Use of performance standards in behavioral health carve-out contracts among Fortune 500 firms

OBJECTIVE

To determine the prevalence and nature of performance standards in specialty managed behavioral healthcare contracts among Fortune 500 companies.

STUDY DESIGN

This was a cross-sectional survey of all companies listed on the Fortune 500 during 1994, 1995, or both.

METHODS

From April 1997 to May 1998 we conducted a mailed survey with phone follow-up. Of the 68% of firms that responded, over one third reported carve-out contracts. The survey focused on whether companies had behavioral health carve-out contracts with specialty vendors and characteristics of these contracts, including the use of performance standards.

RESULTS

More than three quarters of the Fortune 500 companies reporting specialty behavioral healthcare contracts used at least one performance standard. Most common were administrative standards (70.2%) and customer service standards (69.4%). About half of the companies used quality standards, whereas only a third used provider-related standards. Most (58.8%) companies using performance standards also specified financial consequences. Larger Fortune 500 firms were significantly more likely to use performance standards. Risk contracts and contracts that included all covered employees were also more likely to include some categories of standards.

CONCLUSIONS

Administrative and customer service standards may be most common because companies find it easier to specify those standards, especially compared with clinical quality measures. To the extent that employers want to obtain the most value from their behavioral healthcare purchasing, we expect that more will begin to adopt quality standards in their contracts, especially as performance measures become more refined. Reliance on accreditation, however, is an alternative approach for employers.

Public dissemination of provider performance comparisons in the United States

As competition among healthcare providers has increased in the U.S., there has been a rapid growth in the amount of comparative information on provider performance made available to consumers. This availability requires hospitals to have information systems that will allow them to prepare proactively for the public dissemination of comparative performance data. The information contained in provider report cards can be a valuable tool for hospitals to use for internal management and planning.

Lot sampling plans in the measure of quality of care indicators

OBJECTIVE

Application of the lot sampling technique to measure indicators of quality of care on screening activities directed toward women: detection of risk factor for cardiovascular diseases, screening for breast cancer and for cervical cancer.

DESIGN

The sampling plan adopted involved, in each centre, a sample size of 15 and a maximum of four non-compliers that the random sample would tolerate. The binomial distribution was used. This 15-4 sampling plan sets the probability of concluding that an indicator is performing well for a lot or population that has an 80% compliance level at 0.84, keeping the alpha error or provider's risk at 0.16, while those for a population that has a 50% compliance is set at only 0.059, keeping the beta error or consumer's risk at 0.059.

SETTING

Ten primary care centres of the Catalan Health Institute.

PATIENTS

Random sample of all women aged 40-65 years enrolled in each centre.

RESULTS

For indicators of risk factors for cardiovascular disease detection, six out of 10 centres performed well for hypertension and obesity, and five out of 10 centres performed well for hypercholesterolaemia. However, no centre was acceptable either in cervical cancer or breast cancer screening.

DISCUSSION

Rather than seeking to obtain precise estimates, this technique aims to facilitate the decision-making process regarding the quality levels of the indicators examined. Despite some limitations, the technique is a good test for detecting gross departures from stated compliance thresholds. It has several advantages for application in health services: (i) the use of small sample sizes; (ii) the fact that it can detect deficiencies in small areas; and (iii) the simplicity of applying this technique by relying on ready-made tables.

Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services

OBJECTIVE

To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall.

DATA SOURCES/SETTING

Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers.

DESIGN

537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard.

RESULTS

Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use.

CONCLUSION

Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred.

Perceptions of quality of care and the decision to leave a practice

Little is known about how patients' perceptions of quality of care influence behavioral outcomes such as decisions to change the source of their care. We surveyed patients suspected of leaving a primary care internal medicine practice at an urban teaching hospital to examine their reasons for leaving, and to investigate whether decisions to leave were related to perceived quality of care. Of 185 respondents, 27 (15%) had left to follow their doctor to another practice. The other 98 (53%) patients who had left the practice cited reasons such as a change of insurance (51), physician care (31), practice operation (27), parking and transportation (24), physician departure (19), and geographic moves (17). Responses to global assessment items and a physician care rating scale were more closely associated with the decision to leave than were ratings of other specific aspects of care.

Is health care ready for Six Sigma quality?

Serious, widespread problems exist in the quality of U.S. health care: too many patients are exposed to the risks of unnecessary services; opportunities to use effective care are missed; and preventable errors lead to injuries. Advanced practitioners of industrial quality management, like Motorola and General Electric, have committed themselves to reducing the frequency of defects in their business processes to fewer than 3.4 per million, a strategy known as Six Sigma Quality. In health care, quality problems frequently occur at rates of 20 to 50 percent, or 200,000 to 500,000 per million. In order to approach Six Sigma levels of quality, the health care sector must address the underlying causes of error and make important changes: adopting new educational models; devising strategies to increase consumer awareness; and encouraging public and private investment in quality improvement.

