Are characteristics of the medical home associated with diabetes care costs?

OBJECTIVE: To examine the relationship between primary care medical home clinical practice systems corresponding to the domains of the Chronic Care Model and annual diabetes-related health care costs incurred by members of a health plan with type-2 diabetes and receiving care at one of 27 Minnesota-based medical groups. STUDY DESIGN: Cross-sectional analysis of the relation between patient-level costs and Patient-Centered Medical Home (PCMH) practice systems as measured by the Physician Practice Connections Readiness Survey. METHODS: Multivariate regressions adjusting for patient demographics, health status, and comorbidities estimated the relationship between the use of PCMH clinical practice systems and 3 annual cost outcomes: total costs of diabetes-related care, outpatient medical costs of diabetes-related care, and inpatient costs of diabetes-related care (ie, inpatient and emergency care). RESULTS: Overall PCMH scores were not significantly related to any annual cost outcome; however, 2 of 5 subdomains were related. Health Care Organization scores were related to significantly lower total (P=0.04) and inpatient costs (P=0.03). Clinical Decision Support was marginally related to a lower total cost (P=0.06) and significantly related to lower inpatient costs (P=0.02). A detailed analysis of the Health Care Organization domain showed that compared with medical groups with only quality improvement, those with performance measurement and individual provider feedback averaged $245/patient less. Medical groups with clinical reminders for counseling averaged $338/patient less. CONCLUSIONS: Certain PCMH practice systems were related to lower costs, but these effects are small compared with total costs. Further research about how these and other PCMH domains affect costs over time is needed.

Adherence to standards of care by health maintenance organizations in Israel and the USA.

BACKGROUND: The health-care systems in the USA and Israel differ in organization, financing and expenditure levels. However, managed care organizations play an important role in both countries, and a comparison of the performance of their community-based health plans could inform policymakers about ways to improve the quality of care. OBJECTIVE: To compare the adherence to standards of care in Israel and in the USA. STUDY DESIGN: An observational study comparing trends in performance using data from reports of the National Quality Measures Program in Israel and of the National Committee for Quality Assurance in the USA. RESULTS: Differences in specifications preclude a comparison between most measures in the two reports. However, the comparison of 11 similar measures in the 2007 reports indicates that performance was higher in the USA by 10 or more percentage points on four measures (flu immunization, medication for asthma, screening for colorectal cancer and monitoring for diabetic nephropathy). Performance was higher in Israel on three measures in patients with diabetes (blood pressure, low-density lipoprotein (LDL) cholesterol and glycemic control), and similar on the remaining four measures. Between 2005 and 2007, quality of care improved in both countries. However, improvement was slower in the USA than in Israel. CONCLUSIONS: In comparison with the USA, Israel achieves comparable health maintenance organization (HMO) quality on several primary care indicators and more rapid quality improvement, despite its substantially lower level of expenditure. Considering the differences between the two countries in settings and populations, further research is needed to assess the causes, generalizability and policy implications of these findings.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes.

BACKGROUND: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. OBJECTIVE: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. RESEARCH DESIGN: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data. SUBJECTS: This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). MEASURES: Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001-2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. RESULTS: Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). CONCLUSIONS: This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Improving the reliability of physician performance assessment: identifying the "physician effect" on quality and creating composite measures.

BACKGROUND: The proliferation of efforts to assess physician performance underscore the need to improve the reliability of physician-level quality measures. OBJECTIVE: Using diabetes care as a model, to address 2 key issues in creating reliable physician-level quality performance scores: estimating the physician effect on quality and creating composite measures. DESIGN: Retrospective longitudinal observational study. SUBJECTS: A national sample of physicians (n = 210) their patients with diabetes (n = 7574) participating in the National Committee on Quality Assurance-American Diabetes Association's Diabetes Provider Recognition Program. MEASURES: Using 11 diabetes process and intermediate outcome quality measures abstracted from the medical records of participants, we tested each measure for the magnitude of physician-level variation (the physician effect or "thumbprint"). We then combined measures with a substantial physician effect into a composite, physician-level diabetes quality score and tested its reliability. RESULTS: We identified the lowest target values for each outcome measure for which there was a recognizable "physician thumbprint" (ie, intraclass correlation coefficient > or =0.30) to create a composite performance score. The internal consistency reliability (Cronbach's alpha) of the composite score, created by combining the process and outcome measures with an intraclass correlation coefficient > or =0.30, exceeded 0.80. The standard errors of the composite case-mix adjusted score were sufficiently small to discriminate those physicians scoring in the highest from those scoring in the lowest quartiles of the quality of care distribution with no overlap. CONCLUSIONS: We conclude that the aggregation of well-tested quality measures that maximize the "physician effect" into a composite measure yields reliable physician-level quality of care scores for patients with diabetes.

