediting Service'," he adds. Other organizations are offering their own quality measures. Some contenders:

JCAHO-the Joint Commission on Accreditation of Healthcare Organizations-actually jumped into the accreditation game the same time NCQA started. But they jumped right back out. Now the organization that accredits hospitals-and whose stamp of approval is federally required if that institution wants to receive Medicare and Medicaid funds-is getting back in the game with its own custom set of measures.

Consumer Assessment of Health Plans Survey, or CAHPS for short, is organized by the RAND Corp., Harvard Medical School, the Agency for Health Care Policy and Research, and the Research Triangle Institute. Their survey is aimed at more subjective measures of patient satisfaction and demands. "It's designed to give consumers basic information they've said they really want," notes Dennis P. Scanlon, assistant professor of health policy and administration at Pennsylvania State University. CAHPS questions are being merged into the latest iteration of HEDIS.

Ford Motor Co. and GM, working with the Foundation for Accountability and the RAND Corp., are developing a report card on HMOs that they intend to make available to their managed-care enrollees this fall. Cragg says the private initiative will be tailored to health issues most critical to its mostly male, aging unionized workforce. He notes that younger, smaller companies may have different health care emphases based on the gender, age and racial mixes-among many other factors-of their workforces.

Private firms are also in the business. HealthShare Technology Inc., an Acton, Mass.-based company, produces software and packages existing standardized outcome data gathered from hospitals in 30 states to compare which facilities turn out the healthiest patients. Such standardized information has long existed for hospitals, notes HealthShare president and CEO Richard Siegrist, but is just now being developed for managed-care companies. J.D. Power and Associates, working with The MEDSTAT Group, recently compared HMO performance with competing fee-for-service plans. And few employers have missed the periodic Consumer Reports, USA Today, and U.S. News & World Report compendia of managed-care quality on their bookstores' magazine racks.

So comparisons of managed-care performance and quality are available, and improving. But "the availability of that data assumes we have users who understand how to use it," says Penn State's Scanlon. "It's still unclear to me that at the end of the day whether people can feel comfortable making a choice from the information they have."

Small and growing companies often have just one criterion for choosing a managed-care plan: cost. "Cheap is not necessarily bad, and expensive is not necessarily good, in health care," says NCQA's Schilling. "That's definitely a bad shortcut for people to take, to shop expecting they will correlate cost with quality." Yet Golden adds, "At some point dollars and cents becomes a necessary but insufficient answer to the problem."

Comparing the comparisons seems to be the starting point. Look for NCQA accreditation, Cragg advises. Check to see which level has been earned. Compare the HEDIS data available for managed-care plans in your area. Seek out the multitude of varied measures offered by your local chamber, health purchasing coalition, state governments and reputable publications. Don't judge plans based on a few measures, and don't try to nitpick small differences in performance and quality scores: Golden says trifling statistical variations creep in. Look rather at scores in many areas; only broad differences in scoring will be truly indicate quality or the lack of it.