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When Dennis Scanlon, PhD, studied health plans and their quality improvement initiatives, he found a wide discrepancy in the types and intensity of projects implemented by the various plans.
"Everybody says they’re focusing on quality improvement and disease management, but I found a significant amount of variation among the health plans I studied," says Scanlon, assistant professor of health policy and administration at Pennsylvania State University and lead author of a study on what health plans were doing to improve the quality of care for enrollees.
For instance, take diabetes care. At the low end of the spectrum, the diabetes disease management program for some health plans consisted of sending their physicians the American Association of Diabetes guidelines in the mail.
"They may call this quality improvement, but they’re not really doing much to focus on quality," he says.
On the other end of the scale, Scanlon found some health plans with case managers who are nurses trained in diabetes care, who pinpoint the diabetics in the plan and reach out with a telephone call to get them enrolled in a formal disease management program.
These programs often included patient education on how to self-monitor, setting up a relationship with a primary care physician, and making sure that the screenings, eye and foot examinations diabetic patients need are ordered by the physician.
"Health plans do appear to be involved. They’re not just saying they have case managers who focus on disease management but they have coordinated programs," Scanlon says.
While HMOs are measuring and reporting performance, the first step in quality improvement, not all plans are equally effective in assuring that their members receive high quality care, he adds.
Scanlon’s message to health care insurers is: Take your job seriously and understand what the state of the art is in chronic care and disease management. If the care you’re providing isn’t up to snuff, you need to change and improve, he adds.
"This trickles down to the case manager, who hopefully is involved in the decisions about care," Scanlon says.
Documented literature shows that a fraction of primary care physicians are following disease management guidelines when treating their patients, Scanlon says.
"This implies that if you are allowed to go to see whatever doctor you want, there is a chance that your physician might not comply with state-of-the-art recommendations, and that’s troubling," Scanlon says.
Current government efforts to expand patients’ access to health care, and the trends among HMOs to increase access to care may not necessarily mean that patients get better care, he asserts.