The State of

Managed Care Quality

- 1998 -

National Committee for Quality Assurance

Table of Contents

The regions referred to in this report refer to U.S. Census Bureau regions. States in each region include:

The State of Managed Care Quality - 1998

National Average: 52.2%

Advising Smokers to Quit

National Average: 64.0%

Beta Blocker Treatment

National Average: 74.0%

Breast Cancer Screening

National Average: 71.3%

Cervical Cancer Screening

Mountain: 69.0%

Cesarean Sections

National Average: 20.7%

Childhood Immunizations

National Average: 65.4%

Diabetic Retinal Exam

National Average: 39.0%

Follow Up After Hospitalization

for Mental Illness

National Average: 67.3%

Prenatal Care in the First Trimester

National Average: 83.1%

Overall Member Satisfaction

National Average: 55.7%

This measure shows the percentage of 13-year-olds who received appropriate immunizations (for measles, mumps and rubella) during the previous year.

Immunizations are an effective and inexpensive way to significantly reduce the incidence of potentially dangerous diseases. While children are typically immunized during early childhood for measles, mumps and rubella (MMR), an immunization booster shot is required during adolescence to ensure continued protection against these illnesses. Significant outbreaks of measles have been recorded as recently as the past 10 years.

Adolescent Immunization Status

If industry-wide performance were brought up to the 90^th percentile benchmark of 79.1% it would significantly reduce the likelihood of outbreaks of these illnesses. Immunizations are among the most cost effective forms of preventive care.

The percentage of smokers or recent quitters age 18 and older who received advice to quit smoking from a health plan professional.

Smoking is the leading preventable cause of death in the U.S., causing more than 400,000 deaths each year. Nearly 49 million Americans smoke despite these risks, and despite the fact that about 70% of smokers report that they would like to quit. Estimates of the annual negative economic impact of smoking on the U.S. range up to $100 billion dollars. Smokers are more likely to quit if advised to do so by their physician than for any other reason.

Advice to Quit Smoking

If industry-wide performance were brought up to the 90^th percentile benchmark of 74.3%, an additional 4.2 million enrollees who smoke would be advised about the benefits of quitting, and nearly 26,000 more people would quit smoking each year, saving hundreds of lives and saving tens of millions of dollars in health care costs.

Plans should encourage their providers to talk openly with their patients about smoking and provide opportunities and programs that encourage and support members to quit. Evidence suggests that tracking smoking status as a "vital sign" leads to more aggressive counseling and higher quit rates. In addition, health plans should consider offering tobacco cessation classes and/or offering interested members a "stop smoking tool kit" as part of their benefits, and pharmaceutical aids such as nicotine patches and other such smoking cessation supports could be offered without copayment.

The percentage of members age 35 and older who were hospitalized and discharged with the diagnosis of acute myocardial infarction who received a prescription for beta blockers.

Heart disease is the leading cause of death in the United States, and every year, more than 500,000 Americans die from heart disease. Annually, approximately 1.5 million Americans suffer a heart attack. The cost to the nation is enormous; the total cost of medical care and lost productivity due to heart disease is $60 billion annually. Beta blockers are a remarkably effective, low cost drug that have been shown to significantly reduce morbidity and mortality associated with heart disease, as well as reduce the chance of a second heart attack

Beta Blockers After a Heart Attack

If industry-wide performance were brought up to the 90^th percentile benchmark of 93.1%, more than 2,000 cardiac deaths would be avoided among HMO enrollees each year. The number of future heart attacks avoided would be even higher. Expenditures for cardiac care would also be reduced by tens of millions of dollars annually.

Many physicians are unaware of the extent to which these drugs improve cardiac outcomes, and therefore fail to prescribe them when appropriate. The key to improving rates of use is for the plan to educate providers about the value of these agents, provide incentives to encourage their use, and provide physicians with guidelines and other decision support tools that will assist them in prescribing drugs appropriately.

The percentage of women between the ages of 52 and 69 who have had at least one mammogram during the past two years.

Breast cancer is the second most common type of cancer among American women, with approximately 184,300 new cases reported each year. Women who have their breast cancer detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by 20% to 40% among women aged 50 and older.

Breast Cancer Screening

If all managed care plans performed at the 90^th percentile benchmark of 80.9%, an additional 1,287 breast cancer cases would be detected each year. Early detection and treatment of breast cancer would help prevent well over 100 deaths per year and save almost $4 billion in treatment and lost productivity costs associated with this illness.