Measuring practice systems for chronic illness care: accuracy of self-reports from clinical personnel.

BACKGROUND: Purchasers, plans, and clinical practices involved in quality improvement initiatives are increasingly interested in measuring practice systems, particularly in relation to clinical quality and as part of pay-for-quality initiatives. The validity of self-reports of the use of practice systems was examined. METHODS: In 11 medical groups in Minnesota, the Physician Practice Connections Readiness Survey, which was developed on the basis of the concepts and evidence base of the Chronic Care Model, was used to survey office practice personnel about practice systems. Participation rates by medical group ranged from 61% to 94%, with a mean of 76%, yielding surveys from 32 lead physicians and 241 other personnel. Survey results were compared with an on-site audit by trained surveyors. RESULTS: Overall agreement with the on-site audit ranged from 40.9% to 96.7% among lead physicians and from 33.9% to 81.9% among other personnel. Mean agreement was high for quality improvement (96.7% for lead physicians and 81.9% for other personnel), moderate for clinical information systems (71.2% for lead physicians and 66.0% for others), and low for the use of care management (less than 50% for both groups). Mean positive predictive value ranged from 55.2% to 100% among lead physicians and from 49.6% to 100% among other personnel. Both the presence of systems and the accuracy of reporting varied across medical groups. DISCUSSION: The accuracy of self-reports of practice systems varies by type of system being assessed and by type of respondent. Although self-assessment may be useful for quality improvement purposes, self-reported information on clinical practices systems should not be used for accountability purposes, including pay-for-quality efforts or public reporting unless additional documentation is required to ensure fair comparisons.

Management of urinary incontinence in Medicare managed care beneficiaries: results from the 2004 Medicare Health Outcomes Survey.

BACKGROUND: Despite the high prevalence of urinary incontinence (UI) among older persons and the existence of effective treatments, UI remains underreported by patients and underdiagnosed by clinicians. We measured the occurrence of UI problems in Medicare managed care beneficiaries, frequency of physician-patient communication regarding UI, and frequency of UI treatment. METHODS: We used cross-sectional data from the 2004 Medicare Health Outcomes Survey, which measured self-reported UI (accidental leakage of urine) and UI problems in the past 6 months, 36-Item Short-Form Health Survey health measures, discussions of UI with a health care provider, and receipt of UI treatment. RESULTS: The overall incidence of UI within the past 6 months was 37.3%, consistent with previous estimates. Problems with UI were strongly associated with poorer self-reported health. Mean 36-Item Short-Form Health Survey physical and mental health scores were lower by more than 5 points (on a 100-point scale, P<.001) for respondents with major UI problems when controlling for age, sex, race, Hispanic ethnicity, and major comorbidities. These differences were among the largest of any condition measured. Only 55.5% of those with self-reported UI problems reported discussing these problems during their recent visit to a physician or other health care provider. The rate of patient-reported UI treatment was 56.5% and was lower (P<.001) for older individuals (eg, 46.3% for those aged 90-94 years) or those with poor self-reported health status (50.5%). CONCLUSIONS: Among older persons, UI is common, underdiagnosed, and associated with substantial functional impairment. There appears to be considerable opportunity to mitigate the effects of UI on health and quality of life among community-dwelling older persons.

Quality of care in Medicaid managed care and commercial health plans.

