Q Name: Structure: Contracting Basis: Anatomy of a Health Quality Foundation Health Quality Foundation National network of state-based organizations Competitive grants with the National Quality Management Council Q Quality monitoring and community-based quality improvement activities The most significant point of departure between this report's National Quality Management Program and that of the other managed competition proposals including Clinton's Health Security Act is its recommendation to create a state-based network of Health Quality Foundations under contract with the National Quality Management Council. These organizations would be independent private sector organizations funded through a direct draw on the premium dollar. Their primary mission would be to provide ongoing system-wide quality monitoring and to act as a convener for community-based quality improvement initiatives. Health Quality Foundations would be governed by an alliance of consumers, purchasers and health care professionals and they would employ a highly skilled staff of biostatisticians, epidemiologists, quality improvement specialists, data analysts and medical professionals. Given the incentives of managed competition towards undertreatment, this program would focus on such quality indicators as rates of appropriate screening, rates of referral to specialists, rates of compliance with federally approved practice guidelines, and other risk-adjusted outcomes and health status measurements. The evolution of sampling, screening and focusing methodologies currently in use by the Medicare Peer Review Organization program make it feasible to project that meaningful surveillance of all provider-consumer interactions across all venues of care could be achieved in a highly cost-effective manner. By making comparative performance information available to health plans, a Health Quality Foundation would support quality improvement -- not only by those plans whose rates of compliance or clinical adequacy is demonstrably at the low end, but by all providers and plans. It would support and preserve the necessary "safe" environment in which such quality improvement should optimally take place while providing an incentive for decisive and immediate action on problem areas. It would foster collaboration between plans and guide the conduct of community-based quality improvement programs. It would also facilitate ongoing professional learning pursuant to new practice guidelines and provide input to the research and development of future practice guidelines and performance measures. Although the sentinel effect in support of quality improvement activities should be expected to resolve the vast majority of variations, persistent failure to improve identified problems would ultimately result in consequences to plans and providers. At a minimum, consistent quality concerns would be reported to Alliances for use in their contract negotiations. Flagrant and continued violations would be referred to licensing or accrediting bodies for redress. The Health Quality Foundation would also serve as a resource for state regulatory bodies, including the ombudsman and the consumer complaint and appeals authorities to provide independent medical consultation regarding clinical appropriateness and technical quality. A Health Quality Foundation would be responsible for creating an independent community information and resource center for consumers regarding treatment alternatives. It would provide independent, unbiased "user friendly" information to consumers to help inform those choices. Additionally, a Health Quality Foundation would be responsible for compiling, validating, and providing to the Alliance the quality components of its annual Consumer Report Card. Each Health Quality Foundation would also publish an annual "State of the Quality Report" to include state aggregated health status measures and a summary of quality improvement initiatives. Management Council. State-based, independent, Health Quality Foundations (see page 16) would provide the Council with the arms and legs to carry out critical functions such as ongoing quality monitoring, feedback and interaction with plans and providers; interactive educational programs for professionals and consumers; support of state regulatory and enforcement mechanisms; communication with state professional organizations; and, annual reports to the National Quality Management Council on state-aggregated health status indicators. Data Networks, responsible for data collection and aggregation, should also take place as a nationally managed, state based program -- in order to take advantage of existing data collection and analysis mechanisms that currently exist in most states, and to facilitate the data organization's close interaction with the Health Quality Foundation. State Government "These state regulatory mechanisms are expected to be heavily dependent on the Health Quality Foundation for information and expertise regarding medical quality and clinical effectiveness." There is an important role for state government in the overall design of a National Quality Management Program. Building on existing structures wherever feasible, states should be directly responsible for administrative/regulatory control of the delivery system. This would include continued reliance in most states on the state Insurance Commissioner's Office, various state Licensing Boards, an expanded state Ombudsman Program, and a new state Office of Consumer Complaints and Appeals. The apparatus for licensing health plans, providers and professionals already exists at a state level. Health departments issue professional licenses; insurance commissioners oversee the rules regarding the formation of health maintenance organizations and other health insurance plans. These programs are already well-disseminated statewide and could be re-engineered to work within existing state authorities. Likewise, a patient complaint and appeals process could be administered through the state judicial system with relative ease. States currently are required to oversee an ombudsman program for long term care; this could easily be expanded to include health plans. These state regulatory mechanisms are expected to be heavily dependent on the Health Quality Foundation for information and expertise regarding medical quality and clinical effectiveness. Likewise, Health Quality Foundations will be dependent on these state regulatory and enforcement mechanisms to impose penalties on plans and providers in the event of persistent non-compliance with standards and failure/refusal to self-correct. Local Marketplace