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A National Action Plan to Meet Health Care Quality Information Needs in the Age of Managed Care

A National Action Plan to Meet Health Care Quality Information Needs in the Age of Managed Care Abstract Concerted national action is needed to meet the growing demand for health care quality information among all health care stakeholders. We propose a coordinated national network of independent, public-private quality measurement alliances established through strong purchaser and consumer leadership at the state, regional, or local levels. These independent alliances could assume a variety of organizational forms, but all would undertake specific quality measurement and consumer information projects to meet local health care market needs by drawing on various combinations of the emerging national standardized quality measures. Local implementation of quality measures based on national standards will facilitate cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Successful models of such alliances already exist that demonstrate the feasibility of this national strategy, but concerted national leadership and federal matching funding will be needed to meet the scope of implementation required in markets across the country. THE DEMAND for information on the quality of health care in the United States has been growing steadily over the past 2 decades. Recent efforts to meet this demand have made some important progress, but they have been largely fragmented and directed to the needs of specific groups. Increasing pressures for cost control and the spread of managed care throughout the country create an urgent, shared need for information on health care quality among all health care stakeholders: consumers, public and private purchasers, policymakers, health plans, and provider organizations (eg, hospitals, physician groups, and clinics). We believe that concerted national action must be taken now to meet this need. But while the challenge is clearly national in scope, we believe the solution is to be found in a decentralized, market-by-market approach consisting of multiple, independent, public-private quality measurement alliances operating at the state or community level, using various combinations of national standards for quality measurement and consumer information activities. These independent quality measurement alliances would be formed through the leadership of public and private purchasers and consumer groups acting in collaboration with local health plans and providers. These independent alliances would undertake specific quality measurement and consumer information projects designed to meet local health care market needs, but would do so by drawing on various combinations of the national quality measurement standards now emerging from such national standard-setting groups as the Agency for Health Care Policy and Research (AHCPR), the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Foundation for Accountability (FACCT). While organized and operated at the state or regional level to be responsive to local market needs, these alliances would implement quality measures based on national standards, thereby facilitating cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Over time, the experience accumulated through these independent local efforts, working in a coordinated manner to share information and expertise across markets, could significantly advance our collective national knowledge of best practices and help identify the most valid and useful quality measurement methods and measures available. In addition to local implementation of standardized quality measures, quality measurement alliances also would play an important role in developing and testing improved methods for disseminating quality information to consumers and purchasers. This dissemination role could be combined with efforts to meet consumer information needs for guidance on treatment choice and wellness strategies. Progress has been made recently in developing such information, but consumers' access to it may be limited in some situations. The independence and multiple stakeholder sponsorship of the alliances we propose for quality measurement lend themselves to meeting this need at the state, regional, or local level in a manner that will help assure the validity of the information. Prototype alliances A number of promising prototype quality measurement alliances already exist that demonstrate the feasibility of the national strategy we are proposing. For example: The Minnesota Health Data Institute, initiated by a consortium of public and private purchasers and established by state legislation in 1993, is governed by a balanced board of health care stakeholders and operated by a private nonprofit entity under a partnership agreement with the Minnesota Department of Health. The Institute undertakes community-wide quality measurement and consumer information activities and also facilitates collaboration by those with proprietary electronic health information systems. For example, the Institute published a statewide survey of health plan enrollees in 1995 and recently completed a survey of state Medicaid enrollees using the new Consumer Assessment of Health Plans (CAHPS) survey developed by a national consortium of experts with funding from AHCPR. This information has been used by both purchasers and health plans to assess comparative performance based on uniform measures, and the Institute is making a concerted effort to utilize national standards wherever possible. The California Cooperative Health Care Reporting Initiative was organized by private and public purchasers through the Pacific Business Group on Health, but operates in cooperation with the state's health care industry. This collaborative initiative has disseminated statewide health plan comparisons for several years, based on validated information from the Health Plan Employer Data and Information Set (HEDIS) and a standard consumer survey. Since 1993, the Cleveland Health Quality Choice program has published biannual comparative patient satisfaction and clinical outcomes measures for all the hospitals in the greater Cleveland, Ohio, market. In addition to the use of this community-wide information by employers and their health plans for assessing individual hospitals, hospitals themselves have used this information to work with their medical staffs to identify areas for improvement and implement corrective actions. Other examples could be noted, such as the Greater St Louis Health Care Alliance, the Wisconsin Quality Forum, the Central Florida Health Care Coalition, and the Greater Detroit Area Health Care Council. Quality measurement alliances can take various forms. In some cases, they may be a freestanding legal organization, but in others they may be constituted as a task force, consortium, or coalition of existing groups. While a variety of organizational forms exist to accommodate the functions we propose, we believe certain core features are essential. These features include the following: collaboration and coordination to meet shared