CONTEXT: In contrast to the commercially insured population, the proportion of Medicaid beneficiaries enrolling in health maintenance organizations continues to increase. OBJECTIVE: To compare quality of care within and between the Medicaid and commercial populations in 3 types of managed care plans: Medicaid-only plans (serving predominantly Medicaid enrollees), commercial-only plans (serving predominantly commercial enrollees), and Medicaid/commercial plans (serving substantial numbers of both types of enrollees). DESIGN, SETTING, AND PARTICIPANTS: All 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003, including 204 commercial-only plans, 142 Medicaid/commercial plans (plans reported data for the Medicaid and commercial populations separately); and 37 Medicaid-only plans. MAIN OUTCOME MEASURES: Eleven quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) applicable to the Medicaid population. RESULTS: Among Medicaid enrollees, performance on the 11 measures observed in this study were comparable for Medicaid-only plans and Medicaid/commercial plans. Similarly, among commercial enrollees, there was virtually no difference in performance between health plans that served only the commercial population and those that also served the Medicaid population. Overall across all health plan types, the performance for the commercial population exceeded the performance for the Medicaid population on all measures except 1, ranging from a difference of 4.9% for controlling hypertension (58.4% for commercial vs 53.5% for Medicaid; P = .002) to 24.5% for rates of appropriate postpartum care (77.2% for commercial vs 52.7% for Medicaid; P = .001). Differences of similar magnitude were observed for commercial and Medicaid populations treated within the same health plan. CONCLUSIONS: Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees. There were no differences in quality of care for the Medicaid population between Medicaid-only plans and commercial plans that also served the Medicaid population.

The role of accreditation in an era of market-driven accountability.

Accreditation has been widely used to promote accountability in healthcare. However, with the rise of both purchaser and consumer demand for broader and more detailed information on performance beyond licensure and professional self-regulation, especially at the provider level, the role of accreditation is less clear. We hypothesize that for accreditation to be a critical part of a market-driven, consumer-focused healthcare system, accrediting bodies must enlarge their scope of assessment with an emphasis on clinical performance of providers, revise and expand their level of reporting and transparency of assessment, and broaden the base of their governance. A new approach to accreditation could enhance accountability by (1) building on an existing framework and data-collection structure that are proven elements of quality assurance in multiple healthcare sectors; (2) expanding existing involvement of both public and private entities in the process; (3) building on existing linkages to professional and regulatory bodies; (4) providing greater flexibility, compared with regulation, in responding to change; and (5) having a defined source of funding. By these means, accrediting bodies will both improve accountability and successfully drive quality improvement.

Practice systems for chronic care: frequency and dependence on an electronic medical record.

OBJECTIVES: To document the presence and functioning of different practice systems in a small sample of medical groups in Minnesota and to examine the relationship between the presence of practice systems and prior adoption of an electronic medical record (EMR). STUDY DESIGN: Descriptive study of the frequency of practice systems in 11 medical groups. METHODS: We recruited 11 medical groups for the study. Four groups had an EMR; the other groups used paper medical records, often supplemented by electronic ordering or data systems. Using an on-site audit team, we validated the presence of practice systems organized under 8 categories. RESULTS: All of the medical groups had implemented a substantial number of practice systems for care management of patients with chronic conditions. Although the medical groups with an EMR tended to have more comprehensive practice systems in place, the medical groups without an EMR also had most of the practice systems. CONCLUSIONS: Although required in some functions, an EMR may not be necessary in facilitating practice systems that support consistent management of patients with chronic illness. Approaches are needed that will encourage the implementation of practice systems in medical groups with and without an EMR.

A comparison of relative resource use and quality in Medicare Advantage health plans versus traditional Medicare.

