Report measures quality of HMO care Columbia Medical Plan is among top five in national ratings

THE BALTIMORE SUN

WASHINGTON -- In a move that will help consumers and employers compare the quality of health plans, an industry group yesterday released a report that places the Columbia Medical Plan among the top five for "quality of care" in the country.

Using data available to the public for the first time, the report measures plans' performance in dozens of ways such as the percentage of immunized children, the rate of births by Caesarean section and the percentage of doctors who are accepting new patients.

The report by the National Committee for Quality Assurance does not rank plans overall.

However, it shows how each plan compares on each measure with the rest that participated and with national and regional averages.

Columbia, which is owned by Blue Cross Blue Shield of Maryland, scored in the top 10 percent of plans in five of the six measures that indicate quality of care.

Only four other plans in the country rated that high in four or more measures.

They were Harvard Community Health Plan (Boston area), Fallon Community Health Plan (Worcester, Mass.), Welborn Health Plan Evansville, Ind.) and Central Minnesota Group Health Plan (St. Cloud, Minn.).

Until now, while many health plans collected the data, and sometimes made it available to benefits consultants or employers looking to buy insurance, there was no single source for the data.

"Basically, I think this is going to change the rules of the game," said Dr. Cary Sennett, vice president of NCQA, pointing toward some 6,000 pages of report, a stack more than a foot high.

"This should help move the market from price competition to competition on the basis of quality."

Altogether, 226 managed care plans across the country, including eight serving several hundred thousand Marylanders, agreed to allow their data to be made public.

Some others contributed data that was counted toward the averages but was not made public.

While fewer than half of the HMOs across the country participated, and the science of measuring quality is in its infancy, the effort is significant, experts said.

"Many experts believe that without this infrastructure, the health care system will implode in its quest for greater cost savings," said Jonathan Weiner, professor of health policy and management at the Johns Hopkins University School of Hygiene and Public Health.

Among the other Maryland plans, Kaiser Foundation Health Plan of the Mid-Atlantic ranked in the top third in the country in most quality measures. Other plans were in the middle range.

Doctors at NYLCare, which covers about 190,000 Marylanders, said they have used the NCQA data to target their efforts.

They're using computer records to remind specific patients -- and their doctors -- about their missed mammograms or immunizations, said Dr. Raymond Turner, vice president and chief medical officer.

At Kaiser, physicians said tracking the data allowed them to boost their screening of diabetics for retinal disease by 8 percent from 1994 to 1995, thereby helping to prevent or delay blindness, said Dr. Larry Oates, associate medical director.

While Columbia ranked high in the "quality" measures, there were other categories in which it did not do nearly so well.

For example, it was in the bottom third of participating plans in staff turnover.

Dr. Jon Shematek, medical director of quality improvement at Blue Cross of Maryland, which runs five HMOs including Columbia, said the poor figure could be explained by Columbia's smaller number of physicians.

The plan has 120 full-time staff physicians, Shematek said, and if just a few leave, that could make its turnover rate similar to that of a different type HMO -- in which thousands of physicians in private offices participate.

Columbia's high scores in quality also may be attributed to the type of plan, Shematek said.

Its physicians are more tightly managed than those in other style HMOs. Much of their success is also due to the tracking systems in place in managed care, he said.

Employers said the data will help as they search for the best plans, but they are looking for new measures that will truly show how good the care is.

The percent of children immunized, for instance, doesn't show how many children ended up sick, said Russell Long, vice president of the Mid-Atlantic Health Care Purchasing Coalition.

The data have other weaknesses. Many of the measures are based on relatively small samples, Weiner noted.

And plans that have sicker populations, in the inner city, for example, are penalized because the data are not adjusted to account for that.

In some of the categories, it is not clear whether a plan is doing well or badly. For example, a low rate of hospital admissions could mean the plan is keeping its members healthy, or it could mean the plan is denying needed care.

Also, only two preferred provider plans -- managed care plans with loose networks of physicians -- were reviewed. Traditional fee-for-service plans, in which patients pay per service and can go to any physician, aren't included because they typically can't collect this data.

The state of Maryland, through the Health Care Access and Cost Commission, is devising its own HMO evaluation. The agency will take NCQA's data and audit it independently, as well as conduct member surveys. The first report cards should be out in fall 1997.