needs for health information; joint public-private sponsorship; accommodation to a variety of market situations and purchasing strategies; independence from health plan or provider control; flexibility to assess multiple dimensions of quality at both health plan and provider levels of performance; implementation of uniform quality measures, drawing on emerging national standards; organization at the state, regional, or local level. We now address each of these core features more fully in turn. Collaboration to Meet Shared Information Needs All health care stakeholders, whether consumers, public or private purchasers, policymakers, health plans, or providers, are seeking information on the quality of health care. Meeting these shared needs through collaborative arrangements and uniform measures would save money and reduce hassle. At present, they either are unmet or are met separately. Consumers and purchasers are particularly deprived of information by which to choose among health plans and providers, based on uniform comparisons. They have few reliable sources of such information. Consumers are often reluctant to trust information from the health care industry or even their employers. With the exception of only a few markets where comparative performance reports have begun to emerge from independent sources, the only available alternative for most consumers is to piece together the advice and experiences of relatives and friends. Findings from recent studies clearly indicate that both consumers and purchasers would welcome a trustworthy source of meaningful information on the quality of health plans and providers.1 Health plans also experience difficulty in meeting their need for information on the quality of the providers with which they contract. Increasingly, plans' provider networks substantially overlap with one another. Any one plan may represent a relatively small part of a provider's business. As a practical matter, it is difficult for each provider to respond to different data demands from multiple plans, and any individual plan may lack the clout to gain a provider's compliance with its unique demands. Both plans and providers should welcome some common, uniform arrangement for meeting the plans' needs for information on provider quality. We believe the needs of consumers, public and private purchasers, and policymakers should drive the choice of measures and data to be collected. However, there is also a pressing need among health plans and providers for information to serve internal management and quality improvement. While the strategy we propose can serve certain health care industry information needs, it may be impractical in the short term to select measures that simultaneously can inform consumers, purchasers, and policymakers and also provide the full range and depth of data needed for internal management and quality improvement. Nevertheless, there is no reason why measures chosen for the former purpose cannot also serve at least some of the latter need. Indeed, we would argue that serving both purposes represents a compelling reason for investment, particularly insofar as it facilitates use of the same measures for accountability and for improvement. Joint Public-Private Sponsorship Both plans and providers are faced with differing quality-related data demands from multiple purchasers. The larger the purchaser, the more responsive plans and providers must be to a demand for data. HEDIS, currently sponsored by NCQA, began as an effort by health plans to reduce the multiple demands placed on them by large employers; it represents major progress in this regard. But many self-insured, private purchasers contract directly with providers; their demands for quality-related information present the same problems for providers as those of health plans. The problems presented by private purchasers are compounded by yet different demands made by the federal government and, in some cases, by state governments. Joint public-private sponsorship of common data acquisition arrangements and uniform measures, both for plans and for providers, would go far to help address these problems. Accomodating Various Market Situations and Purchasing Strategies While managed care is spreading, the United States will have a hybrid health care system for years to come. Fee-for-service plans will continue to dominate some areas and age groups. Many variations on the managed care theme will come and go; today's preferred provider organizations and point-of-service plans will be replaced by new inventions. Similarly, as long as the exemption under the Employee Retirement and Income Security Act (ERISA) remains, private purchasing strategies will be divided between direct provider contracts and the purchase of insured products from health plans. Medicare and Medicaid seem certain to make the transition to capitated forms of managed care, but many Medicare beneficiaries will stick to traditional coverage as long as they can. Such variety means that quality measurement must permit mixing and matching of information depending on the penetration and configuration of managed care in a given market and the needs both of those purchasing from health plans and those dealing directly with providers. Independence From Health Plan or Provider Control Much of the information on quality will be used by various parties in the marketplace and public sector to hold plans and providers accountable for their value. For this reason, the data underlying such information often may be contentious and subject to gaming by those being measured. Concerns over the reliability and integrity of the data used in performance assessment must be somehow reconciled with the obvious efficiencies of self-reporting. Common sense suggests the wisdom of having providers and plans report their data to some kind of trustworthy, independent entity that can verify and aggregate such data, undertake the needed analysis, and disseminate the results to consumers, public and private purchasers, policymakers, health plans, and providers. Such an independent entity can be particularly useful in administering and reporting quality measurement that involves the measures of multiple standard-setters. The independence of the information source also is critical in meeting the need of consumers and purchasers for trustworthy information on the quality of health plans and providers. The neutrality of such an entity also should make it attractive to health plans and providers as a vehicle for meeting at least some of their information needs to support internal programs for monitoring and improving the quality of care. Multiple Quality Measures at Various Reporting Levels Quality measures are needed that address the specific information requirements of different audiences. Audiences in need of quality measures include individual consumers, public and private purchasers, policymakers, health plans, and providers. Each of these audiences requires information at different levels of the health care system, according to the specific choices and decisions they must make. The levels of the health care system that need