Health plans' use of asthma quality improvement projects to meet NCQA accreditation standards.

BACKGROUND: Managed care represents an important system of healthcare delivery in the United States and the primary source of care for many persons with asthma. OBJECTIVE: To characterize how US managed care health plans address the quality of asthma care through the use of disease-specific quality improvement (QI) programs complying with National Committee for Quality Assurance (NCQA) standards. METHODS: This study was a cross-sectional review of reports from all accreditation surveys conducted in 1996 and 1997 by the NCQA. Each accreditation report was reviewed for evidence of whether the health plan explored asthma care as a way to demonstrate compliance with NCQA accreditation standards. Asthma activity was examined with respect to health plan characteristics such as size of plan and Medicaid contracting. Types of asthma QI activity, use of guidelines, and application of different NCQA accreditation standards were also examined. RESULTS: Approximately 90% of 197 health plans undergoing NCQA accreditation surveys in 1996 and 1997 reported some form of asthma QI activity. There were no statistically significant differences in this activity in large vs small plans or in plans with vs without Medicaid members. Approximately two thirds of health plans used asthma QI activities to meet NCQA accreditation standards in health management systems, and three fifths monitored and evaluated important aspects of asthma care and service. CONCLUSIONS: During the study period, many US health plans conducted asthma care QI activities. The recently released NCQA asthma performance measure may provide the next assessment of how well managed care is contributing to improving asthma care in the United States.

Impact of sociodemographic case mix on the HEDIS measures of health plan quality.

BACKGROUND: The widely used Health Plan Employer Data and Information Set (HEDIS) measures may be affected by differences among plans in sociodemographic characteristics of members. OBJECTIVE: The objective of this study was to estimate effects of geographically linked patient sociodemographic characteristics on differential performance within and among plans on HEDIS measures. RESEARCH DESIGN: Using logistic regression, we modeled associations between age, sex, and residential area characteristics of health plan members and results on HEDIS measures. We then calculated the impact of adjusting for these associations on plan-level measures. SUBJECTS: This study included 92,232 commercially insured members with individual-level HEDIS data and an additional 20,615 members whose geographic distribution was provided. MEASURES: This study used 7 measures of screening and preventive services. RESULTS: Performance was negatively associated with percent receiving public assistance in the local area (6 of 7 measures), percent black (5 measures), and percent Hispanic (2 measures) and positively associated with percent college educated (6 measures), percent urban (2 measures), and percent Asian (1 measure) after controlling for plan and product type. These effects were generally consistent across plans. When measures were adjusted for these characteristics, rates for most plans changed by less than 5 percentage points. The largest change in the difference between plans ranged from 1.5% for retinal exams for people with diabetes to 20.2% for immunization of adolescents. CONCLUSIONS: Performance on quality indicators for individual members is associated with sociodemographic context. Adjustment has little impact on the measured performance of most plans but a substantial impact on a few. Further study with more plans is required to determine the appropriateness and feasibility of adjustment.

Review of studies that compare the quality of cardiovascular care in HMO versus non-HMO settings.

OBJECTIVES: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature. METHODS: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research. RESULTS: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results. CONCLUSIONS: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.

The effect of managed care on nuclear cardiology.

The rapid growth of managed care organizations as a dominant structural model for the delivery of health and medical care has major implications for the nuclear cardiologist. Both governmental and private sector trends portend increased focus on cost containment strategies that may disrupt patient access to cardiovascular specialists and alter traditional physician referral patterns and practices. Issues include who will deliver services, where these services are made available, and how procedures and protocols are developed. The nuclear cardiologist will need to consider approaches to maintain access to patients, clinical autonomy, access to capital, as well as financial and legal risks when positioning a practice to thrive in the future.

Managed care involvement by cardiovascular specialists: prevalence, attitudes and influence on practice.

OBJECTIVES: The purpose of this study was to determine the involvement in and attitudes toward managed care by cardiovascular specialists and the influence of such programs on their practices. BACKGROUND: No in-depth study has measured the impact of managed care on cardiovascular specialists. Therefore, we conducted a mail survey to determine the prevalence of managed care arrangements among cardiovascular specialists and variations among pediatric and adult cardiologists and cardiovascular surgeons; the types of managed care arrangements in which cardiovascular specialists are engaged; the reasons why those not participating in managed care have chosen not to do so; and the general attitudes among cardiovascular specialists with regard to various aspects of managed care. In addition, we evaluated the impact of managed care among several aspects of cardiovascular practice. METHODS: A questionnaire was mailed in the spring of 1993 to 4,577 practicing, domestic, American College of Cardiology (ACC) members selected at random from within each primary cardiovascular specialty group (adult cardiologists, pediatric cardiologists and cardiovascular surgeons). Additional data concerning practice characteristics were cross tabulated using results from the 1992 ACC membership profile survey. RESULTS: In total, 1,961 of the 4,577 members responded to the survey, representing a 43% response rate. Of all survey respondents, 76% reported entering into at least one relationship with a health maintenance organization (HMO) or preferred provider organization (PPO). Of those not participating in managed care arrangements, the most frequently mentioned reason was "concern over the quality of care." This reason was cited by 51% of those not entering into HMO relationships and 41% of those not participating in PPOs. The majority of respondents indicated that they do not strongly object to the gatekeeper approach to managing nonemergent patients, although more than half indicated concern that gatekeepers may not be appropriate in the management of cardiac emergencies. In addition, cardiovascular specialists report that under managed care, referrals have not increased, income has decreased, and managed care formularies have not substantially affected their ability to prescribe appropriate medication to their patients. CONCLUSIONS: Despite concerns over the quality of care and contract requirements and general philosophical opposition of cardiovascular specialists, most are becoming integrated into managed care environments.