"It's a great step forward and will make it really much easier to compare plans," said Cheryl Fish-Parcham, a health-policy analyst with Families USA, a consumer advocacy group.

"The challenge in the years ahead will be to get more plans to participate, and to make sure that employers and others do make the information available to consumers."

Within a few years, NCQA hopes to produce a report aimed directly at consumers.

Given the mass of data and the cost of the report -- $2,000 for a multi-volume printed version, $3,200 for a CD-ROM with complete data -- NCQA said, most consumers will have to get the information from "intermediaries," such as employers, unions and libraries.

Eventually, NCQA hopes to develop better measures of whether HMOs are keeping their patients healthy and curing them when they are sick.

NCQA expects the release of the data to put pressure on more HMOs to make data public.

"What we think is going to happen is that a lot of phones are going to start ringing at plans that didn't submit data," said Margaret O'Kane, president of NCQA.

Mid Atlantic Medical Services (MAMSI) and Aetna are among the Maryland plans that did not participate.

Mike Savage, spokesman for MAMSI, said the plan didn't have its numbers ready for the June 14 deadline but will be included when an updated version of the report is issued this fall.

Aetna officials said they are also considering participating then.

Rankings for Maryland HMOs

A new report provides data on health plans in dozens of categories. This chart shows the percentages in some categories and the ranking compared with other plans, with 1 the highest and 5 the lowest:

CareFirst-

Potomac-

FreeState*

Child vaccine -- 84.1% (3)

Breast screening -- 66.4% (4)

Prenatal care -- 86.8% (3)

Caesarean section rate -- 20.6% (3)

Board certified specialists -- 86.9% (3)

Cigna

Child vaccine -- 74.4% (3)

Breast screening -- 68.6% (3)

Prenatal care -- 96.1% (1)

Caesarean section rate -- 21.0% (3)

Board certified specialists -- 81.8% (3)

Columbia*

Child vaccine -- 96.0% (1)

Breast screening -- 79.9% (1)

Prenatal care -- 97.3% (1)

Caesarean section rate -- 22.3% (4)

Board certified specialists -- 90.9% (2)

Delmarva*

Child vaccine -- 86.4% (2)

Breast screening -- 76.5% (2)

Prenatal care -- 90.1% (3)

Caesarean section rate -- 18.8% (3)

Board certified specialists -- 80.2% (4)

Kaiser

Child vaccine -- 91.8% (2)

Breast screening -- 76.8% (2)

Prenatal care -- 93.5% (2)

Caesarean section rate -- 16.9% (2)

Board certified specialists -- 96.4% (1)

NYLCare

Child vaccine --79.7% (3)

Breast screening -- 74.2% (2)

Prenatal care -- 90.9% (3)

Caesarean section rate -- 23.8% (4)

Board certified specialists -- 81.0% (3)

Prudential-HMO

Child vaccine -- 65.8% (4)

Breast screening -- NR

Prenatal care -- 60.3% (5)

Caesarean section rate -- 21.7% (4)

Board certified specialists -- 85.0% (3)

Prudential-POS

Child vaccine -- 68.5% (4)

Breast screening -- 69.8% (3)

Prenatal care -- 72.5% (5)

Caesarean section rate -- 29.6% (5)

Board certified specialists -- 97.0% (1)

Nat. HMO avg.

Child vaccine -- 77.7%

Breast screening -- 68.7%

Prenatal care -- 87.8%

Caesarean section rate -- 19.3%

Board certified specialists -- 82.5%

What the rankings mean:

1 -- in the top 10 percent of participating plans

2 -- in the top third but not the top 10 percent

3 -- in the middle third

4 -- in the bottom third but not the bottom 10 percent

5 -- in the bottom 10 percent of participating plans

What the categories mean:

Child vaccine -- received four key immunizations in first two years of life

Breast screening -- women ages 52-64 receiving mammograms (breast cancer test) within past two years

Prenatal care -- women for whom care began during first three months of pregnancy

Caesarean section rate -- percent of births to women ages 15-34 by surgical procedure

Board certified specialists -- doctors who have met training and testing requirements for their specialty

* -- Plans owned by Blue Cross and Blue Shield of Maryland

NR -- Not reported by the health plan

HMO -- Health maintenance organization; all care provided by doctors in plan

POS -- Point of service plan; partial benefits for care provided by doctors outside of plan

SOURCE: National Committee for Quality Assurance

Pub Date: 8/22/96

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