to be assessed to meet these different information requirements include the community-level population, health plans and integrated delivery systems, various provider organizations such as clinics and hospitals, and individual practitioners. For example, consumers offered an annual choice of health plans need quality measures reported to them at the health-plan level. Purchasers facing health plan contract decisions likewise require performance information at the health-plan level. But both consumers and purchasers increasingly are seeking quality-related information that distinguishes between services emanating directly from the health plan and those received from providers. Consumers enrolled in health plans already seek information on which to base their choice of a primary care physician, specialist, or hospital. The growth of point-of-service health plans will increase consumer demands for information on the quality of all available providers in a market. Even purchasers contracting with health plans require information about the quality of the providers with which their respective plans may contract. The recent interest in direct contracting by purchasers in some markets will increase the demand for provider-level information even further. Meeting this mix of information needs may require acquiring certain data from individual provider units and then aggregating those data to match varying practice arrangements and relationships with health plans, networks, and the like. These aggregates, of course, must be built in accordance with statistical rules of validity as well as their utility for given purposes. The needed mix of measures also should address key dimensions of performance. Major performance dimensions to be assessed include general service (including access measures), clinical prevention and care, and cost. To provide maximum utility, these need to be assessed both with respect to the overall population for which a health care entity is accountable and with respect to its performance in caring for specific groups of people when they are ill. In all such assessments, balance requires consideration of the structure by which the health care entity operates, the process of delivering services and care, and the attributable outcomes. Use of Emerging National Standards The past few years have seen the emergence of promising national quality measurement standards under the auspices of NCQA, JCAHO, FACCT, and CAHPS funded by AHCPR. While no one of these standard-setters meets all of the needs discussed in this article, in combination they offer a potential solution as the source of needed quality measures. There is, of course, some redundancy among these initiatives that will have to be addressed, but it is the complementarity of their measures that is particularly attractive. Specifically, these include the following: NCQA's HEDIS 3.0, including measures being tested for assessing the effectiveness of care. The data generated by performance measurement systems mandated under the JCAHO's new ORYX initiative. Measurement sets endorsed by FACCT, including asthma, breast cancer, diabetes, major depressive disorder, health risks, and health status. The survey instruments and consumer reporting tools of the CAHPS project. There is a need to assure that the results of efforts to employ these quality measures are conveyed in terms that are meaningful and useful to consumers. Progress has been made by several of the organizations responsible for these measures in developing approaches to information dissemination that take into account the way consumers think about health care quality. Noteworthy in this regard is FACCT's framework for communicating quality information, but there is need for further work in this area by all of the standard-setters, including collaboration in reporting blended results of their measures. Over the long term, providing the needed information on health care quality will require collaboration among all health care stakeholders in building an electronic information infrastructure.2 At present, health plans and providers are investing heavily in proprietary information systems to meet their internal needs. We believe that those groups should collaborate more actively to maximize the potential of their proprietary systems for meeting broader quality measurement and other information needs. The prospects for success in this regard have been greatly increased by the emergence of Internet technology and recent progress in developing standards for health care information transmission and content. We acknowledge that full realization of such systems' potential remains some years distant, but action now can accelerate progress. State, Regional, and Local Organization As should be evident from the previous discussion, we do not believe that one size will fit all when it comes to health care quality information in the United States over the coming years. Even though health plans may consolidate nationally, health care and related services are delivered locally. Meeting the need for information on quality among the combination of consumers, purchasers, policymakers, health plans, and providers in markets that vary by managed care penetration and configuration and prevailing purchasing modes argues for organizational arrangements and measurement plans designed and implemented at the state, regional, or local levels. A single national organization would lack flexibility and sensitivity to local needs. The most useful information on providers and plans will vary widely by market, as will preferences as to organizational arrangements for data acquisition, verification, analysis, and information dissemination. A challenge will be to gain the benefits that come from state, regional, and local quality measurement alliances while meeting the need of many national employers and federal programs for nationally comparable information on the quality of plans and providers. We believe that the key to meeting this challenge lies in national arrangements to facilitate interstate comparisons, based on uniform measures. The need for concerted action: a national health care quality measurementinitiative The success of the early working models of independent quality measurement alliances noted earlier suggests that—with sufficient national leadership, coordination, and funding—it may be possible to achieve national implementation of this proposed community-based quality measurement strategy within 3 to 5 years. Perhaps the greatest challenge in organizing multiple, decentralized independent quality measurement projects under this proposed national health care quality measurement initiative will be securing adequate financing. Simple logic suggests a compelling argument for supporting the scheme we propose. Collaboration both within and across markets to administer standardized surveys and other quality measures will save millions of dollars and overcome problems, such as inadequate sample size, that fragmented projects now encounter. Other industries—ranging from banks (eg, automatic teller machines) to advertising (eg, A.C. Nielsen