Health care quality in the 21st century.

The concepts of healthcare quality have evolved over the years. Many stakeholders have become quite engaged in the movement towards improvement in healthcare quality and safety. The standardization and national endorsement of performance measures, the assessment of outcomes, and the reporting for accountability are now being coupled with more transparency, and technological innovation. As the quality landscape changes to evaluation of episodes of care and performance at the individual clinician level measures (primary and specialty care), collaboration is critical among consumers, purchasers, measure developers, implementers of measures to identify and adopt national standards to tell a clear story of healthcare quality.

Opportunities for improving quality in the health care industry.

This paper discusses the current state of health care quality and describes some of the factors that are hindering efforts to move toward evidence-based practice. The President's Advisory Commission on Consumer Protection and Quality spent one year looking at the state of health care quality and developed a set of recommendations to tackle the serious quality problem in the health care industry. The Institute of Medicine has started an initiative, Quality of Health Care in America Project, which is addressing many of the quality of care areas identified by the President's Advisory Commission on Consumer Protection and Quality. This paper discusses the work of these two groups and concludes with key issues in the advancement of quality health care.

Trends toward a national health care marketplace.

In recent years, the health care industry has experienced considerable growth in organizations that are national in focus-organizations that operate in multiple markets not all clustered in one geographic region. This study summarizes information on trends in ownership of various types of health care organizations (i.e., HMOs, PPOs, hospitals, physician practices) for purposes of assessing the growth rate of national companies and the overall significance of this phenomenon. This is followed by a synthesis of factors that encourage or impede the growth of national managed care companies, the sector that has exhibited the most pronounced growth of national companies. We discuss likely future directions and the degree to which national companies may enjoy long-term competitive advantages.

Janet M. Corrigan, Ph.D.. Interview by Marie E. Sinioris.

The ability of health care purchasers and consumers to make objective evaluations and comparisons of health plan performance is a critical element in achieving competition based on quality and value. The Health Plan Employer Data and Information Set, commonly referred to as HEDIS 2.0, is a step toward making such evaluations and comparisons possible. To get an inside perspective on HEDIS and its implications for health care, QMHC interviewed Janet Corrigan, Ph.D., Vice President, Planning and Development, National Committee for Quality Assurance (NCQA). Dr. Corrigan is in charge of NCQA's efforts to implement and continually improve HEDIS.

Toward the development of uniform reporting standards for managed care organizations: the Health Plan Employer Data and Information Set (Version 2.0).

The cornerstone of HEDIS 2.0 is measurement. Only by measuring how a plan performs with respect to defined measures will an employer be able to assess a plan's value and also hold a plan accountable for its performance. Because of time and resource constraints, there are many issues related to the development and use of the performance measures contained within HEDIS 2.0 that have been incompletely addressed or not addressed at all. Following are some of the issues that warrant further consideration. Selection of performance measures. The present set of performance measures represents only a first attempt to define measures that document health plan performance in a number of areas of health care delivery. The resulting measures constitute a core data and information set and should not be considered to be an optimum set. Many other areas and measures of health plan performance were considered, including costs of specific episodes of care, age-specific utilization of defined services, patients receiving appropriate follow-up care for identified preventive health services, stage of cancer at time of diagnosis in relationship to preventive services screening, and functional outcome assessment. These measures were not included in this revision of HEDIS because of difficulties in developing specifications for the measure and/or in obtaining reliable data. It will be important to address these areas in the future. Risk adjustment of performance measures. To minimize the effects of population differences, most of the recommended performance measures assess discrete aspects of the process of care delivery (for example, percentage of pregnant women with first-trimester visit) rather than outcomes. However, interpretation of certain measures (for example, low birthweight, hospital readmission rate) will be affected by the specific member characteristics of the health plan population. Health plans and employers need to be aware of this limitation when interpreting and comparing certain performance measures, and further refinements will be needed in future ierations.(ABSTRACT TRUNCATED AT 400 WORDS)

Contractual arrangements between residency programs and HMOs.

BACKGROUND: Although one out of seven health maintenance organizations (HMOs) is directly involved in graduate medical education (GME), either as an accredited sponsoring organization or through a contractual agreement with an academic medical center or teaching hospital to serve as an ambulatory rotation site, relatively little is known about the extent to which HMOs have provider contracts with faculty or residents of GME programs. Such provider contracts are not agreements to collaborate on the education of residents, but rather contractual arrangements under which individual physicians or groups (who happen to be residents or faculty) agree to provide services to HMO enrollees in return for some form of compensation. METHODS: In 1990, the Group Health Association of America conducted a survey of a sample of residency training programs in family medicine, internal medicine, and pediatrics to ascertain the extent to which (1) residents and faculty of residency training programs are participating physicians in HMOs; and (2) HMO enrollees are serving as the patient base for GME in ambulatory settings. RESULTS: Overall, 42% of the residency program respondents indicated that they contract with HMOs to provide services to enrollees. Nearly two thirds (64%) of family practice programs have provider contracts as compared with 28% of pediatrics programs and 24% of internal medicine programs. Provider contracts with independent practice associations are by far the most common, followed by group, network, and staff model contracts, in that order. CONCLUSIONS: It is apparent that provider contractual arrangements between HMOs and primary care residency programs are quite common, especially in the area of family practice. These contractual arrangements have probably resulted in a more predictable and stable patient revenue base for residency programs. The long-term effects on provider practice styles and the financing of graduate medical education are less clear.

Identification of factors associated with hospital readmission and development of a predictive model.

Multiple hospital admissions, especially those related to the chronically ill, represent a particular challenge to both the acute and long-term care sectors to identify effective methods of resource management. This study analyzes the multiple admission patterns associated with a cohort of 4,219 adult medical-surgical patients discharged alive from a community teaching hospital in Michigan. The sample was divided into two groups: 3,818 patients who survived and 392 who expired during the one-year follow-up period. For the surviving subsample, the characteristics found to be directly associated with the likelihood of readmission included increased age, advanced stage of disease, greater index-episode length of stay, discharge by an internist rather than a surgeon, Medicare as expected source of payment, decreased physician age, discharge to a community setting, and increased number of prior hospital episodes. For the subsample who died, only one explanatory variable was significantly associated with an increased likelihood of readmission-discharge to a community setting (with or without home care) rather than a nursing home. The article includes illustrates of the importance of decisions regarding posthospital, long-term care services on the likelihood of rehospitalization.

Involvement of health maintenance organizations in graduate medical education.

Prepaid health care plans are likely to play an important part in the current transition from inpatient to ambulatory care training of physicians, because such plans enroll one in seven Americans. In the spring of 1990, the Group Health Association of America conducted a survey of health maintenance organizations (HMOs) to assess their level of involvement in graduate medical education (GME). A questionnaire was sent to the 481 HMOs in the United States that had been operational for at least four years; 58% responded. Fifteen percent (42 HMOs) indicated that they were directly involved in GME. The majority of these 42 indicated that they had an agreement with an academic medical center (AMC) or a teaching hospital to serve as an ambulatory care rotation site. About one-sixth of the 42 HMOs had been approved by the Accreditation Council for Graduate Medical Education to serve as a sponsoring organization. HMOs directly involved in GME were more likely to be staff model and group model HMOs; older plans with an enrollment of 50,000 or more; not-for-profit plans; and those owned or sponsored by an AMC.