Ed Tuller

Tuesday, 29 November 2005 05:28

The quality difference

Business leaders know that quality is the cornerstone of a successful product or service offering. And quality improvement is an essential ingredient in successful cost management.

The health care insurance industry is no exception. Fortunately, quality results for individual health plans, across a broad range of measures, are widely available and updated annually. And the news is very good.

According to the National Committee for Quality Assurance (NCQA), “For the sixth straight year, health care quality for the 65 million Americans enrolled in accountable health plans improved substantially across almost all clinical indicators.”

This year, the NCQA and U.S. News & World Report have collaborated to measure and rank the nation’s commercial, Medicare and Medicaid health plans based on quality. The report is called the U.S. News and World Report/NCQA “America’s Best Health Plans, 2005,” and comes at a time when it is needed most — the annual open enrollment period.

The health plan ranking is based on 41 separate measures of quality summarized into a single overall quality score and further detail in four key areas.

  • Access to care

  • Overall satisfaction

  • Prevention

  • Treatment

The quality equation
For any company, organization or agency, quality doesn’t just happen. It’s the result of well-designed processes and successful integration across the entire organization.

For a health plan, this includes the combined efforts of health care providers, health plan members, health plan purchasers and the health plan itself playing the critical role as integrator. The objective is to make sure people get the right care, in the right place, at the right time.

This quality equation not only provides people with better health care, it has the potential to reduce costs as well.

According to NCQA “...more than $9 billion in lost productivity and nearly $2 billion in hospital costs could be averted through more consistent delivery of best-practice care. ... Expanded performance measurement, better care coordination and broadened accountability throughout the health care system are proven methods of enhancing quality, and it is essential that they be incorporated into the new, less integrated health care delivery system of tomorrow.”

Investing in quality
Gains within health plans and future gains are currently threatened. Rising costs lead employers to accept new health plans with untested results and unmeasured quality, both of which would be necessary for improvement.

According to the NCQA, “... And consumers do not yet have access to the kind of information they need to make informed decisions about their care.” Although these actions can reduce short-term costs, they can have a negative long-term affect because they do not address the quality component needed to keep employees healthy over time.

Take employees with chronic health conditions, for example. Although they may constitute less than 10 percent of the work force, this same group accounts for 80 percent of all health care expenditures.

That translates into 80 percent of inpatient care, 83 percent of prescription drug use and 50 percent of emergency room visits. Providing employees with access to quality health care can substantially lower these costs in the long-term.

When evaluating health plan choices, employers should keep the following in mind.

  • Use publicly available quality information in your decision-making

  • Carefully balance the expense and investment sides of the quality equation

  • Consider direct and indirect cost savings, both current and future

  • Expect health plans to continue and extend efforts to improve quality that truly makes a difference in health and well-being

  • Consider joining other employers in encouraging and supporting broadened public reporting of quality information

Ed Tuller is director of quality development for Care Choices, a nonprofit health care organization and a subsidiary of Trinity Health. Care Choices HMO is ranked as #7 among 257 commercial plans nationwide and is the top-rated plan in Michigan, according to U.S. News & World Report/NCQA “America’s Best Health Plans, 2005.” For more information, visit www.carechoices.com