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Study: Tools Exist to Add Value to Health Care Spending—but Are Largely Unused

By John Reichard, CQ HealthBeat Editor

September 27, 2006 -- If Michael O. Leavitt is right, the nation must get a grip on rising health costs or its long tradition of economic prosperity will die. Proven quality-measurement tools must be used to get more value for the U.S. health care dollar, yet only about one of four Americans benefits from those tools, according to a study released Wednesday by the National Committee for Quality Assurance (NCQA), an organization that accredits health care plans and measures their quality.

The study was the tenth of NCQA's annual assessments of health plan quality, and two things are clear from the decade of annual reports: The measures are linked to an abundance of data suggesting they improve care and save lives; and much of American health care nevertheless goes unmeasured, with little evidence that will change dramatically any time soon.

Yet the stakes are critical as the United States struggles to compete in a world economy where other nations have far lower health costs, Department of Health and Human Services Secretary Leavitt said Tuesday in a speech to health information technology executives.

"We now live in a global marketplace," he said. "We can no longer afford, nor can we remain prosperous if we continue on the glide path that we're on. This is the kind of problem that, allowed to continue unchanged, could have a Draconian impact on the future of this country."

Eliminating wasteful health care spending by creating a marketplace that responds to price and quality is essential if the nation is to continue to lead the world economically, Bush administration officials say. But while quality measurement helps to add the "value" to health care spending that administration officials say is key, measurement lags, quality analysts say.

"The past decade has demonstrated the benefits of measurement, reporting, and accountability, but three out of four people don't enjoy those benefits today," NCQA President Margaret E. O'Kane said at a press briefing Wednesday. "It's time to ask, 'Why not?' "

NCQA requires HMOs to report data on dozens of quality measures in order to gain accreditation. Public reporting of the data allows consumers to compare plans and becomes a powerful prod for plans to improve.

According to the findings of the study, children in commercial health plans that report data on NCQA measures are three times as likely to receive all recommended immunizations, compared with eight years ago. Diabetics were more than twice as likely to have their cholesterol controlled to recommended levels as in 1998. More than 96 percent of patients who suffered a heart attack were prescribed beta-blockers to prevent a second heart attack—up from 62 percent in 1996—saving between 4,200 and 5,300 lives over that period.

Improvements in high blood pressure control saved between 47,800 and 83,000 lives, based on trends over the 1999–2005 period, the study said. In 1999, 39 percent of plan enrollees with high blood pressure had it properly controlled, compared with 68 percent in 2005. Those gains are particularly important, O'Kane said. "There's a long litany of body systems that fail because of high blood pressure," she noted.

NCQA said that overall, long-term improvements on NCQA measures by plans that publicly reported performance data saved between 53,000 and 91,000 lives and prevented "hundreds of thousands of serious complications."

Not all of the latest data is positive, however. Breast cancer screening rates have declined for the past three years, apparently because of news reports raising questions about the value of screening, O'Kane said. "The case has become more cloudy," but "this is a lifesaving technology," O'Kane emphasized.

Mental health care remains poor, the NCQA report said. "Patients on antidepressant medication are about as likely to receive appropriate care today as they were in 1999. Similarly, patients hospitalized for mental illness are only marginally more likely to receive appropriate follow-up care."

But overall, commercial plans saw improvement on 35 of 42 clinical measures.

The bad news is that HMOs are predominantly the plans undergoing measurement and their enrollment is declining as more Americans switch to PPOs. A total of 76.5 million Americans are in "accountable" plans, while 173 million are in an unaccountable system, NCQA said.

A Boost From Bush?
An executive order issued by President Bush on Aug. 22 will help boost the number of Americans in accountable health plans, administration officials say. The order requires health plans doing business with Medicare, the Federal Employees Health Benefits Program, and military health care programs to report data on the cost and quality of their care, among other requirements. The Centers for Medicare and Medicaid Services is requiring PPOs in Medicare to publicly report data on quality measures developed by NCQA in 2007.

And the Office of Personnel Management, which runs the federal employees health program, is requiring PPOs and other fee-for-service plans serving 9 million federal employees to report data on five quality measures in 2007 for public release in 2008.

The Bush initiative also calls on employers to issue the same demands for cost and quality data. Leavitt expressed conviction that the combination of payer pressure, the development of quality measurement standards, increased posting of the prices of health care, and the development of standards to make health care information systems compatible are all combining to transform the health care "sector" into a "health care system."

The way Leavitt sees it, "this is the marketplace beginning to organize itself." Employers want badly to control health care costs. "Their hair is on fire" and they see rising costs as a threat to their economic competitiveness, he says.

"This is a very important moment in health care history," Leavitt told the information technology executives. "All of the components of change are in place." He added that "every component of society is feeling anxiety about health care right now. And I believe that it is putting us in a position where we're prepared to do things that in the past we haven't."

But conviction does not make it so. Quality measurement in PPOs, for example, may occur only gradually, and the number of measures applied to PPOs is limited right now. In some cases, contracts between PPOs and doctors might only allow access to claims data for quality measurement purposes, when a fuller picture of quality requires looking at medical records as well. For example, claims data might show an enrollee's blood pressure has been measured but not that it has been controlled.

But NCQA is applying more pressure to obtain quality data from PPOs. In 2005, it called on them to voluntarily report data on NCQA quality measures, and a total of 80 commercial PPOs providing care to 14 million Americans did so. It now plans to mandate that they provide the data in order to receive accreditation and to urge employers to demand that accreditation. That's the pattern it followed with HMOs, most of which report quality data. But with more than six of 10 Americans in PPOs or other health plans, NCQA has a long way to go.

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