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It seems like a reasonable enough question for patients, employers, and managed care organizations (MCOs) to ask: Where can we get the best health care for the least amount of money? But as more health care consumers begin to demand the answer to that question, more providers are realizing they don’t exactly have it. Physician-provided data on treatment processes is probably available, but what about how the patients ultimately benefited from those processes? And how does the care given by one organization compare to that of a competitor?
Getting that kind of data would require developing new measurement tools that ask individual patients for their input. It would also mean that competing MCOs would have to share their information as well as make it available to the public. On top of that, reporting of the data would have to be standardized so results could be compared accurately.
In a dream world, you may be thinking. But there’s a unique project going on that brings together MCOs, employers, patients, and health care researchers to prove that this type of data can be collected and used to inform consumer decisions and improve the quality of care.
The joint effort of 10 MCOs, nine of the country’s largest employers, and nearly 3,000 patients under the direction of the Health Outcomes Institute/Stratis Health focuses on the treatment of coronary artery disease (CAD) but likely will have broader implications, says Darcy Frana, operations manager for HOI/Stratis Health. HOI/Stratis Health, based in Bloomington, MN, is a not-for-profit organization that promotes the use of patient-reported data in combination with administrative and clinical information to inform decision-making by patients, purchasers, and providers. The employers, which include Ameritech, based in Chicago; GTE, based in Irving, TX; Xerox Corp., based in Stamford, CT; and the MCOs, which include several Blue Cross and Blue Shield systems, as well as Boston-based Harvard Pilgrim Health Care and Humana Health Plan of Chicago, are part of the Managed Health Care Association Outcomes Management System Consortium, which seeks to improve the quality of health care in managed care arrangements.
The specific goals of the CAD project, which began in January, are to assess the feasibility of using simple data collection instruments to help measure and manage CAD treatment, to describe variations in the care and clinical status of patients in different managed care settings, and to assess and compare patient outcomes, Frana says. (See excerpt from the heart health survey, p. 94.) In the first phase of the project, about 3,000 patients across the MCOs filled out a survey developed by HOI in conjunction with the Durham, NC-based Duke University Outcomes Research and Assessment Group. Claims data, medical chart information, and cardiac catheterization reports are being used to verify the accuracy of the patient-reported data. Data analysis is expected to be completed in September, and the findings will be reported to the participating organizations in a blinded format. The experience of the first phase will be used to narrow the focus of a second round of data collection. Organizations will be identified by name in the second phase results, which are expected to be made public.
The heart of the CAD project is getting the information directly from the patients, instead of relying on more traditional clinical data, says Michael Huber, executive director of HOI/Stratis Health. The 17-page heart health survey developed for this project asks patients about their health status at the time of a specified medical visit and at present, knowledge of the disease and its management, feelings, lifestyle, satisfaction with health care providers, medications taken and procedures undergone. The hypothesis is that patient-reported data can be used in place of physician-provided data to predict the results and benefits of certain treatments and that the data can be collected in a systematic, standardized way to provide accurate comparisons across managed care settings.
"The measures are important because when you’re evaluating the effectiveness of health care services, the ultimate criterion for effectiveness is the influence on patients’ quality of life," Huber says. "The patient-reported measures represent the most faithful picture of the ultimate product."
The fact that the patients are providing the data is a large part of the reason Ameritech, a Chicago-based telecommunications and information services company that provides health benefits for 250,000 people, is participating in the project, says Alan Peres, manager of health care policy and chairman of the consortium. "We believe strongly that the viewpoint of the patient is important if that information is gathered in a methodologically sound way," he says. "You can do everything right clinically, but if the patients aren’t doing well, then you’re missing the point."
Peres says understanding the progress patients make under different treatment programs will benefit his company and individual employees. CAD takes a financial and emotional toll on companies in terms of disability, employee replacement costs, and the stress on individuals and their families, he says, and this project has the potential for immediate payback. "We work with several networks that are participating in the project, and we should see results as they learn what to do better. Over the longer term, we can take that information and discuss it with other networks and influence what physicians are doing," he says.
HOI/Stratis Health concluded a similar project related to asthma management last year that spurred the development of the CAD project. Many of the same organizations participated in the asthma project, and many of them found they had much to learn, Huber says. "With the asthma project, even after the first round of data, there were oh my goodness’ remarks from some of the MCOs," he says. "They just didn’t know how they stacked up. So it was a catalyst for them to think about quality improvement initiatives within their organizations dealing with asthma treatment."
Specific questions on the survey relate to patient education how well they understand aspirin use, risk factors, lifestyle modification, and medication and how many procedures cardiac catheterization, bypass surgery, coronary angioplasty they’ve had done. The lack of specific guidelines for CAD treatment and the resulting broad range of therapies make CAD the perfect disease for such a project, Huber says. The MCOs will be able to see how their providers’ courses of treatment differ from those in other plans and use that data to improve their quality. Results will be adjusted for differences in patients’ disease status and other potentially confounding factors. "In a sense, we’re conducting a natural history investigation," Huber says. "We’re trying to understand the nature of the disease and get some glimmer of a picture of the range of therapies being used across settings."
The survey also asks a series of questions on health status and activity levels, including specifics such as whether the patient has difficulty climbing stairs, carrying groceries, pushing a vacuum cleaner, or playing golf. Patients are asked how satisfied they are with the care they have received from their primary care physician and heart specialist, from how long it takes to get an appointment to the competence and thoroughness of the physician. Demographic information also is collected.
"The information could result in improvements in how we deliver care," says Marianne Laouri, director of quality measurement and research for PacifiCare, based in Cypress, CA. PacifiCare, the largest Medicare HMO in the country, has 4.5 million members in 13 states and Guam. "If we see national trends that show something isn’t being done quite right, if there is an opportunity for improvement, and if our data mirror that, then certainly we could take that information back to our providers and let them know about and develop strategies to work with them on those issues."
In the second phase of the project, the focus likely will narrow to the range of secondary prevention services, such as aspirin usage after myocardial infarction and their effects on patients’ health and satisfaction. Cost information may also be collected to give the best overall picture of treatment plans. In the long term, project participants hope that the method of measurement they’re using will be adopted by MCOs and used on a large scale for CAD and other diseases, Huber says.
[For more information about the CAD project, contact:
Michael Huber, executive director, and Darcy Frana, operations manager, HOI/Stratis Health, 2901 Metro Drive, Suite 400, Bloomington, MN 55425. Telephone: (612) 858-9188.
Alan Peres, manager-health care policy, Ameritech, Chicago. Telephone: (312) 750-5264.
Marianne Laouri, director of quality measurement and research, PacifiCare, 5701 Katella, 3rd Floor, Cypress, CA 90630. Telephone: (714) 229-2543.]