Quality monitoring and management in commercial health plans.
OBJECTIVE
To examine the current state of quality monitoring and management activities of US health plans.


METHODS
Cross-sectional survey.


METHODS
We surveyed medical directors of 252 commercial HMOs (96% response rate) drawn from 41 nationally representative markets in the United States. We randomly sampled healthcare markets with at least 100,000 HMO enrollees. The markets in our sampling frame include an estimated 91% of US HMO enrollees and represent 78% of the metropolitan population.


RESULTS
There was near-universal collection of data at the health plan level for each of the 7 outpatient measures we examined (ranging from 92.1% of health plans that collect data on hypertension control and cholesterol management (see p. 379) to 99.2% that collect data on patient satisfaction). There also was substantial data collection at the level of the individual provider or physician group (ranging from 50.4% for hypertension control to 81.4% for diabetes care); this was more common in health plans that primarily use capitation to reimburse primary care physicians. Health plans that collected data typically fed these data back to physician groups, but public reporting to enrollees was infrequent.


CONCLUSIONS
Almost all health plans measured their performance on multiple indicators of quality. The majority of health plans also collected data at the level of the individual physician or group and used these data in quality improvement activities, but not in public reporting. Thus, adoption of physician-level performance measurement and reporting by the Centers for Medicare & Medicaid Services will likely entail a major change for individual physicians.
Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02459, USA. landon@hcp.med.harvard.edu
Bruce E
BE
Landon
Meredith B
MB
Rosenthal
Sharon-Lise T
SL
Normand
Richard G
RG
Frank
Arnold M
AM
Epstein
D003430:Cross-Sectional Studies; D006801:Humans; D008329:Managed Care Programs / Q000592:standards*; D008486:Physician Executives / Q000523:psychology; D019984:Quality Indicators, Health Care / Q000458:organization & administration*; D014481:United States