Exercising purchasing power for preventive care

Assessing PPO Performance on Prevention and Population Health

This article compares preferred provider organization (PPO) and health maintenance organization (HMO) performance on the utilization of and consumer satisfaction with preventive care. Surveys were conducted of California health plans, employers, and the insured population collected between 1996 and 1999. The authors found that PPOs were less likely than HMOs to cover some types of preventive care. PPO enrollees were less likely than HMO enrollees to receive blood pressure and mammography screenings or preventive counseling on gun safety, smoking, and sexually transmitted disease or HIV prevention. PPO enrollees were less satisfied with preventive care than HMOs enrollees. The authors concluded that there are significant differences between the rates at which preventive care is delivered in PPOs and HMOs, which can be understood in the context of PPO benefit plan design, and differences in their structural and financial characteristics. This suggests specific strategies through which it might be possible to improve preventive health care and promote population health among employees enrolled in PPOs.

Assessing PPO Performance on Prevention and Population Health

This article compares preferred provider organization (PPO) and health maintenance organization (HMO) performance on the utilization of and consumer satisfaction with preventive care. Surveys were conducted of California health plans, employers, and the insured population collected between 1996 and 1999. The authors found that PPOs were less likely than HMOs to cover some types of preventive care. PPO enrollees were less likely than HMO enrollees to receive blood pressure and mammography screenings or preventive counseling on gun safety, smoking, and sexually transmitted disease or HIV prevention. PPO enrollees were less satisfied with preventive care than HMOsenrollees. The authors concluded that there are significant differences between the rates at which preventive care is delivered in PPOs and HMOs, which can be understood in the context of PPO benefit plan design, and differences in their structural and financial characteristics. This suggests specific strategies through which it might be possible to improve preventive health care and promote population health among employees enrolled in PPOs.

The association between improved quality diabetes indicators, health outcomes and costs: towards constructing a "business case" for quality of diabetes care--a time series study

BACKGROUND

In primary health care systems where member's turnover is relatively low, the question, whether investment in quality of care improvement can make a business case, or is cost effective, has not been fully answered.The objectives of this study were: (1) to investigate the relationship between improvement in selected measures of diabetes (type 2) care and patients' health outcomes; and (2) to estimate the association between improvement in performance and direct medical costs.

METHODS

A time series study with three quality indicators - Hemoglobin A1c (HbA1c) testing, HbA1C and LDL- cholesterol (LDL-C) control - which were analyzed in patients with diabetes, insured by a large health fund. Health outcomes measures used: hospitalization days, Emergency Department (ED) visits and mortality. Poisson, GEE and Cox regression models were employed. Covariates: age, gender and socio-economic rank.

RESULTS

96,553 adult (age >18) patients with diabetes were analyzed. The performance of the study indicators, significantly and steadily improved during the study period (2003-2009). Poor HbA1C (>9%) and inappropriate LDL-C control (>100 mg/dl) were significantly associated with number of hospitalization days. ED visits did not achieve statistical significance. Improvement in HbA1C control was associated with an annual average of 2% reduction in hospitalization days, leading to substantial reduction in tertiary costs. The Hazard ratio for mortality, associated with poor HbA1C and LDL-C, control was 1.78 and 1.17, respectively.

CONCLUSION

Our study demonstrates the effect of continuous improvement in quality care indicators, on health outcomes and resource utilization, among patients with diabetes. These findings support the business case for quality, especially in healthcare systems with relatively low enrollee turnover, where providers, in the long term, could "harvest" their investments in improving quality.

Support for Smoking Cessation Interventions in Physician Organizations

OBJECTIVES

To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support.

METHODS

This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%.

RESULTS

Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization.

CONCLUSION

Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

Cost-benefit analysis of a new HEDIS performance measure for pneumococcal vaccination

OBJECTIVES

Measurement of the quality of care provided by managed care organizations (MCOs) has achieved national prominence, though there is controversy regarding its value. This article assesses the economic implications of a new Health Plan Employer Data and Information Set (HEDIS) measure for pneumococcal vaccination.