OBJECTIVES: Prior analyses of Medicare health plans have examined either utilization of services or quality of care, but not both jointly. Our objective was to compare utilization and quality for Medicare Advantage (MA) enrollees with diabetes or cardiovascular disease to that for similarly defined traditional Medicare (TM) beneficiaries. STUDY DESIGN: Cross-sectional matched observational study using data for 2007. METHODS: We obtained individual-level Healthcare Effectiveness Data and Information Set (HEDIS) relative resource use (RRU) and quality data for patients enrolled in MA, and then developed comparable claims-based measures for matched samples of TM beneficiaries. MAIN OUTCOME MEASURES: utilization levels for inpatient care, evaluation and management services, and surgery; number of emergency department (ED) and inpatient visits; and quality of ambulatory care measures. RESULTS: We studied approximately 680,000 MA health maintenance organization (HMO) enrollees with diabetes and 270,000 HMO enrollees with cardiovascular conditions. For both conditions and almost all major strata, the RRU was lower for those enrolled in MA than for those in TM. Spending for those with diabetes was $5223 for MA HMO enrollees compared with $6413 for those in TM (cost ratio, 0.81; P < .001). ED utilization rates were consistently lower in MA than TM (567 vs 719 visits/1000 enrollees; rate ratio, 0.79; P < .001). Health plans that are more established, nonprofit, and/or larger generally had lower resource use and better relative quality than did smaller, newer, for-profit HMOs or preferred provider organizations. CONCLUSIONS: RRU for those with diabetes or cardiovascular disease is lower in MA, while quality of care is higher. Better MA plans may add value to the care of these major chronic medical conditions.

Professionalism, regulation, and the market: impact on accountability for quality of care.

This paper examines the interplay of professionalism, regulation, and the market in shaping accountability on the part of hospitals, physicians, and health plans. We pay particular attention to the role of accreditation. We review the development of accountability and examine its recent evolution in the context of changing information technology, consumer demands, the decline of the staff- and group-model HMO, and the reemergence of health care cost inflation. The market is emerging as the dominant influence on accountability; this development will require changes in the roles and structure of regulation, professionalism, and accreditation in assuring accountability.

Measuring patients' trust in physicians when assessing quality of care.

Trust is a fundamentally important aspect of medical treatment relationships. Studies have established that patient trust predicts instrumental variables such as use of preventive services, adherence, and continued enrollment at least as well as satisfaction does, and is more salient for measuring the quality of ongoing relationships. Measuring trust would help to inform public policy deliberations and balance market forces that threaten the doctor-patient relationship. Several validated measures could be easily included in surveys. While further studies to evaluate the cost-effectiveness of measuring trust and test interventions to improve trust are desirable, the action merits serious consideration.

Standardized health plan reporting in four areas of preventive health care.

PURPOSE: This paper discusses first-year reporting by commercial managed care organizations (MCOs) of new measures in the 2000 Health Plan Employer Data and Information Set (HEDIS). The four measures include screening for chlamydia in young women, controlling blood pressure to <140/90mmHg in patients with hypertension, prescribing appropriate medications for persons with asthma (treatment adherence), and providing counseling to women about managing menopause (survey measure). METHODS: In 2000, some 384 commercial MCOs submitted HEDIS results to the National Committee for Quality Assurance (NCQA). Results of the four new HEDIS measures were linked with audit reports and other health plan data-reporting characteristics collected by NCQA. Performance variables were stratified by MCOs' willingness to report their results publicly, size of enrollment, performance on other (non-first year) HEDIS measures, and data collection issues. RESULTS: The mean average performance on the four measures was lowest in chlamydia screening in women (16% for ages 21 to 26 years) and highest for use of appropriate medications for people with asthma (59% for ages 18 to 56 years). The mean average of controlling high blood pressure was 39%. Scores on the management of menopause (MoM) measure ranged from 33.7 (for rating of information) to 72.6 (for exposure to counseling). CONCLUSIONS: The initial MCO baseline rates reported here suggest that much work is needed to improve the quality of care in these areas. Plan characteristics shown to be associated with higher performance on existing HEDIS measures do not predict performance on the new measures. In addition, fewer plans reported on the new measures than on established HEDIS measures. To ensure continued improvement in chlamydia screening in women, controlling high blood pressure, use of appropriate medications for people with asthma, and MoM, incentives for tracking and reporting on these health issues must be explored.

Malpractice prevention, patient safety, and quality of care: a critical linkage.