Plans should work to educate women about the importance of regular mammograms. Some women still fear mammograms; others don't understand why they are important; still others may simply need a reminder that they are due for a mammogram. Plans should also work to make mammograms more convenient. Some innovative health plans regularly provide their practitioners with lists of members who have not received recommended mammograms and allowing practitioners to deliver targeted reminders to women during office visits. Health plans may also consider sending shower cards or mirrors to female reminders instructing them on breast self exam techniques and mammography guidelines.

Approximately 13,000 new cases of cervical cancer are diagnosed each year, and about 4,800 women die of the disease. Early detection can reduce the chance of death from cervical cancer by as much as 75%. A number of organizations, including the American College of Obstetricians and Gynecologists, the American Medical Association, and the American Cancer Society, recommend Pap testing every one to three years for all women who have been sexually active or who are over 18 years old.

Cervical Cancer Screening Rates

If all health plans nationwide performed at the 90^th percentile benchmark of 82.7% last year, an additional 293 cases of cervical cancer could have been detected, and 36 deaths due to cervical cancer could have been averted.

Health plans need to educate women about the importance of Pap tests, to provide information and counseling on the procedure to reduce anxiety and fear, and to make the tests convenient and accessible. Many health plans encourage women to have Pap tests during their obstetric/ gynecologic visit by providing them with notification cards to be filled out during the visit, and then mailed back with results. Other health plans send reminder "birthday" cards encouraging women to receive recommended Pap tests. Allowing an annual OB/GYN visit without a referral also removes one potential barrier to cervical cancer screening, and may help boost screening rates.

Between one third and one half of all C-sections performed in the United States each year are probably unnecessary. C-sections are more expensive than vaginal deliveries, the recuperative period is greater, and there are more complications associated with them. Public health officials are working to reduce the U.S. C-section rate to 12 to 15% by the year 2000.

Cesarean Section Rates

The estimated risk of a woman dying after a C-section is four times higher than the risk of death following a vaginal delivery. C-sections are also typically followed by longer hospital stays and longer recovery times. Currently, 80% of all health plans report C-section rates between 14.8 and 38.4%.

Many women and physicians incorrectly assume that after a woman has delivered via C-section, all subsequent deliveries should also be via C-section. This belief is not supported by available evidence and likely contributes to over-utilization of this procedure. Health plans should educate women and providers about the option of delivering vaginally even after a C-section. Health plans may also lower C-section rates simply by providing practitioners with an analysis of how their own C-section rate compares with other practitioners' rates, thus highlighting any atypical practice patterns. Medical directors should also consider developing educational outreach programs or labor management seminars targeting physicians who have unusually high C-section rates.

The percentage of two-year-old children who received appropriate immunizations by their second birthday. The completed series of vaccines includes many different components. Included here are: four diptheria-tetanus-pertussis, three polio, and one measles-mumps-rubella vaccination.

Childhood immunizations help prevent serious illnesses, such as polio, tetanus, whooping cough, mumps, measles and meningitis. Vaccines are an easy, proven way to help a child stay healthy and avoid the potentially harmful effects of childhood diseases. It is estimated that one million children in the U.S. do not receive the necessary vaccinations by age two.

Childhood Immunization Rates

If all health plans were brought up to the 90^th percentile benchmark of 83%, unnecessary morbidity and mortality among children would be prevented, thus saving lives, life years, and associated costs. The Children's Defense Fund estimates that providing immunizations yields a 10:1 economic return on investment in terms of reduced medical expenditures

Plans should attempt to educate parents about the benefit of childhood immunization and send reminders to parents encouraging their children to become vaccinated. Incentive programs featuring gift certificates or other giveaways have proven to be an effective tool in encouraging parents to have their children appropriately immunized. Health plans should also develop systems to remind parents of the need to immunize children while they are in the doctors office. Similarly, health plans should also develop systems - such as including immunization check lists on medical records - to help remind practitioners of recommended immunization schedules and whether or not individual patients are up to date. Some health plans have also developed effective partnerships with state governments to promote childhood immunizations.

The percentage of people with diabetes age 31 years and older who received an eye exam in the past year. (Note: because some diabetics can safely be screened less frequently than annually, one would not necessarily expect a screening rate of 100% in each health plan.)

Diabetes is the leading cause of adult blindness in the United States. Blindness can be prevented, however, if retinal changes are detected early, and treated with a laser. Therefore, it is important that the approximately 14 million Americans with diabetes have their eyes examined regularly so that appropriate treatment can be initiated at the first sign of a problem.

Eye Exams for Patients with Diabetes

According to one study, regular eye exams for diabetics reduce the risk of blindness due to diabetic retinopathy by an estimated 56%. If all health plans were performing at the 90^th percentile benchmark of 57%, more than 875 additional cases of blindness would be prevented each year.