METHODS

A Markov decision model, with Monte Carlo simulations, was utilized to conduct a cost-benefit analysis of annual HEDIS-associated interventions, which were repeated for 5 consecutive years, in an average Medicare MCO, using a societal perspective and a 3% annual discount rate.

RESULTS

Compared with the status quo, the HEDIS intervention will be cost saving 99.8% of the time, with an average net savings of $3.80 per enrollee (95% probability interval: $0.73-$6.87).

CONCLUSIONS

The new HEDIS measure will save societal dollars. This type of analysis is essential if performance measurement is to become a legitimate part of our health care landscape.

Integrating occupational health services and occupational prevention services

BACKGROUND

Despite the human and monetary costs of occupational injury and illness, occupational health care has focused more on treatment than prevention, and prevention is not part of many clinical occupational health practices. This represents a failure of occupational health care to meet the health care needs of the working patients.

METHODS

MEDLINE searches were conducted for literature on occupational medical treatment and the prevention of occupational injury and illness were reviewed to for linkages between prevention and treatment. Policy discussions which identify examples of programs that integrated prevention and treatment were included.

RESULTS

Although examples of the integration of clinical and preventive occupational health services exist, there are challenges and barriers to such integration. These include inaction by clinicians who do not recognize their potential role in prevention; the absence of a relationship between the clinician and an employer willing to participate in prevention; economic disincentives against prevention; and the absence of tools that evaluate clinicians on their performance in prevention.

CONCLUSIONS

Research is needed to improve and promote clinical occupational health preventive services.

Consumer reports in health care: do they make a difference?

The public release of health care-quality data into more formalized consumer health report cards is intended to educate consumers, improve quality of care, and increase competition in the marketplace The purpose of this review is to evaluate the evidence on the impact of consumer report cards on the behavior of consumers, providers, and purchasers. Studies were selected by conducting database searches in Medline and Healthstar to identify papers published since 1995 in peer-review journals pertaining to consumer report cards on health care. The evidence indicates that consumer report cards do not make a difference in decision making, improvement of quality, or competition. The research to date suggests that perhaps we need to rethink the entire endeavor of consumer report cards. Consumers desire information that is provider specific and may be more likely to use information on rates of errors and adverse outcomes. Purchasers may be in a better position to understand and use information about health plan quality to select high-quality plans to offer consumers and to design premium contributions to steer consumers, through price, to the highest-quality plans.

Expanding health insurance coverage for smoking cessation treatments: experience of the Pacific Business Group on Health

The business case for health insurance coverage of smoking cessation treatments by employers is a strong one. Smoking is one of the nation's costliest health problems, in both human and financial terms. The science behind smoking cessation treatment and promotion of treatment is strong; the cost effectiveness of smoking cessation treatment is among the highest in all of medicine, the time required before a positive return on investment is reasonable for employers, and the short-term costs of treatments are well estimated and manageable for health plans and employers. Armed with this business case, the PBGH Negotiating Alliance has expanded health insurance to include pharmacotherapy, over the counter or by prescription, and behavioral interventions. Because PBGH has been a national leader, we hope that other employers, employer coalitions, and public purchasers will follow their lead. The potential health effect of even small reductions in smoking are striking, and unlike other chronic illnesses, nicotine addiction is curable, at both individual and societal levels. Thus, if employers make the investment in smoking cessation and other tobacco control today, they face the real possibility that the need for such outlays could decrease in the future.

Employers: quality takers or quality makers?