ratings)—have learned that collaboration in developing and using uniform measures and sharing infrastructure can save millions. The irony is that in spite of the promise of such savings, each key health care stakeholder may resist contributing to the cost of the proposed arrangements for meeting shared health care quality information needs. Consumer organizations are notoriously underfunded. Private purchasers have budgets for direct health care costs and premiums but not for quality measurement. Furthermore, there is resistance among the relatively few employers who typically lead such efforts to paying a disproportionate share of the cost of what really is a public good. Government agencies have difficulty persuading state legislatures to appropriate funding for virtually any new expense in the face of taxpayer resistance. Providers and health plans draw on their business income to cover their proprietary quality measurement activities. They would be willing to finance broader efforts only if they could pass that cost on to their customers without competitive disadvantage. This situation of virtually universal resistance to paying the cost of quality measurement suggests the need for some incentive to loosen the stakeholders' purse strings. Insofar as the federal government can meet its own needs through participation in the independent state, regional, and local quality measurement alliances we propose, it should be permitted to use funds appropriated for its quality measurement activities to support such projects. Indeed, the health quality improvement organizations (formerly peer review organizations) currently used to monitor and improve quality under Medicare might make attractive partners or vendors for such projects. Federal funding could be offered in a manner that motivates other stakeholders to contribute to a project's cost. Specifically, we propose that HCFA be permitted to match a substantial portion of the cost of such projects, provided they meet the needs of the Medicare program and allow HCFA's active participation as a project sponsor. Various combinations of state appropriations, plan and provider financial participation, and employer contributions can be expected in response to HCFA's offer. We believe, however, that the offer of federal dollars will be key to the success of the proposed initiative. Even with federal financial incentives, the proposed initiative will require sustained national leadership and coordination if it is to reach a scale sufficient to address the magnitude of national need. To that end, we propose the creation of a National Health Care Quality Measurement Leadership Consortium of interested groups to provide direction for the community-based measurement strategy outlined in this article. Such a leadership consortium would consist of a balanced representation of consumer groups, public and private purchasers, government agencies, health plans, providers, and the national standard-setting organizations. As a collaborative effort, the leadership consortium would not be intended to replace existing organizations already actively contributing to the goals of quality measurement and consumer information, but rather provide a vehicle for these existing organizations and efforts to coordinate and facilitate the implementation of a variety of supportive services needed. These services include the following: A national campaign to promote formation of independent, public-private quality measurement alliances and related projects at the state, regional, and local levels. On-site technical assistance services for those organizing quality measurement efforts at the state, regional, and local levels. Organization of national benchmarking databases to facilitate cross-market comparisons of health care quality, measured in accordance with any one, or combination, of the standards endorsed under the initiative. A series of workshops to introduce state, regional, and local leaders to the concepts underlying the national health care quality measurement initiative and to practical lessons and tools needed to organize and implement quality measurement projects. Intensive courses on quality measurement, its organization and uses, for individuals in key health care consumer and purchaser roles, such as consumer organization leaders, local labor union officials, public and private human resource professionals, and American Association of Retired Persons chapter volunteers. Information exchange activities for those engaged in, or considering, projects under the initiative, including an Internet network and Web page, newsletter, and annual meeting. As a practical matter, some kind of national resource center would be needed to organize and coordinate the range of activities overseen by the leadership consortium. Such a resource center should be organized as a private, nonprofit entity with federal participation and financial support. One possible model for implementing the national leadership consortium and resource center we propose is the Forum for Health Care Quality Measurement and Reporting called for in the recent report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. As proposed, the forum is designed as a private sector group to be inclusive of many stakeholder groups, with significant representation by purchasers and consumers.3 With appropriate leadership and funding, such a forum could oversee implementation of many of the specific supportive services described above. This proposal is offered in the conviction that the time has come to address the real danger of increasing fragmentation among health care stakeholders in meeting their respective quality information needs. The actions taken to date by key players are commendable and provide a firm foundation for future success. However, possible tensions created by differences among standard-setters, national and local employers, public and private sectors, and health plans and providers will serve only to delay and increase the cost of information urgently needed by us all. We urge each of these groups to recognize that its legitimate interests, as well as those of the public at large, would best be served through collaboration in the strategy we are proposing to meet our most pressing national health care quality information needs. References 1. The Henry J. Kaiser Family Foundation and the Agency for Health Care Policy and Research. Americans as Health Care Consumers: The Role of Quality Information. Menlo Park, Calif: The Henry J. Kaiser Family Foundation; October 1996. 2. National Committee for Quality Assurance. A Road Map for Information Systems: Evolving Systems to Support Performance Measurement: HEDIS 3.0, Volume 4. Washington, DC: National Committee for Quality Assurance; 1997. 3. Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality First: Better Health Care for All Americans. Washington, DC: Advisory Commission on Consumer Protection and Quality in the Health Care Industry; March 13, 1998 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

A National Action Plan to Meet Health Care Quality Information Needs in the Age of Managed Care

