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Health Net program may be the first in a wave
In what could be a new trend to increase the information patients have about their care, the second largest health plan in California in December 1998 became the first in the nation to start ranking its practices on disease-specific outcomes. Health Net, based in Woodland Hills, ranked 47 practices on their treatment of asthma patients. The results were sent to members who have asthma, raising the specter that some will opt to leave practices that don’t score well for those that provide above-average care.
Nine groups scored above average, 32 were rated average, and six were below average. Overall, the plan found "poor compliance with established asthma treatment standards." The study also found that specialists provided better care than primary care practices. With a new product that allows patients to go to any plan specialist without a referral for a $30 copayment, practices that don’t provide the best care are even more at risk for losing patients.
Antonio Legorreta, MD, vice president of the Quality Initiatives Division of Health Net’s parent company, Foundation Health Systems, wrote the report. "We strongly believe that providing the opportunity — and the information — that allows members to access the right provider, in the right setting, will help improve the quality of life for many of our members who suffer from several chronic conditions, including asthma."
Over the next nine to 18 months, Legorreta says, other report cards will be implemented and published. Among the chronic conditions surveyed will be diabetes, congestive heart failure, and cardiovascular disease — including hypertension and high cholesterol. Depression treatment will also be rated, he says, but probably using different criteria. Lastly, there will be report cards issued for two acute conditions, breast and prostate cancer.
The initial study ranked groups on quality of care and service measures, as well as outcomes. The care given was compared with practices of the National Asthma Education Program guidelines, and results were published in March 1998 in the Archives of Internal Medicine. Legorreta says that because the study appeared in a peer-reviewed journal, the 40,000 Health Net physicians were more likely to accept the results. He also made sure that the authors included one of their number, as well as an academic institution.
But there were still objections to the project. "Whatever analysis or ranking you do, you will have a bell-shaped curve," he explains, "and to the extent that you have that distribution, there will be a vocal minority against the project, and they tend to be those groups that rank in the lower end. The middle groups aren’t thrilled, but they are pleased they aren’t at the bottom, and those at the top are happy they are above average. But we are empowering patients to make informed decisions about their consumption of health care resources."
Along with providing members with these data so that they can "vote with their feet," says Legorreta, the plan will use the data as a method of determining practice reimbursement rates. "We are committed to using this as a way of determining a significant proportion of reimbursement," he says. "We want 10% or 15% to be attached to this." The plan is working up to that level gradually, starting at half a percent. Currently, about 3% to 4% of reimbursement is based on these performance measures.
"We think this is a positive cycle, that physicians will pay more attention to this kind of system, thus provide us with better data, and then we will be able to fine-tune our measurements."
Legorreta thinks other plans will adopt this kind of report card system as a way to provide the accountability that the government and employers are asking for. "The challenge has always been how to translate the parameters by which we are being made accountable to the physician level," he says. "How do you make it meaningful to physicians without letting it become some antagonistic system? This lets them see the benefits of performing well in a very concrete way."
Another benefit of the data collected, he says, is a verification of otherwise anecdotal information. "If you ask physicians in the community, they have a sense of which are the good medical groups and which are not. The reality is that the answers we got from these data are consistent with that anecdotal information. That’s gratifying."
• Antonio Legorreta, MD, Vice President, Quality Initiatives Division, Foundation Health Systems, Woodland Hills, CA. Telephone: (818) 676-6819.