Agenda - 03-09-1999 - III-B - Laserfiche WebLink

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16 HEALTHY COMMUNITIES many managed care organizations do not collect the types of information needed for surveillance and epidemiologic studies. There have been a number of attempts to assess the quality of care offered by managed care organizations. The National Committee for Quality Assurance (NCQA), which accredits managed care organizations, has developed the Health Plan Employer Data and Information Set ( HEDIS), a set of performance measures for managed care organizations designed to meet employers' and government purchasers' needs for information about the value of services they purchase and to systematize the measurement process (NCQA, 1993). The data systems maintained by some managed care organizations are an important tool for improving performance and maintaining accountability, and simply by having performance monitoring systems, these organizations compare favorably with fee - for - service delivery systems or indemnity insurance companies that typically have no data with which to monitor performance. The committee heard of instances in which a managed care organization's performance --in terms of provision of preventive services, for example —was criticized based on the organization's own data, with the implicit assumption that other providers do better. Such assumptions may well be incorrect and are unfair because they cannot be checked unless the other providers have appropriate data systems. Experience suggests that performance monitoring as a basis for punishing those who are not producing as expected is not an effective way to alter behavior and improve outcomes. Rather, performance monitoring should be used to encourage productive action and broad collaboration (Berwick, 1989; IOM, in press). Population Orientation and Prevention Managed care's responsibility for a defined population -gives it an interest in promoting health and preventing disease in that population, which is the mission of public health. Both managed care organizations and governmental public health agencies have a philosophical emphasis on promoting health and preventing disease. Both address prevention and health promotion in a defined population. However, in actual practice, some managed care organizations seem more concerned about efficiency and controlling short run costs than about prevention or the health status of their members. Governmental public health agencies have a geographic perspective and are accountable to the people within their jurisdiction while many managed care organizations focus on their current enrollees, an ever - changing group, who may only be a subset of the population. Committee discussions suggested that in the long term, it is important for managed care organizations to think more broadly and to promote health in the whole community because anyone may be their enrollee in the future (Box 2). In a PUBLIC HEALTHAND MANAGED CARE 17 capitated system with limited turnover, some prevention activities might result in larger future profit margins. Unlike public. health agencies, managed care organizations are primarily accountable to purchasers, subscribing employers, large groups of payers, and ultimately their stockholders or trustees. As managed care organizations respond to public demands for accountability, more should find ways to measure the quality of services they provide. A focus on health outcomes and prevention objectives, as some organizations which have adopted HEDIS and other performance measures have done, would help. BOX 2. Group Health Cooperative of Puget Sound Group Health Cooperative of Puget Sound is a large, nonprofit health maintenance organization (HMO) that was established in 1947. It has approximately 540,000 enrollees, of whom about 80,000-90,000 are enrolled in the Medicare and Medicaid Basic Health Plan. The cooperative has been involved in community -based health for more than 50 years. Its public health focus grew out of 10 years of involvement with public health in community issues and priorities such as AIDS prevention. In 1992, Group Health adopted a vision statement that calls for delivery of quality health care to the whole community, not just its enrolled population. They also adopted a set of community service principles to recognize the work that Group Health had been doing in the community in the area of health promotion and disease prevention. They currently focus their attention on four areas: (1) childhood immunization, (2) the reduction of infant mortality, (3) health care for homeless families, and (4) the reduction and prevention of interpersonal violence. In their community -based programs, Group Health has gone beyond just providing immunization and preventive clinical services to issues that deal with changing social norms, such as violence and alcohol abuse. Group Health is also working with the State of Washington on surveillance issues to improve their performance measurements and develop more integrated information systems. Group Health considered several factors in implementing its community programs. Improving community health in general is expected to lead to improved health for the members of Group Health as well. Involvement in community -based programs also helps Group Health compete for contracts with large employer groups and with Medicaid and Medicare populations. In addition, community service programs help to encourage innovative approaches to providing services to the patient population. SOURCE: Based on a presentation by William Berry, director, Center for Health Promotion, Group Health Cooperative of Puget Sound, at the February 22, 1996, meeting of the Public Health Committee. co Ch