JAMA , Volume 279 (16) – Apr 22, 1998

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Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.279.16.1254
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Abstract

Abstract Concerted national action is needed to meet the growing demand for health care quality information among all health care stakeholders. We propose a coordinated national network of independent, public-private quality measurement alliances established through strong purchaser and consumer leadership at the state, regional, or local levels. These independent alliances could assume a variety of organizational forms, but all would undertake specific quality measurement and consumer information projects to meet local health care market needs by drawing on various combinations of the emerging national standardized quality measures. Local implementation of quality measures based on national standards will facilitate cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Successful models of such alliances already exist that demonstrate the feasibility of this national strategy, but concerted national leadership and federal matching funding will be needed to meet the scope of implementation required in markets across the country. THE DEMAND for information on the quality of health care in the United States has been growing steadily over the past 2 decades. Recent efforts to meet this demand have made some important progress, but they have been largely fragmented and directed to the needs of specific groups. Increasing pressures for cost control and the spread of managed care throughout the country create an urgent, shared need for information on health care quality among all health care stakeholders: consumers, public and private purchasers, policymakers, health plans, and provider organizations (eg, hospitals, physician groups, and clinics). We believe that concerted national action must be taken now to meet this need. But while the challenge is clearly national in scope, we believe the solution is to be found in a decentralized, market-by-market approach consisting of multiple, independent, public-private quality measurement alliances operating at the state or community level, using various combinations of national standards for quality measurement and consumer information activities. These independent quality measurement alliances would be formed through the leadership of public and private purchasers and consumer groups acting in collaboration with local health plans and providers. These independent alliances would undertake specific quality measurement and consumer information projects designed to meet local health care market needs, but would do so by drawing on various combinations of the national quality measurement standards now emerging from such national standard-setting groups as the Agency for Health Care Policy and Research (AHCPR), the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Foundation for Accountability (FACCT). While organized and operated at the state or regional level to be responsive to local market needs, these alliances would implement quality measures based on national standards, thereby facilitating cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Over time, the experience accumulated through these independent local efforts, working in a coordinated manner to share information and expertise across markets, could significantly advance our collective national knowledge of best practices and help identify the most valid and useful quality measurement methods and measures available. In addition to local implementation of standardized quality measures, quality measurement alliances also would play an important role in developing and testing improved methods for disseminating quality information to consumers and purchasers. This dissemination role could be combined with efforts to meet consumer information needs for guidance on treatment choice and wellness strategies. Progress has been made recently in developing such information, but consumers' access to it may be limited in some situations. The independence and multiple stakeholder sponsorship of the alliances we propose for quality measurement lend themselves to meeting this need at the state, regional, or local level in a manner that will help assure the validity of the information. Prototype alliances A number of promising prototype quality measurement alliances already exist that demonstrate the feasibility of the national strategy we are proposing. For example: The Minnesota Health Data Institute, initiated by a consortium of public and private purchasers and established by state legislation in 1993, is governed by a balanced board of health care stakeholders and operated by a private nonprofit entity under a partnership agreement with the Minnesota Department of Health. The Institute undertakes community-wide quality measurement and consumer information activities and also facilitates collaboration by those with proprietary electronic health information systems. For example, the Institute published a statewide survey of health plan enrollees in 1995 and recently completed a survey of state Medicaid enrollees using the new Consumer Assessment of Health Plans (CAHPS) survey developed by a national consortium of experts with funding from AHCPR. This information has been used by both purchasers and health plans to assess comparative performance based on uniform measures, and the Institute is making a concerted effort to utilize national standards wherever possible. The California Cooperative Health Care Reporting Initiative was organized by private and public purchasers through the Pacific Business Group on Health, but operates in cooperation with the state's health care industry. This collaborative initiative has disseminated statewide health plan comparisons for several years, based on validated information from the Health Plan Employer Data and Information Set (HEDIS) and a standard consumer survey. Since 1993, the Cleveland Health Quality Choice program has published biannual comparative patient satisfaction and clinical outcomes measures for all the hospitals in the greater Cleveland, Ohio, market. In addition to the use of this community-wide information by employers and their health plans for assessing individual hospitals, hospitals themselves have used this information to work with their medical staffs to identify areas for improvement and implement corrective actions. Other examples could be noted, such as the Greater St Louis Health Care Alliance, the Wisconsin Quality Forum, the Central Florida Health Care Coalition, and the Greater Detroit Area Health Care Council. Quality measurement alliances can take various forms. In some cases, they may be a freestanding legal organization, but in others they may be constituted as a task force, consortium, or coalition of existing groups. While a variety of organizational forms exist to accommodate the functions we propose, we believe certain core features are essential. These features include the following: collaboration and coordination to meet shared needs for health information; joint