FORT LAUDERDALE, FlaFor 10 years, the National
Committee for Quality Assurance (NCQA) has been overseeing the
quality of managed care organizations. NCQA is the leading
accreditor of HMOs, and, through HEDIS (the Health Plan Employer Data
Information Set), our impact has stretched beyond accreditation,
Dr. Cary Sennett said at the Fourth Annual Conference of the
National Comprehensive Cancer Network (NCCN).
However, he noted, our work in the area of cancer is truly just
beginning. Currently, NCQA looks only at certain cancer
prevention measuresmammog-raphy rate, cervical cancer
screening, and rates of smoking cessation counselingbut
we are committed to developing a broader set of measures, he said.
As executive vice president for NCQA, Dr. Sennett shares
responsibility with NCQAs president for overseeing efforts to
help purchasers and consumers make value-based choices between and
among managed care plans. NCQA, he said, is a not-for-profit, private
sector quality oversight body. Our mission is to improve the
quality of care and service, he said, and we do this by
providing information about health care organizations.
He said that NCQA has launched a Cancer Measurement Advisory Panel to
assist in the effort to develop measures of quality of care in cancer
and incorporate those measures into HEDIS. Such new measures may
include colorectal cancer screening, follow-up after mammog-raphy,
and stage of diagnosis.
Dr. Sennett said that the lead time from launching a committee to
developing measures and deploying those measures in HEDIS is 2 to 3
years, based on work with other advisory panels in areas such as
asthma, diabetes, and heart disease.
Changing the Rules
He noted that intense price competition is driving the market for
managed care, but that this competition doesnt drive
organizations to provide higher quality or higher value care; rather,
it may be the single greatest impediment to efforts to improve the
quality of care.
Thus, the NCQAs mission is really no less than to try to
change the rules of engagement in a very fundamental way in the
health care marketplace, that is, to try to enable the marketplace to
move from one that is price competitive to one that is value
competitive. And to do this, he said, will require information
about quality. Without this information, there is little
capacity or possibility of competing based on value.
He noted that NCQA provides information through two streams. The
first is its accreditation program, which assesses the health
plans organization and how it operates. Its a look
at the key systems that we believe are essential to providing high
quality care and service, but it is a systems view rather than an
outcome or results view, he said.
Historically independent and complementary to the accreditation
program is HEDIS, the statistics that NCQA collects to give
information on outcomes or results.
Rigorous and Discriminating
Dr. Sennett called NCQAs accreditation program a rigorous
and discriminating process. The process is voluntary, and only
about half of the HMOs in the United States have asked to be
evaluated by NCQA.
When Dr. Sennett started at NCQA 4 years ago, one of every seven HMOs
that were reviewed failed outright. At this point, about 60% of
the plans that are evaluated receive our highest award, which we call
full accreditation, he said. Thus, we have seen some
improvement over time. We think that that reflects the seriousness
with which HMOs are taking our program and the investments that they
have made in improving systems.
Although the program is voluntary, increasingly the marketplace is
mandating that it be done. Many of the Fortune 500 firms make
it a condition of participation that a health plan be NCQA
accredited, and beginning in July of this year, we are going to be
bringing HEDIS performance data explicitly into the accreditation
program. So beginning this year results will count.
He pointed out that HEDIS is a very broad set of measures, including
not only measures of clinical effectiveness but also measures
intended to address the full range of issues that are important to
consumers and to the purchasers of care such as access and service.
We look at patient satisfaction, financial stability, and other
things that matter, he said.
He called HEDIS a rapidly evolving work in progress. It
began in 1993 and was adapted to the Medicaid population in 1995. In
1996, it was reconstituted into a single set of measures (HEDIS 3.0)
that could be applied across insured populations of Medicaid and
Medicare, as well as those of commercial payers.
HEDIS undergoes annual enhancement, he said, and is named by the year
of revisionHEDIS 99, HEDIS 2000, etc. The process is an
incremental one, but one that is broadly participative, he said. A
committee on performance measurement (CPM) sets priorities and
establishes measurement policy. Functioning as working subcommittees
of the CPM are the measurement advisory panels (MAPs).
Dr. Sennett described some lessons learned by NCQA in its
10 years of operation. First of all, he said, it
may not come as any surprise to you, but it comes as a surprise to
many, that there is a huge variation with respect to the performance
of managed care organizations, and this variation has a huge impact
on the well being of populations covered by managed care
In addition, he said, NCQA has learned that there is a growing demand
for information about this variability. As an example, he cited the
increased interest in statistics on the use of beta-blockers after a
The mean rate of beta-blocker use for about 400 plans analyzed was
around 61%, he said, meaning that about two of every five
patients for whom a beta-blocker might have been indicated were not
receiving that therapy. An important point, however, is that in
some managed care organizations, rates of use approach 100%, while in
others rates are far below the mean.
More relevant to the NCCN audience, he said, is the HEDIS measurement
of mammography rates in commercially insured populations (women over
the age of 50). This shows regional variations, ranging from under
70% in the south central states to 76% in New England. The
national average is 71%, he said. Again, as with
beta-blocker use, there is a tremendous opportunity for improvement
in mammography rates.
These regional variations, he said, tell us something about the
health plans and something about the environment in which the health
plans operate. An analysis of a subset of plans in the same
region (south central, the region with the lowest mammography rates),
showed substantial variations, ranging from 65% to about 85%.
The implication is that regional factors, while important, do not
explain all the variation in performance. An 85% mammography rate, he
said, would put this health plan among the top 10% of all plans
in the country. It has managed to succeed despite the fact that it is
located in a part of the country where mammog-raphy rates generally
tend to be lower.
Report Cards for the Public
Public interest in the quality of health plans is, in some
respects, at an all time high, Dr. Sennett said, but he also
mentioned that the public has a long way to go before it really
understands the issues and applies public pressure for change and improvement.
NCQA, he said, is working toward increased public awareness of health
care quality. We produce annual statistics that describe the
performance of the industry and make that data available to
consultants, purchasers, and brokers through a dataset called Quality
Compass, and through the work that we do with the media and with
states to produce report cards.
The media has grabbed this and run with it, he said,
noting that US News and World Report has, for the last 3 years,
produced rankings of HMOs based on NCQA data.
Another public awareness effort involves the Maryland report card,
produced for Maryland residents using NCQA data. This uses a
consumer reports type of format that consumers can understand and
includes detailed information on a number of preventive care measures
for all the HMOs operating in the state, he said.
Dr. Sennett briefly discussed three important outstanding issues in
evaluating managed care. First, he said, the ability to measure
managed care is critically limited by the amount of data required to
support these efforts and the cost of acquiring such data. There
is a need to profoundly enhance data capture and data management
systems, he commented, to link measurement to improvement
or, looked at another way, to link guidelines to measures.
Measurement, I think, creates opportunity and also creates pressure
Second, he said, is the need to accelerate the rate at which measures
are developed and deployed. Finally, he emphasized, there is a need
to extend and coordinate measurement at other levels of the system.
The delivery of care rarely takes place at the managed care
organization, Dr. Sennett said, and it is at the point at
which care is delivered that the greatest opportunity for improvement
exists. So we need to extend our measurements to those other levels
of the system, and we need to do so in a way that is coordinated,
logical, coherent and efficient.