Like other preventive screenings, health plans need to educate physicians about diabetes and work with them to provide and convey information about the benefits of screening, and the ease and access of participating in a screening program. To eliminate one potential obstacle to diabetic retinal exams, health plans should consider allowing diabetic patients to see their optometrist annually without a referral or copay.

The percentage of members age six years and older who were hospitalized with selected mental illnesses who were seen by a mental health provider within 30 days after discharge.

An outpatient visit with a mental health practitioner is necessary to make sure that a recently released patient's transition to the home or work environment is supported and that gains made during hospitalization are not lost. Such visits also help detect early post-hospitalization reactions or medication problems.

Follow Up After Hospitalization for Mental Illness

If all plans were performing at the 90^th percentile benchmark of 86.5%, readmission rates would likely fall, medication problems would be detected earlier and more patients would maintain their treatment regimens, greatly improving their overall outcomes.

Health plans should make a practice of scheduling follow up appointments at the time a patient is discharged. Health plans should also educate patients and providers about the importance of such follow up visits. Systems should be established to generate reminder or "reschedule" notices that are mailed to patients in the event that a follow up visit is missed or canceled. In many cases, it may also be necessary to develop outreach systems or assign case managers to encourage recently released patients to keep follow up appointments, or reschedule missed appointments.

The percentage of women who began prenatal care during the first 13 weeks of pregnancy. Prenatal care consists of patient education, evaluation of the pregnant woman for physical or historic factors requiring special care, careful assessment of gestational age, and determination of the success with which the mother and fetus are tolerating the pregnancy.

Health plans that provide timely and effective prenatal care can help reduce a woman's risk of delivering a low birthweight infant and can detect and address maternal health problems early in the pregnancy. Good prenatal care also greatly reduces infant mortality and complications related to drug or alcohol use during pregnancy. Many potentially serious pregnancy-related complications can be easily corrected if detected early.

Prenatal Care in the First Trimester

Reductions in a woman's likelihood of delivering a low birth-weight infant and other maternal and infant health problems could be achieved if the industry moved towards the 90^th percentile benchmark of 95.1%. By raising the benchmark, preventable loss of life and illness could be avoided.

Health plans and providers should develop comprehensive exercise and educational programs for pregnant women focusing on the importance and benefits of prenatal care for both mothers and infants, and about the significant risks associated with drug or alcohol use during pregnancy. Health plans should also consider developing incentive programs to encourage broader participation in such programs. Assigning case managers to high risk members may also help encourage appropriate prenatal care, and decrease dangerous behaviors.

These measures assess members' overall level of satisfaction with the health plan, as well as the level of satisfaction in specific areas, including choice of physician, referrals to a specialist, waiting time, and available information on members' rights.

These measures will allow prospective members to assess how well others believe the plan is meeting their needs. Member-supplied information complements objective clinical data to provide a more complete view of a health plan's performance. NCQA requires that member satisfaction data be collected by a third party vendor.

Overall Member Satisfaction

Satisfaction with Choice and Service

The State of Accountability -1998

In health care, accountability and quality are closely linked. This is perhaps no surprise and it is a promising finding. What it means for consumers and employers is that there is a real, measurable return on efforts to require health plans to report on their performance - better quality care and service.

Unfortunately, accountability in health care is by no means universal. While the data in this report reflect the willingness of nearly 450 health plans across the country to share their data (some shared their data publicly, others provided data to help calculate accurate national and regional averages), hundreds of other health plans provided no data whatsoever. HMOs that don't report performance data join preferred provider organizations (PPOs) and the fee-for-service sector as the black holes of health care - we know nothing about their quality. This is unacceptable. Accountability in health care is a matter of public welfare, not simply an appealing academic idea. Market pressure will be the key to ensuring that, in the future, we have the objective data and information we need to make informed health care coverage decisions.

This section of the State of Managed Care Quality examines the relationship between performance and accountability. As indicated earlier, the results show that health plans that support accountability far outperform their counterparts.

A Look at the Improvement in Performance

of Plans Reporting Data for both 1996 and 1997

*Note: This graph shows that plans which reported data for both 1996 and 1997 (Paired plans) improved more quickly and demonstrated higher overall performance than plans in general (1997 overall).

These results clearly show the value and importance of participating in public reporting efforts not just intermittently, but consistently, year after year. Encouraging our nation's health plans to publicly report performance data not only satisfies our need for information about health care, but also helps make that care better than it would be otherwise. The numbers speak for themselves: plans that publicly report data on a regular basis work harder to improve.

A Look at the Performance of

NCQA Accredited Plans vs. Non-Accredited Health Plans

The information presented on the preceding page in graph form is presented below in chart form for your convenience.

The data presented above in graph form are presented below in chart form for your convenience.

Performance by reporting status