This article provides a synthesis of past research to help understand the extent to which employers are using their considerable market power to drive health care quality. Are employers quality takers or quality makers? The literature provides some clues about aspects of quality employers are attempting to influence, strategies they are pursuing to influence quality, and their impact. Some employers are interested in some indicators of quality and are incorporating them in a variety of different purchasing strategies. The indicators most frequently used by employers, however, probably are not the ones that clinical experts and policy makers would select as most reflective of clinical quality. It appears that employers as a group are becoming more informed quality takers but are not yet quality makers--with the exception of a few well-resourced outliers. Recent events provide mixed signals about whether the future employer role in influencing quality will diminish, stall, or flourish.

The social roles of Medicare: assessing Medicare's collateral benefits

The Medicare program incorporates a number of functions that go beyond providing health insurance to its beneficiaries. These activities, which we refer to as "collateral" functions, may have important health consequences but are also an increasing source of controversy. In this essay we develop a conceptual framework for categorizing these involvements, introduce some additional options that might complement Medicare's current collateral functions, assess the reaction of policy elites and Medicare's current beneficiaries to these alternatives, and evaluate the role that collateral activities play for Medicare's core mission. A case can be made for expanding some collateral involvements, but only if the Health Care Financing Administration has the strategic direction and administrative capacity to effectively implement these activities.

The limitations and promise of health education in managed care

Managed care has become the predominant form of health insurance in the United States. With its features of capitation, provider monetary risk, and population perspective, managed care represents a huge growth opportunity for advocates of disease prevention and health promotion, including those in the field of health education. In reality, however, health education's role has fallen far short of expectations. This article is presented to initiate a dialogue on the role of health education and its subset, worksite health promotion, within managed care. The worksite is emphasized because of its attractiveness as a site in delivering population-based medicine. Furthermore, employers exercise considerable influence in shaping the health care marketplace. A list of recommendations is presented, offering suggestions on what health education needs to do to increase its impact in the managed care movement. These arguments are posed to better position this profession in a changing health care environment.

Organizational interventions to encourage guideline implementation

Evidence-based guidelines hold considerable promise for continued improvement of health-care delivery. However, the availability of clinical practice guidelines does not automatically lead to changes in practice patterns. Using a "push-pull-capacity" model, this article describes strategies to improve guideline implementation for three types of organizations: national organizations, insurer and health-care organizations, and health-care purchasers. Push strategies focus on the guideline development process and include rigorous review and meta-analysis of peer-reviewed research, and use of multidisciplinary expert teams, subjecting guidelines to peer review and comment and using measurable clinical outcomes to define guidelines. PULL: strategies focus on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives in purchaser contracts and physician compensation agreements. Capacity strategies focus on systems that facilitate guideline implementation. Example strategies are providing benefit coverage and reimbursement for guideline-based treatment protocols, and implementing clinical information systems for population-based tracking, outcomes monitoring, and benchmarking feedback.

The geography of health insurance regulation

The health insurance market consists of three distinct segments--individual, small group, and large group--each governed by different economic and regulatory structures. A number of border-crossing techniques have arisen for avoiding the burdens of one segment and capitalizing on the benefits of others. Drawing from extensive qualitative research into the functioning of existing market structures, this paper describes these techniques and their purposes and effects. This road map helps to identify which reform proposals seek to produce true economic efficiencies and which have the potential to undermine previous reform objectives.

The role of the health care system in primordial prevention

The health care system has the resources to assume an important role in primordial prevention. The extent to which it does so will be determined largely by the financial and economic forces that are transforming the health care system. There is reason to be optimistic about the effectiveness of a partnership between community-based organizations and medical centers in addressing the challenges of primordial prevention in the 21st century.

Policy tools for building health education and preventive counseling into managed care

Six policy tools for building health education and preventive counseling into managed care are presented, and the opportunities and barriers to implementing each are described based largely on managed care plans operating in California in 1998. The six policy tools include (1) covering health education and preventive counseling as defined benefits, (2) increasing access to and use of health promotion programs, (3) incorporating health education into disease-management programs, (4) defining quality performance measures for health education and preventive counseling, (5) defining performance targets and guarantees for health education and preventive counseling to hold health plans accountable for providing these services, and (6) building collaboration between public health agencies and managed care on public health education and health promotion. For each of these, the policy option is described, examples of current practice are provided, and the problems and limitations associated with each are discussed.