public-private sponsorship; accommodation to a variety of market situations and purchasing strategies; independence from health plan or provider control; flexibility to assess multiple dimensions of quality at both health plan and provider levels of performance; implementation of uniform quality measures, drawing on emerging national standards; organization at the state, regional, or local level. We now address each of these core features more fully in turn. Collaboration to Meet Shared Information Needs All health care stakeholders, whether consumers, public or private purchasers, policymakers, health plans, or providers, are seeking information on the quality of health care. Meeting these shared needs through collaborative arrangements and uniform measures would save money and reduce hassle. At present, they either are unmet or are met separately. Consumers and purchasers are particularly deprived of information by which to choose among health plans and providers, based on uniform comparisons. They have few reliable sources of such information. Consumers are often reluctant to trust information from the health care industry or even their employers. With the exception of only a few markets where comparative performance reports have begun to emerge from independent sources, the only available alternative for most consumers is to piece together the advice and experiences of relatives and friends. Findings from recent studies clearly indicate that both consumers and purchasers would welcome a trustworthy source of meaningful information on the quality of health plans and providers.1 Health plans also experience difficulty in meeting their need for information on the quality of the providers with which they contract. Increasingly, plans' provider networks substantially overlap with one another. Any one plan may represent a relatively small part of a provider's business. As a practical matter, it is difficult for each provider to respond to different data demands from multiple plans, and any individual plan may lack the clout to gain a provider's compliance with its unique demands. Both plans and providers should welcome some common, uniform arrangement for meeting the plans' needs for information on provider quality. We believe the needs of consumers, public and private purchasers, and policymakers should drive the choice of measures and data to be collected. However, there is also a pressing need among health plans and providers for information to serve internal management and quality improvement. While the strategy we propose can serve certain health care industry information needs, it may be impractical in the short term to select measures that simultaneously can inform consumers, purchasers, and policymakers and also provide the full range and depth of data needed for internal management and quality improvement. Nevertheless, there is no reason why measures chosen for the former purpose cannot also serve at least some of the latter need. Indeed, we would argue that serving both purposes represents a compelling reason for investment, particularly insofar as it facilitates use of the same measures for accountability and for improvement. Joint Public-Private Sponsorship Both plans and providers are faced with differing quality-related data demands from multiple purchasers. The larger the purchaser, the more responsive plans and providers must be to a demand for data. HEDIS, currently sponsored by NCQA, began as an effort by health plans to reduce the multiple demands placed on them by large employers; it represents major progress in this regard. But many self-insured, private purchasers contract directly with providers; their demands for quality-related information present the same problems for providers as those of health plans. The problems presented by private purchasers are compounded by yet different demands made by the federal government and, in some cases, by state governments. Joint public-private sponsorship of common data acquisition arrangements and uniform measures, both for plans and for providers, would go far to help address these problems. Accomodating Various Market Situations and Purchasing Strategies While managed care is spreading, the United States will have a hybrid health care system for years to come. Fee-for-service plans will continue to dominate some areas and age groups. Many variations on the managed care theme will come and go; today's preferred provider organizations and point-of-service plans will be replaced by new inventions. Similarly, as long as the exemption under the Employee Retirement and Income Security Act (ERISA) remains, private purchasing strategies will be divided between direct provider contracts and the purchase of insured products from health plans. Medicare and Medicaid seem certain to make the transition to capitated forms of managed care, but many Medicare beneficiaries will stick to traditional coverage as long as they can. Such variety means that quality measurement must permit mixing and matching of information depending on the penetration and configuration of managed care in a given market and the needs both of those purchasing from health plans and those dealing directly with providers. Independence From Health Plan or Provider Control Much of the information on quality will be used by various parties in the marketplace and public sector to hold plans and providers accountable for their value. For this reason, the data underlying such information often may be contentious and subject to gaming by those being measured. Concerns over the reliability and integrity of the data used in performance assessment must be somehow reconciled with the obvious efficiencies of self-reporting. Common sense suggests the wisdom of having providers and plans report their data to some kind of trustworthy, independent entity that can verify and aggregate such data, undertake the needed analysis, and disseminate the results to consumers, public and private purchasers, policymakers, health plans, and providers. Such an independent entity can be particularly useful in administering and reporting quality measurement that involves the measures of multiple standard-setters. The independence of the information source also is critical in meeting the need of consumers and purchasers for trustworthy information on the quality of health plans and providers. The neutrality of such an entity also should make it attractive to health plans and providers as a vehicle for meeting at least some of their information needs to support internal programs for monitoring and improving the quality of care. Multiple Quality Measures at Various Reporting Levels Quality measures are needed that address the specific information requirements of different audiences. Audiences in need of quality measures include individual consumers, public and private purchasers, policymakers, health plans, and providers. Each of these audiences requires information at different levels of the health care system, according to the specific choices and decisions they must make. The levels of the health care system that need to be assessed to meet