Women's perceptions of quality and benefits of postpartum care

Increased competition in the United States has led to increased interest in women's perceptions of their obstetric experience. Family-centered postpartum care (FCPPC) was originated to improve women's perceptions of care quality. This study examined differences in and the hypothesized relationship between quality and beneficence in a group receiving traditional postpartum care (TPPC) and a group receiving FCPPC in a safety-net hospital in West Tennessee. Both groups had high mean quality and beneficence scores; however, the FCPPC group's scores were significantly higher than those of the TPPC group. There was a relationship between quality and beneficence for the combined sample. The findings suggest that nurses should incorporate FCPPC approaches as a means of improving perceived quality and benefits.

Monitoring effectiveness of controlling hospital acquired infections by prevalence surveys

OBJECTIVE

To determine the effectiveness of control measures for hospital acquired infection (HAI) by prevalence studies.

SETTING

National Hospital of Sri Lanka in Colombo (NHSL).

STUDY DESIGN AND METHOD

Two prevalence surveys were undertaken, in October 1994 and in July 1997, after implementing infection control measures. The numbers of patients in the two studies were 2563 and 2865. The subjects were assessed for hospital acquired infection through information obtained from case notes and by discussion with ward nursing and medical staff. The changes in infection control activities during this 3-year period included increasing the number of infection control nurses, educational programs to health care workers at all levels, improvements in disposal of clinical waste, implementing published guidelines for use of antibiotics, cannula-site management and urinary catheter care.

RESULTS

The prevalence of HAI in the hospital decreased significantly (p < 0.0001) from 13.5% in 1994 to 8.7% in 1997. A significant decrease (p < 0.0001) in infection rates was observed in medical wards, but the decrease in surgical wards and the burns unit did not reach statistical significance. The intensive care units showed a weakly significant increase (p < 0.05) of infection rate attributable to the large number of war injured who needed intensive care. The most significant reduction in rates of infection was seen in wound infection (p < 0.001), respiratory infections (p < 0.01) and in cannula site infections (p < 0.001).

CONCLUSION

Implementation of infection control policies can have a significant impact on the prevalence of HAI, and their effectiveness could be measured by repeated prevalence surveys.

Trust in performance indicators?

The 1980s and 90s have seen the proliferation of all forms of performance indicators as part of attempts to command and control health services. The latest area to receive attention is health outcomes. Published league tables of mortality and other health outcomes have been available in the United States for some time and in Scotland since the early 1990s; they have now been developed for England and Wales. Publication of these data has proceeded despite warnings as to their limited meaningfulness and usefulness. The time has come to ask whether the remedy is worse than the malady: are published health outcomes contributing to quality efforts or subverting more constructive approaches? This paper argues that attempts to force improvements through publishing health outcomes can be counterproductive, and outlines an alternative approach which involves fostering greater trust in professionalism as a basis for quality enhancements.

Where in the world are the ambulatory benchmarking data?

If you haven't already been forced to take a hard look at your ambulatory care, increasing payer and patient pressures mean you'll have to soon. Ambulatory care accounts for more than half of U.S. health expenditures and could account for half of average hospital revenue by the year 2000. The most difficult data to find is on physician offices but several proprietary databases offer that information, and a new project from the Accreditation Association for Ambulatory Health Care will focus on collecting it. Some free data are available from state and federal sources, but are not very current, not adjusted in any way, and may take you a while to receive.

1996 peritoneal dialysis--core indicators report

The 1996 Peritoneal Dialysis-Core Indicators Study (PD-CIS) retrospectively reviews a random sample of peritoneal dialysis patients from the United States End-Stage Renal Disease (ESRD) program. Peritoneal dialysis (PD) patients are more likely to have a primary diagnosis of glomerulonephritis, less likely to be of African-American heritage, and are younger than hemodialysis patients. One third of PD patients now perform some form of automated peritoneal dialysis (APD) rather than continuous ambulatory peritoneal dialysis (CAPD). The dialysis prescriptions currently employed do not appear to be based on kinetic principles, and the intensity of dialysis achieved is below the proposed minimal guidelines for 30% of patients. In 1996, the mean dialysis index or wKt/Vurea for CAPD patients was 2.0 +/- 0.5 and was not significantly altered from the 1995 value of 2.1. Eighty-four percent of CAPD patients perform four or fewer exchanges daily, and only 27% of patients have prescriptions using infusion volumes greater than 2 L. Although hematocrits have improved since 1995, 30% of PD patients have a hematocrit below 30%. The mean serum albumin for PD patients is 3.5 g/dL, and 25% of patients have a 6-month average serum albumin value below 3.2 g/dL. In general, the indices monitored as predictive of health and well-being of PD patients afford significant opportunity for improvement.

