Southern California health plans, including Santa Ana-based PacifiCare Health Systems Inc., received mixed grades in a report card issued by a national group that monitors HMO quality.
The National Committee for Quality Assurance rated several hundred health plans in the United States in its Quality Compass 2000 report card. Quality Compass is a mix of performance data and patient satisfaction survey results.
The group’s ratings are used by some businesses when they pick managed healthcare service plans for their employees.
As for individual plans, a rating sample released by the committee showed that PacifiCare of California’s scores were lower than national or California health plan averages or both in six of 10 specific measurements included in the sample. The sample showed PacifiCare scored above both averages in using beta-blocker therapies after a heart attack and overall rating of health plan, while it scored above California but below national averages in getting care quickly and cholesterol screening.
PacifiCare of California representatives were not available for comment.
Quality Compass is just one dimension of overall standards for accrediting plans, said Barry Scholl, a spokesman for the quality-assurance committee.
“We have a whole set of standards,” Scholl said, adding that his group also takes into account health plans’ quality-improvement programs and their grievance and appeal procedures, among others.
“Pacific region plans do not have the highest scores,” Scholl said, noting that the plans score “well down the list” on member satisfaction measures and in the middle of the pack on clinical measures.
Quality Compass is partially based on what’s called the Health Plan Employer Data and Information Set. HMOs, large employers and the committee developed that system to help purchasers better understand what they were getting for their healthcare dollars.
Health plans voluntarily submit data to the committee for assessment. Because participation isn’t mandatory, some believe the report card is not the best way to measure HMO quality.
Some HMO officials, however, believe Quality Compass is an accurate measurement.
“It tells us that we provide high-quality care. We’re very pleased,” said Dr. John Brookey, physician director of quality for Kaiser Permanente Southern California.
Kaiser Permanente, which scored above national and California averages or both in eight of the 10 sample criteria released by the committee, uses Quality Compass information to drive internal performance improvement, Brookey said.
Brookey also mentioned fairness issues.
“All health plans are on a level playing field. The public has the ability to look across health plans,” he said.
“There are always opportunities to improve,” said Dr. Milton Schwarz, Aetna U.S. Healthcare’s Western regional medical director for quality. For example, Schwarz said, Aetna took the initiative to call plan members who have diabetes to urge them to be examined for diabetic retinopathy, a leading cause of adult blindness. Aetna’s score on Quality Compass’ comprehensive diabetes care/eye exams category was above the national and California HMO averages.
“Our general feeling is that the concept is very solid,” said Jeff Davis, chief operating officer of Long Beach-based Universal Care. Universal Care has around 40,000 HMO members in Orange County and also operates medical groups.
Davis said, however, the scores “may be more of a test of a plan’s ability to collect data rather than quality of care.” Universal Care, in the sample, scored below both national and California HMO averages on measures like getting needed care and getting care quickly, but scored above both in comprehensive diabetes care/eye examinations.
Quality Compass 2000 was based on 294 submissions encompassing 466 health plans. The figures are for 1999.
Here’s what the report had to say about three criteria:
n Getting Needed Care
This is intended to measure the ease with which members can get medically necessary healthcare. The national average score was 74.02, while California HMOs averaged 67.72.
Among Southern California HMOs, Kaiser Permanente had the highest score, with 73.18 points. Kaiser was followed by Health Net, PacifiCare of California, Aetna, Universal Care and Prudential. Cigna did not report data.
“One concern with managed care is that it may limit access to necessary care,” a Quality Compass summary said. “A relatively low score is an indicator of a potentially very serious management problem within the health plan.”
Much anti-HMO sentiment, whether through media “horror stories” or lawmakers’ attempts to increase regulation of plans, has been driven by patients’ perceptions that such plans attempt to keep premiums down and save money by limiting care.
n Getting Care Quickly
This is intended to measure the ability of HMO members to get necessary care at the provider level. Questions probed patients’ ability to get appointments and how long patients had to wait past their appointment times to see a provider. The national average score was 78.22, while California HMOs’ average score was 72.3. Locally, Health Net scored the highest, at 74.84, followed by PacifiCare, Prudential, Aetna, Kaiser Permanente and Universal Care. Cigna did not report data for this measure.
n Advising Smokers to Quit
That category looks at the percentage of adult smokers or recent quitters who received smoking cessation advice from health professionals who work with or within HMOs. The national average was 63.56, while the California HMO average was 60.42.
Kaiser Permanente’s score was highest, at 67.86, followed by PacifiCare of California, Prudential, Universal Care and Aetna. The category was not applicable to Health Net, while Cigna did not report data. n