Health care delivery and purchasing takes place at a local level so to a significant degree, quality and for organizing the consumer choice function, including the preparation and distribution of consumer report cards. The Alliance should expect to rely on the Health Quality Foundation for the quality information to be published in these consumer reports and for additional quality findings that may assist it in its negotiations with plans. Likewise, Health Quality Foundations will depend on the Alliances to contractually reward or punish plans based on quality determinations. It must not be forgotten that the primary responsibility for quality rests with Health Plans and Providers themselves. Through their own internal management, communication and quality improvement mechanisms, they must be active participants in all aspects of quality. Participation in community-based quality activities of the Health Quality Foundation should be contractually mandated. CRITIQUE OF LEGISLATIVE PROPOSALS How do the quality provisions of the managed competition bills compare with the principles and structure outlined above? All of the proposals currently under consideration place too much reliance on market mechanisms to achieve and maintain the consistently high standards of quality "The theory is that, given proper incentives, Americans should and do expect. The theory is that, While it can be expected that health plans (in regions capable of supporting multiple alternatives) will compete on visible measures of consumer satisfaction, e.g., service quality, there is little reason to think that plans or providers will compete on technical and difficult to extract measures of clinical quality. Even assuming that some comparative quality indicators are made available to the consumer through the consumer report card, consumers are much more likely to be influenced by price, or to choose the plan their own doctor joined than to "vote with their feet" based on that information. Once having chosen, a consumer is extremely unlikely to be able to detect or adequately document clinical deficiencies -especially care that should have been but was not provided. All the current legislative proposals are to be commended, however, for their political courage in mandating a national database that includes reporting on all patient encounters as well as comprehensive data that correlates with performance measures for specific conditions or disease categories. No meaningful evaluation of system quality or performance would be possible without such data. It is anticipated that the rapid movement to computerized medical records keeping will greatly reduce the administrative burden associated with this requirement in addition to enhancing internal quality improvement activities. Of the legislative proposals currently on the table, Clinton's Health Security Act goes the farthest in spelling out the functions and framework of a comprehensive quality management program and provides the starting point on which the foregoing discussion is based. In particular, the plan succeeds in the following respects: Affirms the policy principle that health care plans are responsible for the improved health of the populations served; that ultimately, improved health status should be the outcome of a health care plan; Creates a national health care information database that serves as the underpinnings for quality assessment and improvement activities; "The latest version of the Clinton plan substantially weakens the quality management function by penciling out the state based 'Technical Assistance Foundations' which in the original proposal had been assigned the role of designing and implementing quality measurement and improvement systems." Enshrines the principle of meaningful consumer choice by promising consumers a "report card" that compares plans and providers within plans not merely on costs, but also on specific performance measures; Establishes a state-based complaint and appeals office to permit redress for consumers that believe their benefits have been curtailed by competing health plans; Reaffirms a national commitment to patient outcome research and national practice guidelines. The greatest failing of the Health Security Act with regard to quality is the conspicuous absence of an ongoing monitoring and quality improvement function. To that end, Health Quality Foundations are proposed, the chief purpose of which would be to provide ongoing system-wide surveillance of quality indicators, with organized feedback and education to providers and practitioners. There is obviously some ambivalence on this issue within the Administration itself. The latest version of the Clinton plan substantially weakens the quality management function by penciling out the state based "Technical Assistance Foundations" which in the original proposal had been assigned the role of designing and implementing quality measurement and improvement systems. Instead, this state-based infrastructure was replaced with "Regional Professional Foundations" whose mission it would be to develop programs in "life-time" learning for health professionals. While academic medical centers might usefully play a role in helping drive medical consensus on practice guidelines and providing targeted education to physicians and other health professionals, it is unreasonable to think that an academically-based regional organization could be expected to implement an administratively efficient process for system-wide quality monitoring. In any event, such a role would present an extreme conflict of interest for an academic medical center which is, itself, a health care provider whose performance should be monitored. A better model would be for academic health centers to work actively with the proposed independent Health Quality Foundations to assure that their expertise and skills are utilized effectively. The original plan to create a state-based entity, broadly responsible for quality monitoring and improvement, close to local markets, consumers and practicing health professionals would appear to make a good deal more sense. This report advocates that it be reinstated as health reform makes its way towards law. There are a number of other points on which this proposed plan for national health quality management differs from the Clinton proposal: It would also appear to be administratively easier and provide less appearance of a conflict of interest to house the Ombudsman program within state government rather than within Alliances. Existing state Ombudsman programs for long term care could be expanded to accommodate this function. |