COALITION TEAMS WITH HMOS IN THE NAME OF QUALITY CARE

KANSAS CITY, Mo.-A Kansas City employer coalition is hoping it can improve health care quality and standardize outcomes data reporting by working side-by-side with area health maintenance organizations in crafting health plan objectives.

The coalition has established guidelines to help employers and HMOs contract on the basis of performance rather than other measures such as cost. The coalition anticipates that cost savings will be a byproduct of the program.

The objectives integrate wellness and preventive health, occupational health, high-risk pregnancy prevention, behavioral health and traditional medical care. They rely heavily on performance measures established by the Washington-based National Committee for Quality Assurance and the Portland, Ore. based Foundation for Accountability. The objectives also focus specifically on how health care is being delivered locally-something existing measures such as the NCQA "report cards" have yet to do.

Some health care industry experts say that the coalition's data collection goals are a fairly tall order, given that HMOs currently have limited data collection technology.

Still, the coalition is offering up "Model Performance Objectives for Employer-HMO Contracting" as a starting point for standardizing HMO performance measures, explained Robert L. Brown, president of the 100-member Mid-America Coalition on Health Care, which over the years has worked to develop a model voluntary private sector health reform initiative.

After the conclusion of a nine- to 12-month pilot project scheduled to begin this summer, the objectives will be implemented over a three- to five-year period, according to Mr. Brown. It took the coalition nearly two years to develop the guides.

"The coalition believes strongly that collaboration among employers and health plans is the most productive path for reform of the health system, improvement in the delivery of care and containment of health costs for employers and employees," he said.

"Wouldn't it be great for the Fortune 500 companies, including the five or six that are here, to agree on something like performance contracting? That way the health plans would say, 'Wow, we know what you're coming in for," Mr. Brown suggested.

Instead, "If you look at what employers are asking for in the country, and also locally, they're all frequently asking for different things or they don't ask for anything," Mr. Brown said.

While few industry experts are familiar with the coalition guidebook, as it was just released, those that reviewed it were impressed.

"It's nice to see they took a multi-employer approach," said Tim Beck, Buck Consultant Inc.'s Southern California health and welfare practice leader in Los Angeles. "If we can all get on the same page, then we can share the cost."

In fact, it was this quest for standardization that enabled the coalition to win the support of several Kansas City-area health plans, he said.

So far, three of the plans have agreed to participate in a pilot project implementing the objectives with five separate employer groups beginning this summer, according to Mr. Brown, who declined to identify the participants until the contracts have been finalized.

The objectives, outlined in a 90-page, two-part guidebook, also may serve as an alternative to state and federal proposals to mandate similar health care quality measurements legislatively, Mr. Brown suggested.

"There's no need for 50 different systems," he said, pointing to such moves as a recent proposal by the Missouri Legislature to require health plans to participate in a statewide data reporting program similar to the NCQA's HEDIS project.

That proposal, dubbed "MOHIS" for Missouri Health Information Set, died in committee last month.

Besides attempting to standardize HMO data reporting, the coalition's guidebook directs employers and health plans to work together on developing preventive health strategies and programs, many of which the NCQA has identified as worthwhile.

In fact, it was the HEDIS project that helped the coalition prioritize preventive health areas that produce the greatest benefit in terms of total cost, improved outcomes of care and higher employee satisfaction and productivity in the workplace, according to Mr. Brown.

"The employers, when they get that focus, can do so many things in the workplace," such as offering incentives to encourage employee participation in periodic health exams, health risk appraisals, screenings and tests, he said.

As part of its wellness objective, the guidebook also offers suggestions for improving occupational health and safety, drawing from recommendations made by the Centers for Disease Control and Prevention in Atlanta.

This was an effort to get the health plans more involved with wellness and injury prevention programs usually provided to employers by unrelated outside vendors, Mr. Brown explained.

"This approach is an effort to bring the parties together to talk about a plan," he said. "You need a game plan that takes you along a track that you both are monitoring."

The coalition thinks such coordination will not only improve employees' overall health quality, but reduce workers compensation claims as well.

"The focus is truly on the employee and recognizes that the employee doesn't just punch out at 5 o'clock," observed Mr. Beck of Buck Consultants.

"This is the beginning of a truly integrated approach," he said.

Ultimately, the coalition hopes such coordination will cut health care costs across the board.

"The employer could expect that HMO management would be prepared to reduce its rate to the employer if lower utilization rates occur and the employer makes greater use of wellness promotion and illness prevention programs in the worksite to slow cost levels down and improve outcomes," the guidebook states.

"Savings to the HMO should be passed on to employers under agreed-upon terms. In effect, a modified experience-rated HMO product will evolve serving as an incentive to major purchasers to establish preventive health and early treatment strategies in health benefits management," the document suggests.

Mr. Brown acknowledged it will be difficult to implement the objective that HMOs break out each employer's experience individually.

"Employers have no interest in national databases," Mr. Brown said. "They're more curious about their own workforce."

For example, rather than receiving information on the rate of an HMO's Caesarean-section deliveries or mammograms nationwide, an employer is more interested in finding out what percentage of its employees have undergone such procedures, he explained.

This objective will be difficult to achieve-few, if any, HMOs have the technology necessary to do such individualized reporting, health care industry experts warn. Because HMO physicians receive a capitated fee, there's no need for the HMO to track individual procedures.

"It's a very tall order," said Buck's Mr. Beck. "A very expensive order. One of the big problems we face is data collection. They (health plans) simply aren't set up to do this kind of data tracking."

"Plans have been good about cooperating with requests for data, but if every employer started asking for specific data, it would be overwhelming," said Dr. Christopher H. Coulter, executive director of UltraLink, a Costa Mesa, Calif.-based subsidiary of Allianz Life Insurance Co. that provides network management, consulting and administrative services to major employers.

In fact, most HMOs today are pretty much on the "honor system" when they report their HEDIS measures to the NCQA, as they don't have ready access to patient records, he said.

Because "much of the health care information is still sitting in physicians offices," the HMOs must accept each doctor's estimation of how many patients received procedures measured by HEDIS, Dr. Coulter explained.

Besides, "We've only had data from HMOs in the last 12 to 18 months," points out Armando Baez, a principal with UltraLink.

"We're at the beginning stages. At some point in the future, everything will be computerized. But for now, HMO resources are focused on other areas," he said.

But even though such data collection systems may not be in place yet, "the point is to set some goals, to give some direction," Mr. Brown insisted.

The coalition's data collection guidelines "provide a minimum level of information, and we can build on it," agreed Buck's Mr. Beck.

"You've got to start someplace," observed J. Robert Dinneen, a coalition board member and assistant vp of corporate benefits for Sprint in Westwood, Kan.