Organizational systems used by California capitated medical groups and independent practice associations to increase cancer screening.

BACKGROUND: Patients in health maintenance organizations (HMOs) appear to have higher utilization of cancer screening tests than patients with fee-for-service insurance. METHODS: The authors surveyed the medical directors of 174 physician organizations in a California network model HMO to obtain information regarding their organizational structure, implementation of guidelines, and use of systems to increase cancer screening. RESULTS: The majority of independent practice associations (IPAs) and medical groups (IMGs) in this California HMO had guidelines and office systems aimed at improving cancer screening. These activities were reported more frequently for mammography and Papanicolaou (Pap) smears than for colorectal carcinoma screening. IMGs reported using flow sheets more often than IPAs. Chart audits were performed more frequently for mammography (48% for IMGs and 40% for IPAs) and Pap smears (45% and 40%, respectively) than for colorectal carcinoma screening (38% and 30%, respectively). Approximately 50% of IPAs and IMGs reported mailing reminders to patients for mammography and Pap smears, but only a few did so for colorectal carcinoma screening. Annual fecal occult blood testing was believed by most medical directors to be a reasonable strategy for managed care patients (86% of IPAs and 96% of IMGs); however, fewer believed that screening sigmoidoscopy for patients ages 50-70 years was a reasonable expectation (71% and 78%, respectively). CONCLUSIONS: The majority of IPAs and IMGs in this California HMO reported using both guidelines and office systems to improve cancer screening rates. Further research is needed to understand the effect of these systems, as well their complex interactions with competing incentives, on cancer screening in managed care patients.

Evaluating the quality of cancer care: development of cancer quality indicators for a global quality assessment tool.

BACKGROUND: The rise of managed care has increased interest in measuring, reporting, and improving quality of care. To date, quality assessment has relied on a leading indicator approach, which may miss important variations in care. The authors developed cancer specific indicators using a novel case-based approach for a quality measurement tool designed to compare different managed care organizations. METHODS: Based on a review of the literature, quality indicators were developed for 6 types of cancer and the human immunodeficiency virus (HIV) as well as 39 general adult conditions (GAC). The validity and feasibility of these candidate indicators were evaluated using three modified Delphi expert panels. The strength of evidence, type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, and follow-up), and modality (history, physical examination, laboratory, medication, or other intervention) of the cancer/HIV quality indicators were compared with indicators developed for GAC. RESULTS: The final system included 117 of the 145 proposed cancer/HIV quality indicators (81%) and 569 of the 705 proposed GAC indicators (81%). A greater percentage of the cancer/HIV indicators were based on evidence from clinical trials compared with the GAC indicators (59% vs. 31%; P = 0.001). Cancer/HIV had significantly more indicators pertaining to chronic care than did GAC (74% vs. 56%; P = 0.001) as well as more indicators for treatment (53% vs. 39%; P = 0.004). CONCLUSIONS: Using the case-based approach, it is feasible to develop quality indicators for cancer that cover the continuum of care. Future studies will evaluate the reliability and validity of measurements made using these indicators in three managed care plans.

Tracking managed care: the importance of a cash incentive for medical director response to a survey.

OBJECTIVE: To assess the impact of a monetary incentive in a survey mailed to medical directors of large medical groups and independent practice associations (IPAs). STUDY DESIGN: Mailed survey. METHODS: We mailed a survey to the medical directors of all medical groups and IPAs contracted with Blue Cross California Care, a large California managed care health plan (n = 174). After 2 mailings without any monetary incentive, we included a $50 bill in the third mailing to increase the response rate. RESULTS: Only 46 medical directors responded to the first and second mailings (response rates of 17% and 13%, respectively). The third mailing, which included a $50 bill attached to the front of the survey, yielded 78 responses (66%), for an overall total of 124 (76%). We found no significant differences in the physician organizations of medical directors who responded to the mailing with the $50 incentive compared with the physician organizations of those who responded to 1 of the first 2 mailings, although medical directors who responded without the financial incentive were more likely to report that their organization had staff for quality assurance (96% vs 82%; P < or = .03). CONCLUSION: Including a $50 bill improved the rate of response to a survey mailed to medical directors from 13%-17% to 66%.