these different information requirements include the community-level population, health plans and integrated delivery systems, various provider organizations such as clinics and hospitals, and individual practitioners. For example, consumers offered an annual choice of health plans need quality measures reported to them at the health-plan level. Purchasers facing health plan contract decisions likewise require performance information at the health-plan level. But both consumers and purchasers increasingly are seeking quality-related information that distinguishes between services emanating directly from the health plan and those received from providers. Consumers enrolled in health plans already seek information on which to base their choice of a primary care physician, specialist, or hospital. The growth of point-of-service health plans will increase consumer demands for information on the quality of all available providers in a market. Even purchasers contracting with health plans require information about the quality of the providers with which their respective plans may contract. The recent interest in direct contracting by purchasers in some markets will increase the demand for provider-level information even further. Meeting this mix of information needs may require acquiring certain data from individual provider units and then aggregating those data to match varying practice arrangements and relationships with health plans, networks, and the like. These aggregates, of course, must be built in accordance with statistical rules of validity as well as their utility for given purposes. The needed mix of measures also should address key dimensions of performance. Major performance dimensions to be assessed include general service (including access measures), clinical prevention and care, and cost. To provide maximum utility, these need to be assessed both with respect to the overall population for which a health care entity is accountable and with respect to its performance in caring for specific groups of people when they are ill. In all such assessments, balance requires consideration of the structure by which the health care entity operates, the process of delivering services and care, and the attributable outcomes. Use of Emerging National Standards The past few years have seen the emergence of promising national quality measurement standards under the auspices of NCQA, JCAHO, FACCT, and CAHPS funded by AHCPR. While no one of these standard-setters meets all of the needs discussed in this article, in combination they offer a potential solution as the source of needed quality measures. There is, of course, some redundancy among these initiatives that will have to be addressed, but it is the complementarity of their measures that is particularly attractive. Specifically, these include the following: NCQA's HEDIS 3.0, including measures being tested for assessing the effectiveness of care. The data generated by performance measurement systems mandated under the JCAHO's new ORYX initiative. Measurement sets endorsed by FACCT, including asthma, breast cancer, diabetes, major depressive disorder, health risks, and health status. The survey instruments and consumer reporting tools of the CAHPS project. There is a need to assure that the results of efforts to employ these quality measures are conveyed in terms that are meaningful and useful to consumers. Progress has been made by several of the organizations responsible for these measures in developing approaches to information dissemination that take into account the way consumers think about health care quality. Noteworthy in this regard is FACCT's framework for communicating quality information, but there is need for further work in this area by all of the standard-setters, including collaboration in reporting blended results of their measures. Over the long term, providing the needed information on health care quality will require collaboration among all health care stakeholders in building an electronic information infrastructure.2 At present, health plans and providers are investing heavily in proprietary information systems to meet their internal needs. We believe that those groups should collaborate more actively to maximize the potential of their proprietary systems for meeting broader quality measurement and other information needs. The prospects for success in this regard have been greatly increased by the emergence of Internet technology and recent progress in developing standards for health care information transmission and content. We acknowledge that full realization of such systems' potential remains some years distant, but action now can accelerate progress. State, Regional, and Local Organization As should be evident from the previous discussion, we do not believe that one size will fit all when it comes to health care quality information in the United States over the coming years. Even though health plans may consolidate nationally, health care and related services are delivered locally. Meeting the need for information on quality among the combination of consumers, purchasers, policymakers, health plans, and providers in markets that vary by managed care penetration and configuration and prevailing purchasing modes argues for organizational arrangements and measurement plans designed and implemented at the state, regional, or local levels. A single national organization would lack flexibility and sensitivity to local needs. The most useful information on providers and plans will vary widely by market, as will preferences as to organizational arrangements for data acquisition, verification, analysis, and information dissemination. A challenge will be to gain the benefits that come from state, regional, and local quality measurement alliances while meeting the need of many national employers and federal programs for nationally comparable information on the quality of plans and providers. We believe that the key to meeting this challenge lies in national arrangements to facilitate interstate comparisons, based on uniform measures. The need for concerted action: a national health care quality measurementinitiative The success of the early working models of independent quality measurement alliances noted earlier suggests that—with sufficient national leadership, coordination, and funding—it may be possible to achieve national implementation of this proposed community-based quality measurement strategy within 3 to 5 years. Perhaps the greatest challenge in organizing multiple, decentralized independent quality measurement projects under this proposed national health care quality measurement initiative will be securing adequate financing. Simple logic suggests a compelling argument for supporting the scheme we propose. Collaboration both within and across markets to administer standardized surveys and other quality measures will save millions of dollars and overcome problems, such as inadequate sample size, that fragmented projects now encounter. Other industries—ranging from banks (eg, automatic teller machines) to advertising (eg, A.C. Nielsen ratings)—have learned that