Health plans are tiny nations, each with a territory to guard. Their medical directors are mandated to protect borders of market differentiation by lowering costs and demonstrating superior outcomes. But regionally and nationally, directors are meeting to share best practice data and protocols, a move encouraged — and in some cases demanded — by purchasers.
Employers, of course, have the market clout to encourage cooperation. But some managed care organizations are beginning to work together on their own to make better medicine. All the medical directors interviewed for this article repeated the same belief: Market differentiation should be based on superior delivery of care, not the quality of care delivered.
"Health plans should not be differentiating based on the quality they provide," says David Gregg, MD, vice president and medical director for health initiatives and business development at HealthPartners, a staff- and network-model HMO based in Minneapolis with about 660,000 covered lives. "Quality care should be the given."
Cooperation among plans to improve the quality of care — by sharing best practice methodologies and data — brings smiles to purchasers, and many want to do whatever they can to encourage it.
"There's a growing group of us that are telling plans a very consistent story: We don't want them competing based on quality or effectiveness of individual providers," says Francois de Brantes, program leader for health care initiatives at General Electric. "They need to cooperate in order to improve the performance of their providers. No single plan has enough critical mass of members in a physician's office or hospital to change the way they provide care, even for a specific set of performance measures. If providers are receiving three different sets of instructions from three different plans on how to collect and report data, it's our experience they will ignore all three."
All HMOs define high or desired quality of care as meeting specific performance standards, but the standards differ. Most plans use aggregate group data collected by accreditation organizations, such as the Health Plan Employer Data and Information Set (HEDIS) measures generated by the National Committee for Quality Assurance. Some health plans have internal measures.
Health plans have different ways of collecting data, and many systems for distributing the data they collect to providers. They should share those methodologies, de Brantes and others say. If they don't share best practice information, employers should go directly to providers and promote what works, some employers assert.
De Brantes, for example, helped develop the Bridges to Excellence program, which launched a pilot project on April 10 that pays doctors in Boston, Cincinnati, and Lexington, Ky., bonuses of up to 10 percent if they prove they are taking better care of cardiovascular and diabetes patients through the use of established guidelines. (For more on this, see "Program Rewards Physicians For Delivering High-Quality Care" (News and Commentary, May 2003.))
Participants include GE, Ford, Verizon, UPS, and several others. "We have a single set of standards that stretches across the board," says de Brantes, "and it should send a clear message to the market, that we're serious about reducing the noise, and confusion."
GE's efforts to get plans to cooperate has met with some resistance, says de Brantes, and some very positive responses. "It's mixed," he says. "Some are very excited and agree with this not-so-simple concept. Others feel threatened, and say the design of their performance measures is their own turf."
When plans do cooperate, the results can be productive. For example, the technology giant Lockheed Martin has about 125,000 employees and nearly a half million beneficiaries in its health plans. The company has been working with plans to improve care for several years (primarily by rewarding demonstrably effective plans with increased business) and is a very active member of the Leapfrog Group, the national employer coalition that encourages patient safety initiatives in hospitals. (See interview with Leapfrog's executive director, Suzanne Delbanco).
In December Lockheed Martin took a novel, unilateral step. It sponsored a forum for its health plan directors to share information on provider compliance with Leapfrog patient safety standards, population management, clinical indicators, and other issues, says John Rust, Lockheed Martin's director of group insurance supplier management. "It's the kind of interaction that hasn't occurred before with our health plans," says Rust. "But I know of several employers, like us, pushing for plans to share data."
The idea for the forum came to Rust as he traveled around the country meeting with medical directors of the approximately two dozen health plans associated with his company. At each site he saw something unique, an innovative and effective way of doing business. An innovation in a plan's claims management processes reduced overall administrative costs, for example, or a pioneering protocol led to a particularly effective means of chronic disease management.
"I kept wondering whether these guys ever talked to each other, whether they'd be willing to," says Rust. "Some of these plans have been competing for a number of years. But many plans are starting to say that sharing data on quality is something they can get behind, that it can make good business sense."