Use of the therapeutic footwear benefit among diabetic medicare beneficiaries in three states, 1995

OBJECTIVE

To determine the extent to which Medicare provided reimbursement for therapeutic footwear to diabetic Medicare beneficiaries in Washington, Alaska, and Idaho in 1995.

RESEARCH DESIGN AND METHODS

Using inpatient, outpatient, and durable medical equipment claims data, we selected a cohort of diabetic Medicare beneficiaries. Therapeutic footwear claims were identified using a set of billing codes intended only for the diabetes footwear benefit. People at "high risk" or "possibly increased risk" for foot problems who might benefit from therapeutic footwear were identified using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes in any of the databases.

RESULTS

Among 608,804 beneficiaries, 10.2% (62,170) met the inclusion criteria for diabetes. Of the diabetic beneficiaries, 13.0% (8,079) had at least one "high risk" diagnosis, and 14.0% (8,686) had at least one "possibly increased risk" diagnosis. The percentage of diabetic beneficiaries with therapeutic footwear claims was 2.9% among those with diagnoses high risk, 0.7% among those with diagnoses indicating possibly increased risk, and 0.1% among those with no diagnosis from the list. Altogether, only 0.6% of beneficiaries meeting the diabetes case ascertainment criteria had a therapeutic footwear claim in 1995.

CONCLUSIONS

Few diabetic Medicare beneficiaries in Washington, Alaska, and Idaho had claims for reimbursement for therapeutic footwear in 1995. The low utilization of the footwear benefit may represent an important opportunity to improve care for Medicare beneficiaries with diabetes. Further work should be done to characterize the use of the benefit in other regions and to assess whether the low level of usage reflects underutilization.

Resident behaviors and characteristics as determinants of quality of residential care: an observational study

The effects of resident behaviors and resident characteristics on the quantity and quality of care they receive from direct-care staff was examined. Four hundred and fifty-two residents with severe and profound mental retardation and 416 direct care staff members were involved. Naturalistic observations were conducted on direct-care staff behavior, that is, staff-resident initiatives, staff affection, staff communicative behavior, on resident behaviors (i.e., maladaptive, stereotypic, and adaptive behavior, position, attending, and communicative behavior), and on resident characteristics (i.e., gender, age, ambulancy, sensory handicaps, and seizure disorder). By importance, residents' ambulancy/motoric skills, their communicative behavior, and attending behavior accounted for the greatest differences in the quality and quantity of the care they receive from direct-care staff. Given that certain resident characteristics can be ameliorated through training, residents themselves may control, to a certain extent, the care they receive from direct-care staff in residential facilities.

The use of ACE inhibitors for congestive heart failure among Delaware Medicare beneficiaries

The analysis upon which this publication is based was performed under Contract Number 500-96-P603, entitled, Utilization and Quality Control Peer Review Organization for the State of Delaware, as sponsored by the Health Care Financing Administration (HCFA), Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the Health Care Quality Improvement Program initiated by HCFA, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore, required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

Time series monitors of outcomes. A new dimension for measuring quality of care

OBJECTIVES

Despite the popularity of risk-adjusted outcomes as quality of health care indicators, their instability with time and their inability to provide reliable comparisons of small volume providers have raised questions about the feasibility and credibility of using these measures. In this article the authors describe a new analytic strategy to address these problems by examining risk-adjusted mortality with time, "Time Series Monitors of Outcome" (TSMO), and its application to cardiac surgery performed throughout the Department of Veterans Affairs between April 1987 and September 1992.

METHODS

Expected operative mortality for 24,029 patients undergoing coronary artery bypass surgery at all 43 centers performing this procedure was estimated using a logistic regression model to adjust for patient-specific risk factors. The ratio of observed-to-expected operative mortality was calculated for each hospital for each of the 11 6-month periods. Poisson regression models were used to identify high and low outlier hospitals based on significant deviation from the 5.5 year overall mean and/or the individual hospital's trend of observed-to-expected ratios with time.

RESULTS

This method identified four high and one low outlier hospitals based on significant deviations from the overall mean and three upward and seven downward trending outlier hospitals based on significant deviations in trend with time. A significant downward trend in observed-to-expected ratios of 4% per year also was observed for all coronary artery bypass graft procedures performed throughout the Department of Veterans Affairs during the last 5.5 year period.

CONCLUSIONS

Time Series Monitors of Outcome should help reduce misclassification of outliers due to random variation in outcomes as well as provide more reliable comparative information from which to evaluate provider performance.