Measuring and reporting managed care performance: lessons learned and new initiatives

Performance measurement has become increasingly popular in the health care delivery system of the United States. Until recently, the hospital was the most commonly scrutinized setting. With the expansion of managed care and the resulting compilation of large administrative databases, interest in performance measurement beyond the hospital setting has increased considerably. In particular, the performance of health maintenance organizations is now being assessed and reported publicly. The performance of individual physicians is also garnering considerable attention. This paper summarizes some of the many developments in performance measurement in managed care. The Health Plan Employer Data and Information Set (HEDIS) is described in the context of the national Report Card Pilot Project and with respect to local report card projects emerging around the United States. The lessons learned are identified, particularly with respect to external auditing of HEDIS data. Finally, the new initiatives of physician profiling and outcomes reporting are discussed.

Satisfaction and choice: a view from the plans

Community-wide surveys have demonstrated that managed care enrollees tend to express higher satisfaction with their health plan if they have been given the opportunity to make a choice between managed care and fee-for-service plans. This DataWatch shows similar results with plan-specific data, even for enrollees whose plan benefits include coverage for out-of-network services. That is, what matters seems to be choice at the time of enrollment, not at the point of service. Further, in the practical application of ranking plans on overall enrollee satisfaction, choice appears to be a more important influence than other factors that may receive attention, including enrollees' health status. We discuss this phenomenon with respect to competition and strategy in the managed care marketplace.

Imapct of a primary care group practice on emergency room utilization at a community hospital

This paper reports the effects on a community hospital's emergency room utilization that were brought about by the development of a primary care group practice. The practice, which has replaced the hospital's traditionally structured outpatient clinics, employs full-time, salaried physicians and provides evening office hours and 24-hour coverage. The primary care group appears to have effected a substantial reduction in pediatric emergency room use. To a lesser extent, utilization by former clinic users among the adult atients was also reduced. These reductions, however, created only modest impact in the context of the hospital's total emergency room use, owed in part to the relatively small size of the patient population who formerly had depended upon the hospital for primary care.

Hospital-based group practice and comprehensive care for children of indigent families

The replacement of a community hospital's pediatric outpatient clinics with a physicians' group practice is described, and the effects of this development on the receipt of services by children of indigent families are analyzed. An expanded patient population, frequent telephone utilization, decreased emergency room use, and satisfactory parental perceptions are found. A comparative measure of effectiveness is obtained from a record review of the preventive care received by infants delivered by the hospital's staff obstetricians. The latter data show the group practice to be more successful than the clinics in initiating and maintaining well-child care in its facility, and in achieving the timed completion of immunizations and screening procedures. The experience indicates an acceptance by low-income families of an outpatient service that emphasizes the physician-patient relationship with limited use of outreach services and nonphysician providers. It also inidicates that such a system of care can be provided to a heterogeneous patient population within the same facility.

An emergency room's patients: their characteristics and utilization of hospital services

Utilization of the emergency room at an urban community hospital is studied in a format designed to accomplish three complementary objectives: 1) to characterize a sample of individual patients, rather than an unweighted sample of visits, 2) to estimate the number of individuals served during a specified period and the magnitude of the relationship between these patients and the utilization of other hospital services, and 3) to introduce the patient's "frequency-of-visit" as an important variable in the analysis of emergency room utilization. Some specific findings are: 1) the vast majority of patients who used the emergency room did so very infrequently; 46,527 visits were made in one year by an estimated 34,286 different patients; 2) an estimated 2,586 patients made three or more visits during the year; a disproportionately large number of these "high-frequency" users were black, low-income, and from inner-city areas; a relatively small percentage of their visits were for accidental injury, 3) approximately 53 per cent of the hospital's inpatient admissions and 68 per cent of the inpatient days were generated by patients who also made at least one emergency room visit during the year studied.

A study of consumer attitudes about health care: the role of the emergency room

Contrary to the traditional role of the emergency room (ER) as a care source for the treatment of urgent medical needs, it is evident that substantial numbers of people now use the ER for the treatment of nonurgent problems. In this paper, we report on public opinion about the role of the ER, the accessibility of medical care, and factors that prompt the use of the ER rather than other sources of care. The data result from a community survey of households (N = 521) in the area of Rochester, New York, representative of a population of about 580,000 people. The findings, which relate ER utilization to source of payment, use of other sources of care, demographic variables, and consumer attitudes illustrate the rationality of the patient's use of ER facilities and reflect the patient's view of the ER as a place to obtain medical treatment when other sources are not available.