In the first study, Getting Behind the Numbers: Understanding Patients' Assessments of Managed Care, Margaret Gerteis and colleagues at the Picker Institute highlight patient-centered practices that contribute to an overall positive experience for plan members. Using data from the Medicare Managed Care Consumer Assessment of Health Plans Survey (MMC-CAHPS), Picker staff found that successful plans tend to focus on each member individually, recognizing that patients' subjective experiences are crucial to the quality of care. Practices in place at high-performing plans include:
- using performance-tracking criteria that reflect patients' expectations about access to timely care, rather than administrative concerns alone;
- being up-front with prospective plan members about the scope and limitations of covered benefits and referral policies;
- building on established physician referral networks in order to limit patients' perceived need to go outside the network;
- recruiting doctors known for their ability to communicate well with patients;
- providing physicians with feedback from their patients;
- using clinical practice guidelines that incorporate protocols for shared decision-making;
- providing customer support at the clinical site, so that patients' questions about plan coverage, policies, and procedures are answered when they most often arise.
The study team identified several strategies that are essential to developing and sustaining patient-centered practices in managed care. First, plans must recognize that consumers, not purchasers, are their primary customers, and take steps to understand and address the specific needs of their members. Managing consumers' expectations is also important. High-performing plans, the authors determined, invest heavily in keeping members informed about plan operations, benefits, and service both before and immediately after enrollment.
Because the division of responsibility between plans and providers can often be confusing for members, many of the plans studied seek to ""manage"" consumers' perceptions by keeping plan involvement in clinical decisions as invisible to patients as possible. A far less common but emerging strategy, however, is to enhance the plan's visibility as an active promoter of clinical quality, by giving patients information on clinical guidelines, treatment options, and physician performance.
Incorporating members' feedback about the quality of care and service provided is a practice common to all plans in the study. Better-performing plans also had procedures in place for transmitting this feedback to plan-wide strategic planning and quality-improvement committees, which used it to identify priorities and establish continuing performance measures.
Finally, successful plans, the authors found, link provider incentives to patients' reported experiences. Where financial rewards were offered, physicians commented that although the amount was not large, the incentive did indicate that the plan cared as much about quality as it did about costs.
In the second study, Effective Clinical Practices in Managed Care: Findings from Ten Case Studies, authors Suzanne Felt-Lisk and Lawrence C. Kleinman, M.D., of Mathematica Policy Research, Inc., and Lehigh Valley Hospital, respectively, note that despite research showing that managed care can improve health care quality, much of this potential remains unrealized.
Based on visits with some of the nation's highest-performing managed care plans-those that scored well on HEDIS quality indicators-Felt-Lisk and Kleinman found that delivering high-quality care is a driving force for nearly all. When plan staff members were asked to rank their plan's priorities in 19 listed areas, among the highest were quality of care, accreditation from the National Committee for Quality Assurance (NCQA), patient satisfaction, and performance on HEDIS measures.
Plan leaders stressed that excellent physicians are the major assets of their organizations. Rather than control the clinical process, plan leaders saw their role as helping doctors improve performance by providing them with the resources needed to promote quality. Nearly all plans studied have also long placed a strong emphasis on generating and using clinical data to improve care and demonstrate best practices. Many of the best plans grew out of excellent local clinical systems, but starting out this way, the authors note, is not essential for success. Market conditions can also play a key role. In several instances, employers demanded high quality. In other cases, strong competition from other managed care organizations in the same market encouraged better performance. Because Felt-Lisk and Kleinman's study examined only high-performing plans, it was not able to assess whether lower-performing plans are pursuing similar strategies and what kind of success they are having. As plans work to improve their clinical performance, the authors suggest that they consider three basic questions: How solid is the plan's foundation for quality? To what extent does the plan have an effective overall approach to clinical improvement? Do specific improvement strategies capitalize on current thinking?
Facts and Figures
- Nine of the 10 plans studied by Felt-Lisk and Kleinman regarded partnership with clinical leadership to improve members' health as a major part of their role, and used their data, organizational, and financial resources to support that goal.
- Gerteis and colleagues found that CAHPS scores were consistent with plans' own assessment of their strengths and weaknesses at the time the survey was conducted. Low CAHPS scores, however, did not necessarily reflect sustained poor performance, nor did high scores necessarily reflect sustained good performance.