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NCQA: Top Rated Plans Losing Popularity

OCTOBER 3, 2005 -- Quality is up but enrollment is down at the nation's highest rated health plans, according to a report released Monday by the National Committee for Quality Assurance.

Based on its ratings of 289 commercial health plans, the NCQA said performance improved on 18 of 22 clinical measures in 2004, saving thousands of lives.

But the 289 plans are almost exclusively HMOs, which have steadily lost enrollment to preferred provider organizations in recent years. Although HMOs charge lower premiums, consumers and employers have drifted away from those plans because they place tighter limits on which doctors and hospitals patients can use.

The latest data show that the year-in, year-out process of measuring performance yields important gains in quality, NCQA President Margaret O'Kane said at a press briefing. NCQA quality measures for treating heart attacks, high blood pressure, and diabetes have saved up to 68,000 lives since 1996, she said.

The most notable improvements in the latest report were in the percentages of people in the health plans whose high blood pressure was under control and in diabetic enrollees whose cholesterol was under control. For the former, the percentage climbed 4.6 percent points to 66.8 percent, the latter 4.4 points to 64.8 percent. Improved blood pressure control stemming from the NCQA rating system is saving between 8,600 and 15,000 lives per year, O'Kane said.

But the improvements noted by the report only apply to 64.5 million Americans, the number enrolled in publicly reporting plans, NCQA said. That's only about 20 percent of the U.S. health system and "represents a decline of 4.5 million from a year ago, largely due to shifting enrollment patterns," the organization said in a press release.

"Enrollment in PPOs and high deductible health plans is up sharply; with few exceptions, these plans tend not to measure or report on their performance," the release said.

Employers took the lead in pressuring HMOs to gather and report data on quality of care, but they need to apply the same kind of pressure on PPOs, said NCQA Vice President for Public Policy Richard Sorian.

"The new mantra for health care purchasers needs to be, 'Show us your data,'" O'Kane said. "Why trust your family's health to an organization that operates behind closed doors?"

NCQA hopes that a new venture with U.S. News & World Report will fuel consumer and employer demand for quality ratings from health plans. The magazine, noted for picking the nation's best hospitals, released its first-ever ratings of "America's Best Health Plans" in its October 10 issue using the NCQA data. Top ranked: Harvard Pilgrim Health Care, which operates in Massachusetts and Maine.

Sorian added that Medicare's adoption of quality measures for PPOs could spur the employer community to apply the same measures to PPOs. Medicare plans will begin reporting the data in 2007 based on 2006 data.

Wide Quality Variations
Gaps between recommended and actual use of best treatment practices lead to between 39,000 and 83,000 avoidable deaths per year, the report added.

"The missed opportunities are staggering and heartbreaking," said Glenn Hackbarth, chairman of the Medicare Payment Advisory Commission. Hackbarth, who said he was expressing his own views and not necessarily those of the commission, said the wasted opportunities reflect the primacy in the U.S. health system of the values of patient choice and physician autonomy. The health system needs to give equal weight to a third value—accountability, he said.

Dartmouth College medical researcher Elliott Fisher noted another problem in the system: sharply varying geographic rates of surgery that he said suggest a failure to inform patients about their treatment choices and their relative risks and benefits. Better informed patients are more likely to try non-surgical approaches, he said.

For example, a Medicare enrollee in Fort Wayne, Ind. is five times more likely to get a spine fusion than a similar enrollee in Terre Haute, despite sketchy data showing the procedure's value for lower back pain, Fisher said.

Fisher praised plans by NCQA to develop measures of how often plan doctors inform patients of treatment options.

While speakers at the briefing said measurement and reporting should be universal, they were reluctant to advocate mandates.

"There's more than one way to skin a cat," said O'Kane, urging "payment for performance" as a way to boost use of measurement. Fisher said the first step is voluntary reporting and the second is payment for performance. If that doesn't work, mandates should be considered, he said.

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