A report released this past October by the private, non-profit National Committee for Quality Assurance (NCQA) finds that the overall quality of health care delivered through both commercial and public health plans was static in 2008.
“This breaks a 12-year run of significant progress. While it could be a one-year blip, I fear it may be the beginning of a troubling trend,” writes Margaret E. O’Kane, NCQA president, in the annual “State of Health Care Quality” report.
NCQA estimates that if every health plan performed as well as those ranked in the top 10 percent, up to 115,000 lives and $12 billion in medical costs and lost productivity could be saved per year.
Participating health plans submit quality data using NCQA’s Healthcare Effectiveness Data and Information Set, known as HEDIS, a set of standardized performance measures. A total of 979 health plans, which collectively cover 116 million Americans, contributed to the report, a nine percent increase over the previous year. Commercial plans improved on only 43 percent of “trendable measures,” while Medicare and Medicaid lagged with 14 and 36 percent, respectively.
But while health plan participation increased, across-the-board quality reached a plateau. In fact, the report described care for mental health and substance abuse as “dreadful” and “pitiful.”
“I think the word ‘dreadful’ comes from two things. One is the level of performance and the other is the amount of improvement, particularly because we’ve seen so much improvement in other areas,” says NCQA Assistant Vice President for Research and Analysis Sarah H. Scholle, D.P.H., M.P.H.
Among the behavioral health measures averaging less than 50 percent are follow-up care after mental illness hospitalization, 49.8 percent; initiation and engagement of substance abuse treatment, 42.6 percent; patients receiving antidepressant medication management, 46.4 percent; and follow-up care for children on attention deficit/hyperactivity disorder (ADHD) medication, 34.1 percent.
“That’s what ‘dreadful’ is, only about a third of children on these medications get follow-up treatment,” Scholle says.
NCQA researchers are particularly disappointed in behavioral health results when they look at quality measures for other chronic diseases and see improvement. For example, blood pressure management shows steady improvement from 1999 to 2008 (with a break for a measurement change). Like behavioral health, blood pressure management involves not just clinicians, but patients who have to participate in their own care.
“That’s why we can look at these comparisons and say, improvement is possible,” Scholle says.
On the other hand, measuring behavioral health care quality faces several challenges. One is the lack of outcome measures.
“We don’t have the equivalent of an A1c [diabetes management test] for depression. So we don’t have a measure that looks at whether your depressive episode has resolved,” Scholle says.
That doesn’t mean researchers haven’t thought about it. Outcome measures for behavioral health would require widely accepted evidence-based practices plus the feasibility of collecting the data.
“It shouldn’t be our measure that drives practice. It should be, this is an accepted, evidence-based tool,” Scholle says. “Once that exists and people use it, then we can create a measure to say how well we are accomplishing that goal.”
To measure behavioral health, then, NCQA focuses on data that’s available, typically medication monitoring and follow-up visits, process rather than outcome measures. Such data is typically available on claims forms.
Another challenge to behavioral health quality measurement is silos in the health care system in which psychiatric medication might be offered in a primary care setting but stigma, patient apathy or plan limits could inhibit follow-up care with a specialist. Scholle thinks better coordination between behavioral health and primary care would enhance the overall quality of care.
“We need to think of ways to break down those barriers. Some will come from system reform, but some also has to come from individual players,” she says.
Bright spots in the report include a 12 percent jump in providing beta-blocker drugs to Medicare patients who had a heart attack within the previous six months, near universal care for people with asthma and significant gains in helping Medicaid beneficiaries stop smoking.
Evidence also shows that the quality of care varies among regions, with New England plans outpacing all others, particularly in care for diabetes and cardiovascular disease and in screenings for cancer.
The report attributes the lack of health care improvement to the economic downturn, which has driven health plan purchasing to focus primarily on cost control rather than coverage, which in turn prompts health plans to negotiate discounts rather than tout quality.
Another problem is that pay for performance is not being used enough, especially by the giant Medicare program, the report says.