NOVEMBER 2006 Data Brief COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM The National Committee for Quality Assurance’s The State of Health Care Quality 2006 Stephen C. Schoenbaum and Alyssa L. Holmgren The Commonwealth Fund For more information about this ABSTRACT: The National Committee for Quality Assurance’s 2006 report on the per- study, please contact: formance of U.S. health plans found overall improvement in HEDIS clinical quality Stephen C. Schoenbaum, measures for those plans that collect and publicly report performance data. Improve- M.D., M.P.H. ments, moreover, were broad-based. There are several lessons for those pursuing high Executive Director, performance of the U.S. health system as a whole. Most importantly, the results show Commission on a High Performance Health System there is hope; performance on some HEDIS measures is now approaching 100 percent. The Commonwealth Fund Diffusion of measurement has been slow, but steady.The nation needs more and bet- Tel 212.606.3505 ter measures of performance, mechanisms for setting standards of performance, and Fax 212.606.3515 tools, such as performance-based contracts, for ensuring that improvement occurs. E-mail scs@cmwf.org * * * * * BACKGROUND The National Committee for Quality Assurance (NCQA) recently released The State of Health Care Quality 2006, the 10th in an annual series of reports analyzing the performance of the nation’s health plans.1 These reports, based on clinical measures drawn from HEDIS2 and reported this year by 616 plans that collectively cover more than 76 million Americans, provide remarkable documentation of the nation’s progress in improving the quality of health care. The new results, which reflect plans’ performance in 2005, are worth noting: G For the seventh consecutive year, health plans that measure and report on This and other Commonwealth Fund publications are online at their performance showed an overall improvement in clinical quality; how- www.cmwf.org. To learn more ever, not all plans report clinical performance information and patient about new publications when experience data. NCQA recommends that all plans report in the future. they become available, visit the Fund’s Web site and register to receive e-mail alerts. G Improvements in patient care were broad-based: for commercial health Commonwealth Fund pub. 969 plans, performance improved on 35 of 42 HEDIS measures; for Vol. 1 Medicaid plans, on 31 of 40 measures; and for Medicare plans, on 10 2 The Commonwealth Fund Commission on a High Performance Health System Table 1. HEDIS Effectiveness of Care Measures, Selected Trends, 2003–2005 2003 2004 2005 Commercial averages Adolescent immunization status—Combination 2 41.6 46.9 53.7 Controlling high blood pressure 62.2 66.8 68.8 Childhood immunization status—Combination 2 69.8 72.5 77.7 Beta-blocker treatment after a heart attack 94.3 96.2 96.6 Comprehensive diabetes care: HbA1c testing 84.6 86.5 87.5 Comprehensive diabetes care: Lipid control (<100 mg/dL) 34.7 40.2 43.8 Medical assistance with smoking cessation 68.6 69.6 71.2 Medicaid averages Adolescent immunization status—Combination 2 33.9 38.1 42.4 Controlling high blood pressure 58.6 61.4 61.4 Childhood immunization status—Combination 2 58.5 63.1 70.3 Beta-blocker treatment after a heart attack 83.5 84.8 86.1 Comprehensive diabetes care: HbA1c testing 74.8 75.9 76.2 Comprehensive diabetes care: Lipid control (<100 mg/dL) 27.8 30.6 32.6 Medical assistance with smoking cessation 65.8 66.9 65.6 Medicare averages Controlling high blood pressure 61.4 64.6 66.4 Beta-blocker treatment after a heart attack 92.9 94.0 93.8 Comprehensive diabetes care: HbA1c testing 87.9 89.1 88.9 Comprehensive diabetes care: Lipid control (<100 mg/dL) 41.9 47.5 50.0 Medical assistance with smoking cessation 63.3 64.7 75.5 Source: National Committee for Quality Assurance, The State of Health Care Quality 2006 (Washington, D.C.: NCQA, 2006). of 23 measures (Table 1). NCQA concludes not as high as those reported by HMOs. that “measurement does lead to quality More importantly, however, it is now possi- improvement.” ble to get some clinical performance data from PPOs—something that only a few G The 2006 NCQA report included, for the years ago was not thought feasible. With first time, data from 80 preferred provider PPOs joining the ranks of plans that report, organizations (PPOs), not just health main- the number of Americans enrolled in tenance organizations (HMOs) and point- “accountable health plans” has increased for of-service (POS) plans (Table 2). In many the first time in three years (76.5 million instances, the results reported by PPOs were people in 2005 vs. 69 million in 2004). Table 2. HEDIS Effectiveness of Care Measures, Select HMO/POS and PPO Plan Averages, 2005 HMO/POS Plans PPO Plans Breast cancer screening 72.0 64.6 Chlamydia screening (combined rate, ages 16–26) 34.9 28.1 Imaging studies for low back pain 75.4 72.9 Appropriate treatment for children with an upper respiratory infection 82.9 83.3 Flu shots for adults 36.3 36.8 Source: National Committee for Quality Assurance, The State of Health Care Quality 2006 (Washington, D.C.: NCQA, 2006). The National Committee for Quality Assurance’s The State of Health Care Quality 2006 3 G Some quality measures are not improving. In health plans on this measure was 62.2 percent. The particular, NCQA notes, “the quality of care upper 10th percentile was performing at the 88 for Americans with mental health problems percent level. Thus, on this measure, had a score remains as poor today as it was several years been assigned to the country and the upper 10th ago,” as assessed by measures of follow-up percentile been taken as the benchmark, that score care provided within seven days of a mental would have been 71. But, as one examines Figure 2, health hospitalization and measures of care it is clear that average performance has improved for patients on antidepressant medications greatly and is approaching perfection. The upper (Figure 1). 