Cost-sharing and the utilization of clinical preventive services

BACKGROUND

Little is known about the effect of different forms of patient cost-sharing on the utilization of clinical preventive services or if the effect varies by type of health plan.

OBJECTIVES

To assess empirically the relationships between the utilization of recommended preventive services and different forms of patient cost-sharing and how the effect is mediated by type of preventive service (counseling, blood pressure, Pap smear, mammogram), type of cost-sharing (deductibles/coinsurance, copayments), and type of health plan (HMO, PPO/indemnity plan).

RESEARCH DESIGN

Sixteen logit models were estimated to assess variation in receiving recommended preventive care as a function of cost-sharing within plan type.

SUBJECTS

A sample of 10,872 employees, aged 18 to 64 years, of seven large companies served by 52 health plans with diverse cost-sharing arrangements who responded to the Pacific Business Group on Health, Health Plan Value Check Survey (response rate, 50.3%).

MEASURES

Receipt of recommended preventive care was based on the U.S. Preventive Services Task Force Guidelines. The effect of cost-sharing was measured as the percentage change in the probability of receiving recommended preventive care in the cost-sharing group compared to the non cost-sharing group.

RESULTS

The negative effect of patient cost-sharing was greatest on preventive counseling in PPO/indemnity plans (-15%) and on mammograms in all health plan types (-9%-10%). The effect on Pap smears was negative (-8%-10%) for deductibles/coinsurance in PPO/indemnity plans and copayments in HMOs. The effect of cost-sharing on blood pressure was mixed. Deductibles/coinsurance had a greater negative effect than copayments.

CONCLUSIONS

Eliminating patient cost-sharing for selected preventive services may be a relatively easy and effective means of increasing utilization of recommended clinical preventive care.

Health Education's Contributions to Public Health in the Twentieth Century: A Glimpse Through Health Promotion's Rear-View Mirror

A lesson of the first half of the century was that growth and technological development brought new health problems and challenges in their wake, many of which were to prove more intractable to technological fixes than the ones that had been so dramatically fixed before. Massive expansions of resources in support of the extension of these medical fixes resulted in an escalation of costs that had to be reigned in by breaking from the resource-based planning cycle that had prevailed through two eras of expansion. The 1970s ushered in an era of cost containment as the central theme of new policies. They included provisions for health promotion that sought to find new handles on the intractable social and behavioral aspects of the demand for health care resources, especially through primary prevention and building of capacity for community, family, and individual self-management of health problems and programs. Lessons from this era for public health in the next century are considered.

Raising the bar: the use of performance guarantees by the Pacific Business Group on Health

In 1996 the Pacific Business Group on Health (PBGH) negotiated more than two dozen performance guarantees with thirteen of California's largest health maintenance organizations (HMOs) on behalf the seventeen large employers in its Negotiating Alliance. The negotiations put more than $8 million at risk for meeting performance targets with the goal of improving the performance of all health plans. Nearly $2 million, or 23 percent of the premium at risk, was refunded to the PBGH by the HMOs for missed targets. The majority of plans met their targets for satisfaction with the health plan and physicians, as well as cesarean section, mammography, Pap smear, and prenatal care rates. However, eight of the thirteen plans missed their targets for childhood immunizations, refunding 86 percent of the premium at risk.

Medicaid managed care and public health data

In summary, there are a number of ways in which state public health data can be of value in the design of Medicaid managed care plans. At the level of the purchaser, such as a state Medicaid agency, public health data can assist in decision-making around pricing policy and can be useful in prioritizing interventions for those conditions that most severely affect the covered population. Quality assurance standards such as the HEDIS clinical performance measures can be used to define a baseline of prevention-oriented services or, by adding additional customized data points, to emphasize a particular service. From the standpoint of the managed care plan, public health data can be useful in understanding the needs of a community it serves or would like to serve and in estimating the prevalence of various conditions in that community that will influence the premium it will charge. Thus, there are multiple routes through which public health goals and priorities can be incorporated into managed care and can leverage the power of managed care to improve the public's health.

