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HealthBiz: Gaps persist in quality of care

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WASHINGTON, Sep 23, 2004 (United Press International via COMTEX) -- Health plans are doing better on quality-of-care issues but there still are huge gaps in the U.S. system that allow some people to get really good healthcare and others to get poor service. That's the gist of the National Committee for Quality Assurance's annual State of Health Care Quality report issued Thursday.

NCQA poured over performance data from 563 health plans covering 69 million people and found in key quality areas -- blood pressure, cholesterol, diabetes, betablocker treatment -- the plans were making significant improvements -- many areas showing a 4-percentage-point increase or more in quality measures over 2002.

The health plans are doing better but not all of them are reporting, and that goes for the rest of the healthcare system -- hospitals, doctors and other providers.

"The data we have tell a great story -- healthcare quality for some is improving consistently and dramatically," said NCQA President Margaret E. O'Kane. "But we only have data for accountable health plans. Why don't we have performance data for the other 75 percent of the U.S. healthcare system? All types of health plans, hospitals and doctors should report on their performance. How else can we make informed choices?"

O' Kane told a briefing on the report the health plans that are reporting data "really have staked out a road map for the rest of the system in what has not been "a friendly environment" for that industry segment.

There are big quality gaps within the larger system and O'Kane said they are costly in terms of lives and dollars. If the rest of the system could bring its quality of care up to the top 10 percent of health plans -- it could save the United States $1.8 billion a year in healthcare spending and anywhere from 42,000 to 79,000 lives lost because they did not get needed care.

One part of the solution, experts agree, is to change the way the United States pays for medical care -- making it a performance-based payment. The best and most financially efficient doctors or hospitals or providers would be paid better than those who do not perform as well. Another key is educating the public so they know how to seek out the best providers of care.

"Measuring performance allows us to do three very important things: inform consumer choice, reward quality and identify opportunities for improvement," said Dr. Mark McClellan, Centers for Medicare and Medicaid Services administrator.

Medicare is beginning some performance pay pilot programs to test the best ways of adjusting payments to healthcare providers in the senior's health insurance program.

"This report underscores a value disconnect in healthcare," said Peter Lee, president of the Pacific Business Group on Health, which is part of California's pay for performance program. He said this year $50 million will go toward performance bonuses to providers who meet key standards and goals.


Most experts agree we do not know the impact health savings accounts will have on the group insurance industry. The issues are adverse selection and dividing the risk pool -- which is used by insurers to set premium rates.

There are concerns that if young or healthy people who generally use fewer healthcare dollars buy HSAs -- high-deductible catastrophic health plans coupled with tax-free savings accounts -- their exit from the traditional employer-sponsored group market could leave that insurance option with an overload of sick folks who use more healthcare dollars.

If HSAs really take off -- there are worries this flight could create what is called a "death spiral" for traditional group plans that depend on a more balanced risk pool -- where premiums from the young and healthy who do not access a lot of medical services help cover the older and sicker members who do.

Could adverse selection occur -- in which plans favor the young and healthy because it is less expensive to cover them? There are valid arguments on both sides.

Mark Pauly, a professor at the University of Pennsylvania, told the Joint Economic Committee on Capitol Hill Wednesday adverse selection just isn't a big problem in the U.S. insurance market.

"Of all the things that are wrong with U.S. health insurance ... risk issues are a distraction," he said. "This seems to me to be a very low priority item."

This isn't an issue for people who purchase HSAs on the individual, non-group market because, as Pauly pointed out, there is no cross subsidization from the group in that setup.

He said employers would be foolish to create a system that penalizes sicker people who stay in group coverage by making HSAs too incentivized and attractive but he added even if it happened that only HSA plans were offered by employers as a benefit option if it is a good HSA structure "it's not the end of the world."

Linda Blumberg, a senior research associate with the Urban Institute, said insurers will pursue a lower cost risk pool.

"So I'm concerned about the direction of HSAs," she said, and added such policies "all have a tendency to move our market to a more segmented risk scenario."

James Cardon of Brigham Young University said concerns about HSAs distorting the insurance markets are "greatly exaggerated." He said HSAs are similar to other high-deductible plans and benefit managers know how to balance out risk.

"The markets will provide the test," he said, and added HSAs "are worth a try."


The money saved when physicians prescribe a stronger once-daily dose of medicine, rather than two smaller doses each day -- isn't a must as many believed it would be.

A study published in the Journal of Managed Care Pharmacy finds the savings may not be enough to warrant the cost of the program needed to inform physicians of the benefits of daily dosing.

Researchers at pharmacy benefit manager Express Scripts analyzed more than 500,000 claims for a mid-Atlantic health plan from November 2002 to February 2003. They found about 9 percent of physicians who received letters asking them to switch did change patient prescriptions. About 4 percent made the switch without being contacted.

The researchers concluded health plans would save only about 3 cents per member per month in drug costs through the initiative.



Copyright 2004 by United Press International.


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