10th percentile is, indeed, now performing at 100 percent, and the average across all health plans is 97 percent. So, the country’s score for this one indicator now is 97. If this type of improvement and overall performance is achievable for one indi- cator, why not for many more? RELATIONSHIP TO NATIONAL SCORECARD The NCQA report offers some important take- away messages relating to the work of The Commonwealth Fund’s Commission on a High Performance Health System, which in September 2006 released its National Scorecard on U.S. Health The NCQA report shows that improved qual- System Performance.3 The Commission’s scorecard ity has social and economic benefits. NCQA esti- compares national performance on 37 health sys- mates that if the entire health care system performed tem indicators against achieved benchmarks—in at the level of the top plans, between 37,600 and general, the top 10 percent of U.S. states, hospitals, 81,000 lives would be saved each year. These qual- heath plans, or other health care providers, or the ity gaps also lead to over $10 billion in lost pro- best-performing countries. The average score ductivity and nearly 65 million avoidable sick days. across these indicators was 66 out of 100. Second, diffusion of measures into wide First, the NCQA report holds out hope for use takes time. HEDIS originated in the late overall improvement in the performance of the 1980s when Daniel Wolfson, then CEO of The U.S. health care system: A good example is found HMO Group, and Howard Veit, then a consultant at in the data from commercial health plans on beta- Mercer Consulting, created a process for developing blocker treatment after a heart attack (Figure 2). a set of measures of health plan performance that In 1996, the average performance reported by would be responsive to the needs of employer- 4 The Commonwealth Fund Commission on a High Performance Health System purchasers.4 Although “accountability” was not a about as close to a clinical performance standard- popular term at the time, the notion underlying setter as we have in the U.S. Accredited commercial, HEDIS was that employers—who were increasingly Medicare, and Medicaid health plans performed encouraging their employees to choose managed care better than non-accredited plans on about 90 plans—felt it was important to hold health plans percent of HEDIS effectiveness-of-care measures. accountable for their performance. It took about Furthermore, on the vast majority of measures, three years from the beginning of the development commercial and Medicaid health plans that of the prototype set of measures, HEDIS 1.0, which publicly report performed better than those that was used formally by only one health plan, to the did not. transfer of responsibility for its further develop- Accreditation and public reporting are ment to NCQA, and to the release of HEDIS 2.0. important ways of holding health plans and Further diffusion of HEDIS measurement providers of care accountable for their performance. occurred through a variety of mechanisms. Over This year, NCQA recommended that all health the years, one of the most powerful has been a plans publicly release information on their clinical state requirement that traditional HMOs either performance and their patients’ experience. The become accredited through NCQA (measuring and combination of requirements for accreditation and reporting on HEDIS performance is an important public reporting would likely lead to improved U.S. part of the accreditation process) or simply report health system performance, reduced morbidity, and on HEDIS measures to NCQA, or to the state reduced mortality—or, as framed by the National itself. More than 30 states now have such require- Scorecard on U.S. Health System Performance, to ments in place. The Centers for Medicare and longer, healthier, and more productive lives. Medicaid Services also requires all Medicare man- Finally, measurement and reporting are aged care plans to report HEDIS to NCQA. just the beginning of the process of per- Third, while the processes of measure formance improvement. NCQA, in conjunc- development, and of measurement itself, tion with U.S. News and World Report, has just have become much more sophisticated over released the list of top-performing health plans in the years, progress has been slow. Some meas- the U.S. (Table 3).5 A large number of them are in ures are still controversial, and there is room for the Northeast, and three of the top five Medicaid many more measures focusing on different aspects health plans are in Rhode Island—all of the of performance. For example, the continued poor Medicaid plans in that state. For eight years, performance of plans