To his surprise, all the medical directors he asked to come to Washington said yes. "I really didn't know whether they'd go for this; they're all pretty busy people, and they're not used to sitting down with each other. But they all were enthusiastic."
The move was an attempt by Lockheed Martin to help improve the way the health care market works, a push to get plans to communicate with each other and with payers to improve the overall quality of care.
"We see this emphasis on encouraging the sharing of data as an investment," says Rust. "The more we go down this road, the more we believe it to be true this is good business. When we get enough information, we'll put the metrics in place to establish whether improving quality creates cost reduction."
One attendee at Lockheed Martin's Washington forum was Jerry Salkowe, MD, senior medical director for quality improvement at MVP Health Care in Schenectady, N.Y.
MVP has about 540,000 covered lives in the Albany area, which includes Schenectady and several other cities. MVP is also part of a coalition of HMOs in northeastern New York named the New York Health Plan Association that has been working for several years to "line up our data, collate our information" on performance measures for diabetes and other chronic diseases, says Salkowe. "The driving force behind all this has been the realization that when it comes to quality, a rising tide raises all boats," he says.
The fact that many of the CEOs of HMOs that participate in the Healthcare Quality Roundtable know each other and trust each other has helped make a significant degree of regional cooperation possible.
"It isn't easy to coordinate data or best practices, even among regional HMOs with similar populations and overlapping networks," he says. "HMOs have different ways of collecting data, so even figuring out the performance on the same docs can be very difficult."
Salkowe spoke to his peers at the Washington forum about physician profiling protocols, especially how to validate the information used to measure physician performance and how to communicate with physicians so "they have trust in what we say." He described the software that MVP Health Care uses to gather and collate individual provider performance data, and how the HMO maintains relationships with the physicians who receive the profiles by sending staff to practices to explicate the profiles.
"One of our strongest assets is the breadth of the reports we develop," says Salkowe. "We produce quality-of-care and utilization profiles on specialists and hospitals, as well as our primary care doctors. We found over time that that's allowed us to flush out common issues across the line, and as a result our PCPs don't feel so picked on."
He cautions that the process is "very resource- and labor-intensive, and we periodically question whether we should be doing something else with our energy, but in the end it is critical that our provider side be completely engaged in a quality improvement effort on our part, and if it is, it's worth the investment."
Salkowe's investment of time and energy at the Washington forum was most definitely appreciated, says Ron Hunt, MD, medical director of Blue Cross Blue Shield of Georgia.
"It was invaluable information," says Hunt. "Sharing that kind of stuff shows we have more in common than differences, that we all place an emphasis on quality improvement and the only real issue is how to get there."
Some plans have been working to get there for several years. HealthPartners and its regional competitors are a good example. Gregg also made a presentation at the forum. He talked about clinical indicators and the work of the Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minn., a collaboration of six regional health care organizations.
"It's an excellent example of how medical groups joined together to organize a coordinated effort at literature reviews and the development of best practices," says Gregg. ICSI provides quality improvement services, such as about 60 sets of clinical guidelines, to 40 medical organizations, including 6,000 physicians in practices ranging from small independent groups to large groups associated with the Mayo Clinic.
Gregg talked to the medical directors about the use of HEDIS data to improve care across medical groups and improve the comfort level of physicians who are asked to report data and are evaluated based on those reports.
"We worked incrementally," says Gregg. "At first our reports were blinded, allowing physicians to measure their performance against others but not reporting individual or group results. Then, three years ago, we unblinded the reports and provided the names of specific care systems. Now, we report this information on a publicly accessible web site. It wasn't always easy, but moving incrementally made a big difference in the degree of acceptability of HEDIS feedback among the doctors."
Other medical directors agree, of course. It's hard to improve the quality of care. But, some say, working together — avoiding HIPAA concerns by concentrating on aggregate data and best practices and avoiding antitrust issues by not sharing market data and contracting information — is a good way to make life easier.
"It's not complicated," says Salkowe. "Our purpose is health care. What is best for the patient is what is best for the plan."