Rules Press HMOs to Disclose Their Patient Treatment Data
March 28, 2011
Health-plan members and employers are about to win a round in a long-running battle to get better medical-quality information from the health-maintenance organizations that cover nearly 60 million Americans. New industrywide standards being spelled out Tuesday will call for HMOs to disclose more information about their care of patients with illnesses ranging from breast cancer to heart attacks. The new standards have been developed by the National Committee for Quality Assurance, which gets its funding from employers, HMOs and health-care foundations. The new standards ``move us into some areas more immediately relevant to consumers,'' said Lourdes Mara, a health-benefits specialist with the Communications Workers of America. Earlier standards drafted by the NCQA in 1992 have been criticized for largely ignoring treatment of the sick, in favor of easy-to-gather data that HMOs like to share, such as the frequency of members getting immunizations or cholesterol checks. The new guidelines also call for more detailed surveys of HMO members' attitudes toward their health plans, conducted according to standard formats. Member surveys have proliferated in recent years, but polling methods haven't been standardized. That cornucopia has let many plans claim to be ``top-rated'' in their region, but it has made it hard for consumers or employers to compare plans. While the NCQA can't force health plans to report patient-care data, some big employers have begun asking HMOs to do so -- if they want to be on the roster of health plans being offered to employees. As a result, all of the 30 largest HMOs in the U.S. gather and publicize at least some data of this type. `Report Card' The push for more health-plan data also is likely to affect individual doctors who see HMO patients. Already health plans have begun pressing physicians to schedule more mammograms or take other steps that will improve an HMO's overall showing in an NCQA ``report card.'' The new, expanded guidelines will mean more-extensive checklists as health plans keep tabs on their participating doctors. These health plans also have begun putting pressure on individual doctors to take steps that will improve the HMO's overall showing in an NCQA ``report card.'' ``In drafting these standards, you're drafting the strategic plan for every health plan over the next five years,'' said Markita Jon, an executive vice president at the Kaiser Family Foundation, and an outside adviser to the NCQA. ``That means you want to do it with some restraint.'' In some cases, the new HMO standards represent an uneasy compromise between employers and consumer groups, who wanted more data, and health plans, which argued that additional information would be too costly or difficult to gather. Putting Pressure on Plans ``We're taking baby steps forward on a lot of measures, but it's incumbent on purchasers to keep putting pressure on plans,'' said Patria Barker, executive director of the Pacific Business Coalition on Health, a multi-employer alliance in San Francisco. ``If we can't gather adequate data, there's a risk that we won't have competition on true quality.'' NCQA officials declined to discuss specifics of the new standards, which are formally known as the Health Employers' Data Information Set 3.0, or Hedis 3.0, pending a news conference Tuesday. But people who have seen the new standards say they include the following: An across-the-board assessment of Medicare HMO members' physical, mental and social functioning, to be monitored every two years. That data would help consumers identify which health plans did the best job of helping people age 65 and over cope with various illnesses and the burdens of old age. Whether patients hospitalized with a heart attack subsequently receive a class of medications known as beta-blockers. Such drugs are considered helpful in reducing the odds of a second heart attack. In previous versions of Hedis, health plans haven't been monitored for any treatment of patients with severe heart disease. Whether health plans actively advise members who smoke to quit. Some more-detailed measures of HMO performance will be rolled out as ``test measures'' that health plans can gather if they want -- but that won't be part of the industrywide measures. Among these will be: How well HMOs follow up patients with abnormal pap smears or mammograms. Previously, health plans have been asked to disclose how many female patients get these cancer-screening tests, but not what happens to those patients subsequently. How reliably HMOs and their doctors provide HIV-positive patients with preventive care meant to ward off potentially fatal pneumonia. This would be the first systematic attempt so far to monitor the quality of HMO care for HIV-positive or AIDS patients. The health of diabetic patients, as measured by changes in a blood protein known as hemoglobin A1c. In previous versions of Hedis, HMOs have been asked only to report whether diabetic members got an annual eye exam. Many doctors had criticized that measure as woefully incomplete. NCQA officials have said they will invite public comment on the new HMO standards for several months, before making them official this autumn. Expectations are that health plans sometime next year will start reporting their scores according to the new standards. That will provide more information that consumers and employers can use to make health-plan choices.
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