Prevention of sexually transmitted diseases. A model for overcoming barriers between managed care and public health. The IOM Workshop on the Role of Health Plans in STD Prevention

CONTEXT

The growth of managed care has spurred re-evaluation of the roles and responsibilities of public health agencies and private health plans for providing public health services. Although rates of curable sexually transmitted diseases (STDs) in the United States are the highest in the developed world, many clinicians and managed care organizations are not systematically providing high-quality, comprehensive STD-related services to their patients and the community.

OBJECTIVE

To examine issues around managed care and STD prevention as a model for overcoming barriers that impede managed care organizations from providing comprehensive public health services and collaborating with health agencies.

SETTING

Two-day invitational workshop.

PARTICIPANTS

Representatives from 18 health plans, 10 public health agencies, 6 academic institutions, 1 purchasing coalition, and 5 other health organizations.

RESULTS

Major obstacles include: turnover and heterogeneity in the health care system; deficiencies in clinical knowledge and skills; differences in organizational culture and language; low priority of STDs; inadequate public health surveillance data and performance measures; confidentiality concerns; and lack of coverage for sex partners.

CONCLUSIONS

Potential approaches for addressing these barriers include: requiring that STD-related services be covered by Medicaid managed care programs; implementing performance measures; requiring collaborative activities; promoting education of and outreach to stakeholders; funding of pilot projects; and researching the cost-benefit and cost-effectiveness of STD-related services for various populations.

Creating systems of developmental health care for children

The value of innovation must be measured against the costs, financial and political, associated with changing the current employer-based insurance system and the Medicaid, Title V, Title XXI/SCHIP, and other federal and state programs that supplement it. Although imperfect, this system still provides most children with insurance, and in the near term, it will need to continue to do so. Administrators, child advocates, and politicians understand how it works and how to make it work for many children. Yet, no close observer of the children's health “nonsystem” can escape the uneasy awareness that uninsurance, access barriers, and inadequate benefit packages and a lack of attention to developmental monitoring and services continue to constitute serious problems, particularly for lower-income children. However, many of the very trends and forces that complicate and are undermining the current children's health care system may suggest the potential shape of solutions. For example, the desire of payers to control costs and the consequent growth of large integrated managed-care organizations that focus primarily on cost control issues also has created new opportunities to improve quality. The key to quality improvement seems to be the improved measurement and evaluation techniques that more-integrated organizations can potentially bring to bear on developmental health. Another key to a more developmental approach to health is the creation of community oversight mechanisms, possibly in the form of outcomes trusts or health insurance purchasing cooperatives, that allocate funding for services based on a larger vision of developmental health outcomes. To do this, communities will first need to develop a vision of developmental health and then to begin to create the outcomes trusts that can coordinate the full range of services needed to promote developmental health. As communities develop a shared vision of developmental and contextual health promotion, the contemporary emergence of integrated managed-care organizations may ultimately prove to have been a necessary precursor to more-comprehensive “three-dimensionally” integrated systems of developmental health care for all children.

A broader vision for managed care, Part 1: Measuring the benefit to communities

For the past quarter-century managed care plans have been judged almost exclusively in terms of their influence on the health and health care of individual enrollees. However, policymakers are now paying attention to the ways in which health care organizations affect the broader well-being of their communities. These forms of "community benefit" emerged originally from legal criteria for tax exemption but are increasingly applied to all health care organizations, whatever their form of ownership. In this paper we identify different paradigms for defining community benefit and trace the factors that have encouraged or discouraged their application to health care. We suggest several strategies encouraging managed care plans to broaden their goals to include community benefit.