National quality monitoring of Medicare health plans: the relationship between enrollees' reports and the quality of clinical care.

BACKGROUND: The clinical quality of health plans varies. The associations between different measures of health plan quality are incompletely understood. OBJECTIVE: To assess the relationships between enrollee reports on the quality of health plans as measured by the Consumer Assessment of Health Plans Study (CAHPS 2.0) survey and the clinical quality of care measured by the Medicare Health Plan Employer Data and Information Set (HEDIS). DESIGN: Observational cohort study. SAMPLE: National sample of 233 Medicare health plans that reported data using the CAHPS 2.0 survey and Medicare HEDIS during 1998. MEASURES: Five composite measures and four ratings derived from the CAHPS survey and six measures of clinical quality from Medicare HEDIS. RESULTS: Two composite measures ("getting needed care" and "health plan information and customer service") were significantly associated with most of the HEDIS clinical quality measures. The proportion of enrollees having a personal doctor was also significantly associated with rates of mammography, eye exams for diabetics, beta-blocker use after myocardial infarction, and follow-up after mental health hospitalization. Enrollees' ratings of health plan care were less consistently associated with HEDIS performance. In multivariable analyses, the measure of health plan communication ("health plan information and customer service") was the most consistent predictor of HEDIS performance. CONCLUSIONS: The pattern of associations we observed among some of the measures suggests that the CAHPS survey and HEDIS are complementary quality monitoring strategies. Our results suggest that health plans that provide better access and customer service also provide better clinical care.

HEDIS performance trends in Medicare managed care.

The authors analyzed performance trends between 1996 and 1998 for health plans in the Medicare managed care program. Four measures from the Health Employer Data and Information Set (HEDIS) were used to track performance changes: adult access to preventive/ambulatory health services, beta blocker treatment following heart attacks, breast cancer screening, and eye exams for people with diabetes. Using a cohort analysis at the health plan level, statistically significant improvements in performance rates were observed for all measures. Health plans exhibiting relatively poor performance in 1996 accounted for the largest share of overall improvement in these measures across years.

Performance: a multi-disciplinary and conceptual model.

We contend that the scientific study of performance requires a model or paradigm. We propose a performance model with an underlying mathematical basis that is well defined, has explicit assumptions and has the potential to be both heuristic and scientifically testable. The model is based on an integration of concepts from health sciences and psychology that have been adapted to performance measurement in health care. The proposed performance model consists of a combination of four primary elements: quality of care, cost of care, access to care and satisfaction. Satisfaction is defined as a function of perceived and expected outcomes of care and perceived and expected input. This performance model can serve as both a tool for understanding and as a vehicle for comparing performance within and between health care organizations. We believe that this model can be used to develop a performance profile report and the future report card.

Impact of risk adjusted clinical outcomes methodology--quality measures on hospital mortality data: a statistical and case study approach.

The effectiveness of risk adjustment in improving mortality as a performance measure for hospitals remains uncertain. New techniques of risk adjustment should be empirically tested, and health care professionals, using the data derived from such measures, should be queried before final acceptance of these technologies of measurement is warranted. The Risk Adjusted Clinical Outcomes Methodology-Quality Measures (RACOM-QM), a relatively new risk-adjustment methodology developed by the QuadraMed Corporation, was used by Maryland hospitals for risk adjustment for the first time in 1997. A research study was undertaken by the Maryland Hospital Association to determine the impact of RACOM-QM on mortality rates, its empirical validity, and its acceptance in the field. The relationship between RACOM-QM mean risk scores and mortality rates was examined using inpatient hospital mortality data for Maryland in 1996. Using these same data, the empirical relationship between risk-adjusted and unadjusted mortality by diagnosis-related group (DRG) was also investigated. Case studies were undertaken to glean information about the use and acceptability of this new methodology in 2 hospital settings in Maryland. There was a strong relationship between mean mortality risk scores and mortality rates. The analysis of the empirical relationship between risk-adjusted and unadjusted mortality by DRG yielded support for the impact of RACOM-QM in adjusting inpatient mortality rates. The case studies supported the utility of this method of risk adjustment in increasing the interpretation of mortality data and in helping to identify areas in which to investigate quality in more depth in 2 hospital settings. This study provides overall support for the usefulness of risk adjustment and, specifically, the RACOM-QM, in increasing the interpretation of inpatient mortality rates in Maryland's acute care hospitals. This study also suggests that use of the RACOM-QM improved comparative analysis of inpatient mortality rates among Maryland hospitals. Finally, the results of the case study analysis suggest that improved internal review of mortality rates and increased clinician acceptance of these rates as indicators of performance were enhanced by the use of a risk adjustment methodology.

Cesarean section rates: effects of participation in a performance measurement project.

BACKGROUND: A decade-old indicator-based research initiative, Maryland's Quality Indicator (QI) Project, analyzed data for cesarean section rates among its approximately 1,100 voluntarily participating hospitals. It was posited that continuous participation in this performance measurement initiative would be associated with decreased primary and repeat C-section rates. METHODS: A retrospective study compared a group of 110 hospitals that reported on the C-section indicator continuously between 1991 and 1996 with a group of hospitals that did not continuously report data on the C-section rate. RESULTS: Among the 110 continuously participating hospitals in the QI Project, the total C-section rate declined from 22.5% in 1991 to 19.4% in 1996 (p < .01). For this same group, the primary C-section rate declined from 15.8% to 13.9% (p < .01), and the repeat C-section rate declined from 75.0% to 61.2% between 1991 and 1996 (p < .01). The comparison group of 957 hospitals that did not continuously participate in C-section reporting between 1991 and 1996 did not experience a statistically significant difference in total C-section rates during this time (from 21.2% in 1991 to 20.7% in 1996). In attempting to investigate alternative explanations for these results, a subsequent analysis of eight hospital variables potentially related to cesarean delivery rates found no significant differences between the two groups. CONCLUSIONS: This study provides support for the positive association between continuous participation in a performance measurement project and performance improvement.

A Hawthorne strategy: implications for performance measurement and improvement.

The Hawthorne experiments are a backdrop for diverse studies assessing the impact of treatment and experimentation on human and organizational performance. The Hawthorne effect is used to describe the positive impact on behavior that sometimes occurs in a study or experiment as a result of the interest shown by the experimenter in humans who are being treated, studied, or observed. We propose that the Hawthorne effect can be viewed as an active construct to develop a coherent strategy for performance improvement. We propose a "Hawthorne strategy" that transcends the Hawthorne effect in that it offers an approach to improving performance indefinitely. This strategy uses external observations of performance to increase internal commitment to performance improvement. The focus of individual responsibility increases as does the perceived connection between individual efforts and external performance improvement. The sense of accountability is maintained by institutional recognition and periodic reinforcement of individual behaviors that contribute to performance improvement. A successful Hawthorne strategy encourages providers of care to be evaluators of their performance as individuals, as members of groups, and as members of institutions.