There is growing evidence of a negative effect of the current American preoccupation with malpractice on efforts to reduce error, enhance safety, and improve other domains of quality. The use by some insurers of systems assessment and risk analysis programs, linked to rewards for performance--which, taken together, we term proactive risk management--offers an opportunity to enhance our focus on systems and to bring patient safety and malpractice risk reduction into close congruence with other quality improvement efforts. Given the increasing burden of malpractice, as well as the emerging concerns about patient safety, managed care organizations and their providers need to work together with malpractice insurers and quality improvement experts to refocus their efforts on creating systems improvement; driving measurement, analysis, and feedback; and developing incentives for performance that will align quality and risk management efforts and drive breakthroughs in quality, including patient safety.

The evolving role of physician organizations in quality related activities.

As the fields of quality assessment and improvement become integral parts of medical practice, the roles of National Medical Associations, and other physician organizations in these endeavors have undergone major changes in scope and intensity as well. The survey based report in this journal by Levi et al. suggests some major overall trends but also notes wide variation from country to country. In this commentary, we touch on some likely reasons for the variation seen in the focus of physician organization participation in quality activities, and offer some suggestions for why expanded involvement by physician organizations may be critical to quality efforts going forward.

Seeking lower prices where providers are consolidated: an examination of market and policy strategies.

The ongoing consolidation between and among hospitals and physicians tends to raise prices for health care services, which poses increasing challenges for private purchasers and payers. This article examines strategies that these purchasers and payers can pursue to combat provider leverage to increase prices. It also examines opportunities for governments to either support or constrain these strategies. In response to higher prices, payers are developing new approaches to benefit and network design, some of which may be effective in moderating prices and, in some cases, volume. These approaches interact with public policy because regulation can either facilitate or constrain them. Federal and state governments also have opportunities to limit consolidation's effect on prices by developing antitrust policies that better address current market environments and by fostering the development of physician organizations that can increase competition and contract with payers under shared-savings approaches. The success of these private- and public-sector initiatives likely will determine whether governments shift from supporting competition to directly regulating payment rates.

Physician professionalism and accountability: the role of collaborative improvement networks.

The medical profession is facing an imperative to deliver more patient-centered care, improve quality, and reduce unnecessary costs and waste. With significant unexplained variation in resource use and outcomes, even physicians and health care organizations with "the best" reputations cannot assume they always deliver the best care possible. Going forward, physicians will need to demonstrate professionalism and accountability in a different way: to their peers, to society in general, and to individual patients. The new accountability includes quality and clinical outcomes but also resource utilization, appropriateness and patient-centeredness of recommended care, and the responsibility to help improve systems of care. The pediatric collaborative improvement network model represents an important framework for helping transform health care. For individual physicians, participation in a multisite network offers the opportunity to demonstrate accountability by measuring and improving care as part of an approach that addresses the problems of small sample size, attribution, and unnecessary variation in care by pooling patients from individual practices and requiring standardization of care to participate. For patients and families, the model helps ensure that they are likely to receive the current best evidence-based recommendation. Finally, this model aligns with payers' goals of purchasing value-based care, rewarding quality and improvement, and reducing unnecessary variation around current best evidenced-based, effective, and efficient care. In addition, within the profession, the American Board of Pediatrics recognizes participation in a multisite quality improvement network as one of the most rigorous and meaningful approaches for a diplomate to meet practice performance maintenance of certification requirements.

Multiple risk factors and the likelihood of patient-physician communication and health maintenance services in medicare health plans.

This study examined both individual and combined effects of race, education, and health-based risk factors on health maintenance services among Medicare plan members. Data were from 110 238 elderly completing the 2006 Medicare Health Outcomes Survey. Receipt of recommended patient-physician communication and interventions for urinary incontinence, physical activity, falls, and osteoporosis was modeled as a function of risk factors. Low education decreased the odds of receiving services; poor health increased odds. Race had little effect. Evidence suggested moderation among competing effects. While clinicians target services to most at-risk elderly individuals, patients with low education experience gaps. Synergies among co-occurring risks warrant further research.

Medicare beneficiaries more likely to receive appropriate ambulatory services in HMOs than in traditional medicare.

With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and older Medicare HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. Our results suggest that the positive effects of more-integrated delivery systems on the quality of ambulatory care in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments.

Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.

Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.