State of Health Care Quality: Some States Better Than Others

Peggy O’Kane has been running the NCQA for longer than she might care to remember. NCQA is Peggy4an independent, non-profit organization whose mission is to improve the quality of health care everywhere, but it’s best known for creating the HEDIS measures that rate health insurer and provider performance. I’ve been a fan of Peggy since I met her in the mid-1990s. Today she shows she’s still fighting the good fight. This is her first contribution to THCB —Matthew Holt

Suppose you’re one of the 22 million Americans living with diabetes and you have to decide where you  want to live. Your choices: Providence, Rhode Island, or Houston, Texas.  Providence is pretty and you’d have easy access to lobster dinners and weekends at the Cape. But Houston is warmer in the winter and just a hop, skip and a jump from a weekend in Cancun.  A hard decision but you’re leaning toward Houston because, let’s face it, you hate shoveling snow!But then you take a look at the 13th annual State of Health Care Quality Report by the National Committee for Quality Assurance (plug alert: I run the place) and you find out the quality of care for diabetics is nearly 11 percentage points better in New England than it is in the South Central region of the U.S. and you begin to reconsider. In fact, you look at the newest data released October 22 and you find that the quality of care in the Texas region of the country is consistently the worst while care in New England is almost always the best.  Providence here I come!

Here’s the problem: Most people don’t have a choice of moving from Texas or Oklahoma or Alabama to Massachusetts, Connecticut or Rhode Island. They have to live with the health care system they have. For a diabetic, those 11 points can translate into more kidney problems, loss of vision, toe or foot amputations or, heaven forbid, a shorter lifespan.The thing is, it doesn’t have to be this way. True, care isn’t going to be identical in all parts of the country. And, true, the population of Dallas may have a lot more health problems than the people in Hartford. But 11 points is too big a gap to explain away with demographics.

Regional variations in quality are just one part of this year’s State of Health Care Quality. After 12 years of steady and often remarkable improvements in care by our nation’s health plans, 2008 was marked by a stalling of progress. Care quality in commercial health plans as well as those serving Medicare and Medicaid beneficiaries barely improved. For commercial plans, this may be the beginning of a plateau. For Medicare and Medicaid, which serve more than 100 million Americans, this is the third straight year of disappointing results. That’s never good news but these two safety net programs are slated to grow sharply in the next 5 to 10 years.  Medicare will swell its ranks as the rest of my Baby Boom generation reaches 65 and becomes eligible. Medicaid is already growing due to the recession and is projected to gain 10 to 15 million more beneficiaries under most of the health reform plans on the Hill.

So what do we need to do?

First, I’d like the governors of the southern and south central states to join with me to develop a collective plan of action to improve health care quality. One or two states cannot do this alone.  But working together we can turn the worst to first.Second, as Congress tries to turn five health reform bills into one for the President to sign, tell your elected representatives not to forget quality.  The good news is that each of the bills contains good, solid provisions to improve quality. But I worry that as the sausage-making process reaches its final stages those provisions will be cast aside or watered down.  The final bill must contain provisions that will:-   Create insurance exchanges and require plans that participate to report on clinical quality (HEDIS®) and patient experience (CAHPS®) and maintain accreditation;

–   Expand the experiments with the Patient Centered Medical Home so that more Americans can benefit from this “whole patient” approach to care;

–  Create new payment systems that reward quality and penalize inefficiency. Medicare Advantage is one of the only payers that doesn’t use some form of pay-for-performance. That needs to change quickly. And Medicaid programs need some federal direction on the use of quality measurement and reporting to spur improvement. Twelve years of success taught us how to improve quality. One year of flat performance tells us we need to recharge our engines and go at this together.

6 replies »

  1. Since when did what is good population based care become the standard for what is considered real quality clinical care in health/medical care. Now I’m a poor- house doctor epidemiologist, and given a HEDIS manual and a patient’s diagnosis and core demographics I could assure you that patient would get their proper tests, and even meds. Diabetic patients, get annual eye exams, microalbumins, foot exams, eye exams, and semi annual HgA1c’s, adults get annual flu shots, women under 75 get mammograms, etc. That’s good population based care, – not a bad thing, but is that really quality care?
    I think we all know what quality healthcare is, its getting the correct care to address our particular medical needs at the time we have them, and to appropriately protect our ongoing health and wellbeing. More suscinctly is is an accurate diagnosis, correct – even inspired treatment, and an appropriate dose of prevention. It is very patient centered.
    HEDIS measures – an algorythmic classification system generates a nice set of numbers that bureaucratic systems can sell to eachother as “quality care”, but really this is the equivalent of the routine you hope to get from Mr. Goodwrench when your car is serviced, and not true high level quality care.
    There is a tale us old epidemiologists tell of the guy looking for a lost ring at the corner under the street light. When asked where he lost the ring, he says – probably a few dozen yards up the street. So why is he looking at the corner? “Because the light is better here!”
    The light might be better (cheaper) for measuring HEDIS data from an EHR or a medical chart, but that dosen’t mean these measures combine to total true quality healthcare. Beware bureaucrats bearing cost-effective systems, demand patient centered systems for assessing the quality of healthcare or we’ll all be well immunized as we’re put into our early graves.

  2. Medicaid plans are evaluated for quality each year by an External Quality Review Organization (EQRO), but there is no assurance that all EQROs apply the CMS standards and protocol in the same way; in fact, I’m sure they don’t. If CMS can achieve consensus among EQROs about the standards used to asses quality, we are a giant step closer to being able to compare and improve the quality of Medicaid programs.

  3. Interesting that quality of health care can be so different from state to state. Medicaid rates and qualifications alter as well. I wonder if either are related. As noticeable is the problem – it seems that the solution will be much more difficult.

  4. it sounds so simple ‘teeth’. Please explain how you manage such a system? I just dont see it as feasible. Jean Carl Parisien

  5. I don’t understand what your beef is with the Medicare Advantage Pans. My experience with both Humana & Coventry has been They are far better that generic MEDICARE with their emphasis on prevention.
    However, I would prefer Health Savings Accounts with medicare paying 80% of Premium that they pay Adv Plans to fulfill their contractual oblig they assumed when Medicare was withheld from my pay since 1966. All HSA’s should be allowed to purchase Catastrophe ins.