Additional Statement, Submitted by Dennis P. Scanlon, Ph.D., Assistant Professor, Department of Health Policy and Administration, Pennsylvania State University

The growth of managed care and other non-traditional insurance products has resulted in major initiatives to measure the quality of care provided by these organizations. For example, the Health Employer Data and Information Set (HEDIS) and the Consumer Assessment of Health Plans Survey (CAHPS) were both created for the purpose of comparing the performance of health plans on a variety of dimensions. Both of these measurement systems have achieved some success in providing consumers, regulators, and the public with standardized tools that can be used to compare plans.

At the same time, the rapid growth of integrated delivery systems and managed care products has made the accountability for and the assessment of quality challenging. For example, while HEDIS and CAHPS currently report at the plan level, the locus of clinical care occurs at the individual provider or provider group level, making these data sets less relevant for some purposes. Likewise, the various forms of managed care products and contractual arrangements between plans and providers means that some plans are in a better position than others to enforce standards and to establish processes that lead to the provision of effective care.

However, few details are known about the characteristics of successful and unsuccessful organizations, and more importantly, what attributes cause some organizations to take patient safety and quality seriously.

Ironically, while many analysts believe that well run managed care plans and organized delivery systems can promote safety and quality by coordinating care across the continuum of providers, the public and the media do not necessarily agree as evidenced by the so called ‘managed care backlash’. This highly contested debate has led to a national focus on the need for, and form of, patient protection legislation. However, it is not entirely clear whether the primary issue in this debate is ‘choice’ or ‘quality’. In some cases it appears that many view quality as synonymous with choice.

Additional research should address this apparent disconnect, so that scientific evidence can inform the public, health care providers, and policymakers about the advantages and disadvantages of organized and coordinated medicine relative to the traditional model of unrestricted choice, solo practice, and fee-for-service reimbursement. In particular, evidence and education must move beyond the simple ‘managed care’ v. ‘no managed care’ debate, and instead explore which models lead to the best outcomes for patients most efficiently.

In research supported through a subcontract from RAND with funds provided by a grant from the Agency for Healthcare Research and Quality (AHRQ) [Grant #HS09204], my co-authors and I conducted in depth expert interviews with Medical Directors, Chief Executive Officers, and Directors of Quality Improvement at twenty-eight managed care organizations in four states. The findings of this study are documented in two articles that are included with this testimony and that are in press at health services research journals.

The first article is forthcoming in Medical Care Research and Review and is entitled, "Are Managed Care Plans Organizing for Quality." The study’s goal was to examine the degree to which managed care organizations are reorganizing to take responsibility for the quality of care and service they provide. We found that plans are facing real pressure to focus and engage in quality improvement activities with much of the pressure being applied by public purchasers and accrediting bodies such as the National Committee for Quality Assurance. Plans seem to have modified their organizational structures such that the board of directors and high-level managers are now actively involved in quality improvement activities. At the same time, many plans appear to be moving tentatively in terms of developing the technical capabilities necessary for successful quality improvement (e.g., data collection, analysis).

In short, we found that managed care organizations in our study sample may offer an effective source of quality improvement that may not be recognized by the public, but at the same time, our analysis suggests there is great variability among these managed care organizations in terms of their ability to effectively manage quality.

The second article is entitled "The Role of Performance Measures for Improving Quality in Managed Care Organizations," and is in press at Health Services Research. This objective of this article is to understand how managed care plans use performance measures for quality improvement and to identify the strengths and weaknesses of currently used standardized performance measures such as HEDIS and CAHPS. We found that plans are engaged in measurement and that measurement results often lead plans to develop quality improvement initiatives. However, there is significant variation in the role that measures play for improvement. For example, measures can be used to evaluate current performance, to target quality improvement initiatives, to establish new performance goals, to identify the root cause of problems, and to monitor the progress of quality improvement initiatives. Our respondents also identified several characteristics of performance measures (e.g., standardized, actionable) that make them particularly useful for quality improvement activities. Finally, HEDIS and CAHPS were found to be the most widely used set of performance measures for quality improvement, however respondents identified several issues that compromise the utility of these measures.

Although the research findings described above suggest there may be significant variation in organizations’ capacity and ability to address these issues, more scientifically sound research studying the underlying reasons for this variation is needed. Because we could find very little prior research on these topics, we designed our study to be exploratory and qualitative in nature. Hence, the results in both of these articles should be viewed as identifying questions and hypotheses for future research rather than results that can be relied on for current policy analysis. However, this is exactly the point of my testimony, namely that managed care organizations are responsible for the health care received by millions of Americans, yet we seem to have little more than anecdotal evidence about the quality of care provided by these organizations. I hope the task force finds our analyses useful for identifying topics for future research.

Current as of September 2000

Internet Citation:

Additional Statement by Dennis P. Scanlon. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/ascanlon.htm

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