collaboration in developing and using uniform measures and sharing infrastructure can save millions. The irony is that in spite of the promise of such savings, each key health care stakeholder may resist contributing to the cost of the proposed arrangements for meeting shared health care quality information needs. Consumer organizations are notoriously underfunded. Private purchasers have budgets for direct health care costs and premiums but not for quality measurement. Furthermore, there is resistance among the relatively few employers who typically lead such efforts to paying a disproportionate share of the cost of what really is a public good. Government agencies have difficulty persuading state legislatures to appropriate funding for virtually any new expense in the face of taxpayer resistance. Providers and health plans draw on their business income to cover their proprietary quality measurement activities. They would be willing to finance broader efforts only if they could pass that cost on to their customers without competitive disadvantage. This situation of virtually universal resistance to paying the cost of quality measurement suggests the need for some incentive to loosen the stakeholders' purse strings. Insofar as the federal government can meet its own needs through participation in the independent state, regional, and local quality measurement alliances we propose, it should be permitted to use funds appropriated for its quality measurement activities to support such projects. Indeed, the health quality improvement organizations (formerly peer review organizations) currently used to monitor and improve quality under Medicare might make attractive partners or vendors for such projects. Federal funding could be offered in a manner that motivates other stakeholders to contribute to a project's cost. Specifically, we propose that HCFA be permitted to match a substantial portion of the cost of such projects, provided they meet the needs of the Medicare program and allow HCFA's active participation as a project sponsor. Various combinations of state appropriations, plan and provider financial participation, and employer contributions can be expected in response to HCFA's offer. We believe, however, that the offer of federal dollars will be key to the success of the proposed initiative. Even with federal financial incentives, the proposed initiative will require sustained national leadership and coordination if it is to reach a scale sufficient to address the magnitude of national need. To that end, we propose the creation of a National Health Care Quality Measurement Leadership Consortium of interested groups to provide direction for the community-based measurement strategy outlined in this article. Such a leadership consortium would consist of a balanced representation of consumer groups, public and private purchasers, government agencies, health plans, providers, and the national standard-setting organizations. As a collaborative effort, the leadership consortium would not be intended to replace existing organizations already actively contributing to the goals of quality measurement and consumer information, but rather provide a vehicle for these existing organizations and efforts to coordinate and facilitate the implementation of a variety of supportive services needed. These services include the following: A national campaign to promote formation of independent, public-private quality measurement alliances and related projects at the state, regional, and local levels. On-site technical assistance services for those organizing quality measurement efforts at the state, regional, and local levels. Organization of national benchmarking databases to facilitate cross-market comparisons of health care quality, measured in accordance with any one, or combination, of the standards endorsed under the initiative. A series of workshops to introduce state, regional, and local leaders to the concepts underlying the national health care quality measurement initiative and to practical lessons and tools needed to organize and implement quality measurement projects. Intensive courses on quality measurement, its organization and uses, for individuals in key health care consumer and purchaser roles, such as consumer organization leaders, local labor union officials, public and private human resource professionals, and American Association of Retired Persons chapter volunteers. Information exchange activities for those engaged in, or considering, projects under the initiative, including an Internet network and Web page, newsletter, and annual meeting. As a practical matter, some kind of national resource center would be needed to organize and coordinate the range of activities overseen by the leadership consortium. Such a resource center should be organized as a private, nonprofit entity with federal participation and financial support. One possible model for implementing the national leadership consortium and resource center we propose is the Forum for Health Care Quality Measurement and Reporting called for in the recent report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. As proposed, the forum is designed as a private sector group to be inclusive of many stakeholder groups, with significant representation by purchasers and consumers.3 With appropriate leadership and funding, such a forum could oversee implementation of many of the specific supportive services described above. This proposal is offered in the conviction that the time has come to address the real danger of increasing fragmentation among health care stakeholders in meeting their respective quality information needs. The actions taken to date by key players are commendable and provide a firm foundation for future success. However, possible tensions created by differences among standard-setters, national and local employers, public and private sectors, and health plans and providers will serve only to delay and increase the cost of information urgently needed by us all. We urge each of these groups to recognize that its legitimate interests, as well as those of the public at large, would best be served through collaboration in the strategy we are proposing to meet our most pressing national health care quality information needs. References 1. The Henry J. Kaiser Family Foundation and the Agency for Health Care Policy and Research. Americans as Health Care Consumers: The Role of Quality Information. Menlo Park, Calif: The Henry J. Kaiser Family Foundation; October 1996. 2. National Committee for Quality Assurance. A Road Map for Information Systems: Evolving Systems to Support Performance Measurement: HEDIS 3.0, Volume 4. Washington, DC: National Committee for Quality Assurance; 1997. 3. Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality First: Better Health Care for All Americans. Washington, DC: Advisory Commission on Consumer Protection and Quality in the Health Care Industry; March 13, 1998

Journal

JAMAAmerican Medical Association

Published: Apr 22, 1998

Keywords: quality of care,managed care programs,quality indicators,quality measurement,benchmarking

References