Despite skepticism about the long-term viability of Independent Practice Associations (IPAs), enrollment in them is growing rapidly according to recent data published in Medical Economics. HMOs built around IPAs accounted for 43 percent of HMO enrollees as of July 1, 1996 — the largest share of the HMO model — and have seen a 47 percent enrollment increase since July 1, 1994. Second generation IPAs are embracing global capitation for all medical services, including hospital inpatient care. The goal of these IPAs is to remain independent, but add business acumen to ensure their survival. Part of the reason for their rapid growth is the advent of physician management companies, described in earlier parts of this series, which have picked up the administrative and cost management functions for many physician groups. PhyCor, for example, currently manages IPAs covering 17,600 physicians and 1.1 million enrollees.
Examples are also available of IPAs that collect and disseminate performance-based data on their physicians, with names included, creating better accountability. Other key success factors for IPAs include the use of accrual accounting to retain earnings for capital investments such as new computer systems.
Specialty “Teams”
Meanwhile Oxford Health, despite all its recent problems on Wall Street, is implementing an innovative plan to assemble teams of physicians by specialty. According to Modern Healthcare, the team is responsible for coordinating all the care for a particular illness or condition, including lab work and hospitalization. Teams are paid a predetermined rate per case and reimbursed over time as specific treatment steps are taken. Stop-loss coverage is provided to ensure that providers are not bankrupted. Performance profiles are being built for each specialist so patients can choose among the teams. To date, more than 600 New York-area physicians have signed up for the program. Oxford indicated that the plan is saving about 15 to 20 percent on the plan’s specialty contracts. The physician specialist teams hope to offer their services in the future to other plans. It is essential that neurosurgeons take note of this process and become informed about it, for other plans may emulate it. Oxford also hopes to market these networks of specialists as a separate point-of-service product, particularly to self-insured employers or plans outside its region that lack the medical management expertise to develop such networks themselves.
Managed Care “Report Cards”
The National Committee for Quality Assurance (NCQA) recently released its first “State of Managed Care Quality” report and “Quality Compass 1997”, a national database of comparative information about the performance of 329 managed care plans covering 37 million Americans. The two reports show that the performance of the nation’s HMOs and other managed care organizations varies greatly in terms of patient satisfaction, keeping people healthy, treating selected illnesses, providing access to care, and delivering high quality service.
“The range of health plan performance across the country, and even within regions, is striking,” said NCQA president Margaret O’Kane. She said, for example, that studies have repeatedly shown that treating heart attack patients with beta blockers saves lives, but fewer than 30 percent of such patients in some plans receive them as compared to more than 90 percent in others.
This year’s version of Quality Compass, which was introduced last year, includes health plans NCQA accreditation status and 1996 results from NCQA’s current version of the Health Plan Data and Information Set (HEDIS 3.0). HEDIS is a standardized set of performance measures that includes measures related to smoking cessation, member satisfaction, cancer screening, cardiovascular disease, diabetes, asthma and other public health issues.
The report on the state of quality in managed care plans, which the NCQA intends to publish annually, compiles national and regional averages and benchmarks for plan performance. It also shows not only how well plans are performing, but what level of performance is actually possible. For example, in New England, 81 percent of children under age two receive appropriate immunizations, but in the Mountain region, the rate is only 59 percent. As the report points out, these differences are likely to reflect cultural, demographic and public policy differences.
Information in Quality Compass, which is available on CD-ROM or as electronic data files, is a decision support tool for employers and other purchasers of health care. It allows users to compare plans with one another, against national and regional averages and against the top-performing plans identified as “benchmarks.”
“Getting the data into the hands of our employees puts real pressure on the plans to compete based on quality and satisfaction,” said Maureen Coleman, manager of benefits at Allied Signal, as reported in Integrated Healthcare Report. Many employers will use Quality Compass data to generate customized report cards to show their employees how well each of their offered plans performed in each area of concern.
As so often stated, once cost concerns began to be sorted out, plans would begin to compete on quality as demanded by the payers. This is some of the first evidence for this and neurosurgeons should become aware of these efforts.