California Insurance Commissioner will issue the first state supported report card for PPOs

California Insurance Commissioner Steve Poizner hopes his proposed PPO report card system will put pressure on physicians to be more accountable for providing patients with the best care possible.
"The quality of health care should not be a mystery to consumers," said Poizner, who has issued the report card mandate. "I want to raise the bar of health quality in California. Consumers should know what they're getting when they pay their health care premiums."
By 2009, the California Insurance Commissioner will produce the first-ever mandated report card grading the quality of care patients receive through their PPO. But a few years ago, the National Committee on Quality Assurance, the nonprofit organization that rates health-care maintenance organizations, started to work with health plans to build a national report card for PPOs.
Aetna, CIGNA, and Blue Cross of California have jumped ahead of the upcoming California mandate to issue a report card on Preferred Provider Organizations, a health insurance product that covers six out of 10 Americans. The three huge managed care companies have joined a national volunteer reporting system that identifies the quality of care members receive.
Since physicians provide patient care, more pressure could be placed on some physicians to meet a litany of standards as plans compete to gain the best score possible. But health-care officials and Poizner, believe the PPO report card system will entice plans to do better, and save lives.
The quality of care for more than 80 million Americans enrolled in 767 accountable health plans improved in 2006, but the gains were smaller than they have been in past years, according to a new report by the National Committee for Quality Assurance released on September 25. The majority of reporting is on HMOs, but a growing number of PPOs are volunteering its information to participate in the report card system. The full report card can be viewed at www.ncqa.org.
In 2005, NCQA called on PPOs to voluntarily report HEDIS data and 80 plans did so. This year, 141 PPOs (83 commercial and 58 Medicare) -- covering more than 21 million Americans -- reported audited HEDIS results. The expanded reporting allows NCQA to report the results of 22 measures of clinical quality and eight measures of consumer experience.
Despite the gains in quality reporting, more than 100 million insured Americans remain in health plans that do not report quality performance data. In July, NCQA published new standards that require PPOs to report on the quality of care and will take those scores into account in determining an accreditation decision.
Health plans accredited by NCQA undergo regular review of their quality improvement initiatives, utilization management, patient protection and access to care. Accredited plans consistently perform at a higher rate than unaccredited plans. In 2006, for example, accredited plans provided needed prenatal care to 92.2 percent of the women they serve compared with only 83.5 of the women in unaccredited plans.
Despite advances in quality, the U.S. health care system still has a great deal of room to improve. If the entire health care system were to perform as well as the top 10 percent of the plans on the report card, NCQA officials estimates that between 35,000 and 75,000 deaths could be avoided each year.
Such improvements are not out of reach. Since 2000, improvement in just four areas of care -- beta-blocker treatment for heart attack patients, cholesterol management, controlling high blood pressure and improving blood sugar control among diabetics -- has saved the lives of almost 125,000 Americans.
"Health care represents the central fiscal challenge facing the nation," said Peter Orszag, Director of the U.S. Congressional Budget Office, "yet we do too little to measure what we receive in return for the money we're spending. Recognizing -- and rewarding -- high-value health care is essential to improving our fiscal outlook and the efficiency of the health care sector."
California's rating scale will resemble one used by the Department of Managed Health Care to evaluate HMOs based on clinical data and patient satisfaction scores. However, the state will work closely with NCQA to develop the report card system.
NCQA will also collect PPO data using industry standard measures such as the Healthcare Effectiveness Data and Information Set and the Consumer Assessment of Healthcare Providers, which gauges patient satisfaction. As provider organizations start to get 100 percent compliance with standards of care, the measures are dropped, because improvement has occurred, according to Poizner's office.
The six largest PPOs -- United, CIGNA, Blue Shield, Health Net, Blue Cross of California and Aetna -- agreed to collaborate with the insurance department to collect this information during 2008. An independent auditor will tabulate the results. The technology involved in implementing the report card system makes it too expensive for most of the countless smaller PPOs, but they will eventually be included.
Jennifer Kerns, spokesperson for the Department of Insurance, notes that just the act of reporting this data "improves health care results," thus driving up the quality of medical care. The NCQA contends that reporting results in measurable improvements in the areas of diabetes, cardiovascular disease, immunizations, and mammograms.
The HMO quality of care report card strives to "take complicated information and make it useful to consumers," says Sandra Perez, director of the Office of the Patient Advocate, which produces the document and publishes it on the managed care Web site. Perez notes that studies have shown that consumers like the fine dining style star system now used to rank the HMOs because people understand the symbols easily. In addition, research shows that consumers favor shopping for medical providers by conditions, such as diabetes or asthma, so the card includes seven different measures of illnesses. For example, patients can look up how HMOs scored on asthma medication dispensing, back pain testing, cancer screening, children's care, chlamydia screening, diabetes control, heart care and maternity and mental health care. "Quality depends on your needs," says Perez, adding that measuring quality has become "a whole science."
Many providers, including the Palo Alto Medical Foundation, evaluate consumer satisfaction internally, but PAMF's Tomas Moran, senior director of quality and planning, still thinks the PPO report card is a great idea.
efficiency of cars. "Without them, we won't know when we're improving performance."
Doctors generally agree with the system, "once we get them past the confidence (barrier) regarding the measures" used to gauge patient care, says Moran. In his experience, doctors might initially be skeptical of the measures of quality, but will then try to improve so that they provide the best possible care they can for their patients. The HEDIS and CAHPS surveys are medical industry standards usually accepted by doctors.

Eren Goknar is a contributing writer for Healthcare Journal of Northern California.

--By Eren Goknar