on mental health measures RIteCare, Rhode Island’s Medicaid managed care may reflect the state of mental health care in the program, has been offering bonuses to health plans U.S., but it also may reflect the use of measures meeting certain levels of performance. Are the suc- that, at least according to those responsible for per- cesses of plans in Rhode Island and the rest of the formance improvement, are poorly designed. Not Northeast applicable elsewhere? While it is possible having adequate measures and measurement can that conditions in that region are not replicable itself be considered a sign of suboptimal perform- elsewhere, this seems unlikely. ance. Ideally, those who are concerned about the We as a nation need to discover ways to learn quality of performance measures would help from the top performers and assist those plans and devise better ones. providers whose performance falls below the Fourth, we need mechanisms for setting benchmark. The high-performers on HEDIS are clinical standards. NCQA, because it ties HEDIS public knowledge. The challenge now is for others performance to accreditation of health plans, comes to meet the benchmark—or better yet, exceed it. The National Committee for Quality Assurance’s The State of Health Care Quality 2006 5 Table 3. Top Health Plans TOP TEN COMMERCIAL PLANS TOP FIVE MEDICARE PLANS Harvard Pilgrim Health Care Preferred Care Massachusetts, Maine (HMO/POS) New York (HMO) Score: 93.2 Score: 91.2 Tufts Associated Health Maintenance Organization Harvard Pilgrim Health Care Massachusetts, New Hampshire, Rhode Island (HMO/POS) Massachusetts (HMO) Score: 92.7 Score: 90.3 Harvard Pilgrim Health Care of New England Tufts Associated Health Maintenance Organization New Hampshire (HMO/POS) Massachusetts (HMO) Score: 92.4 Score: 90.1 Blue Cross and Blue Shield of Massachusetts Capital Health Plan Massachusetts (HMO/POS) Florida (HMO) Score: 91.4 Score: 89.9 Capital District Physicians' Health Plan Kaiser Foundation Health Plan of Southern California New York (HMO/POS) California (HMO) Score: 90.8 Score: 89.6 ConnectiCare Connecticut (HMO/POS) TOP FIVE MEDICAID PLANS Score: 90.7 Neighborhood Health Plan of Rhode Island UPMC Health Plan Rhode Island (HMO) Pennsylvania (HMO/POS) Score: 90.3 Score: 90.7 Blue Cross & Blue Shield of Rhode Island Group Health Cooperative of South Central Wisconsin Rhode Island (POS) Wisconsin (HMO) Score: 89.6 Score: 90.6 Kaiser Foundation Health Plan of Hawaii Independent Health Association Hawaii (HMO) New York (HMO) Score: 88.5 Score: 90.6 UnitedHealthcare of New England Preferred Care Rhode Island (HMO) New York (HMO/POS) Score: 88.5 Score: 90.4 Independent Health Association New York (HMO) Score: 87.3 Source: U.S. News & World Report and NCQA, “Best Health Plans, 2006,” U.S. News & World Report, Nov. 6, 2006. NOTES Results from a National Scorecard on U.S. Health System Performance (New York: The Commonwealth Fund, 1 National Committee for Quality Assurance, The State Sept. 2006); C. Schoen, K. Davis, S. K. H. How, and of Health Care Quality 2006 (Washington, D.C.: S. C. Schoenbaum, “U.S. Health System Performance: NCQA, 2006). Available at http://www.ncqa.org/ A National Scorecard,” Health Affairs Web Exclusive Communications/SOHC2006/SOHC_2006.pdf. (Sept. 20, 2006):w457–w475. 2 4 HEDIS—the Health Plan Employer Data and S. C. Schoenbaum, “What’s Ahead in Quality: The Information Set—is the set of measures used by the Managed Care Perspective,” Physician Executive nation’s health plans to measure and report on their Nov.–Dec. 1993 19(6):40–42. performance. 5 U.S. News & World Report and NCQA, “Best 3 The Commonwealth Fund Commission on a High Health Plans, 2006,” U.S. News & World Report, Performance Health System, Why Not the Best? Nov. 6, 2006. ABOUT THE AUTHORS Stephen C. Schoenbaum, M.D., M.P.H., is executive director of The Commonwealth Fund Commission on a High Performance Health System and executive vice president for programs of The Commonwealth Fund, with responsibility for coordinating the development and management of the Fund’s program areas. He is a lecturer in the Department of Ambulatory Care and Prevention, Harvard Medical School, the author of more than 140 scientific articles and papers, and the editor of a book on measuring clin- ical care. Dr. Schoenbaum received an A.B. from Swarthmore College, an M.D. from Harvard Medical School, and an M.P.H. from Harvard School of Public Health. He also completed the Program for Management Development at Harvard Business School. Alyssa L. Holmgren, M.P.A., is research associate for the president of The Commonwealth Fund and also provides assistance to staff in the research and evaluation area. She has also served as program asso- ciate for the State Innovations program and health care coverage and access, and as program assistant for The Commonwealth Fund’s Task Force on the Future of Health Insurance. She holds bachelor’s degrees in economics and Spanish from the University of Georgia and a master of public administration degree in public sector and nonprofit management and policy from New York University’s Wagner Graduate School of Public Service. The mission of The Commonwealth Fund is to promote a high performing health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff, or of The Commission on a High Performance Health System or its members.