Quality-of-Care Improvement in Open-Access Health Insurance Plans

Huda Fadel; Kathy Laing
Abstract: Demand for open access to providers and less health plan management has fueled enrollment preference for preferred provider organizations (PPOs) over health maintenance organizations (HMOs). These same features, however, create challenges for measuring and improving the clinical quality of care delivered in these plans. Quality technology has been adapted from HMO models where appropriate, yet the lack of physician accountability and information infrastructure support has required PPOs to manage quality in innovative and collaborative ways. In this article, challenges and some of the solutions are discussed, using examples from a large PPO plan.

Key Words
health maintenance organizations
preferred provider organizations
quality improvement

Enrollment trends for commercial health insurance indicate consumers prefer greater freedom in selecting providers and less medical management and utilization controls over traditional health maintenance organization (HMO) models. More than half of commercially insured individuals are now covered by a preferred provider organization (PPO) plan, making PPOs the most common and fastest growing form of healthcare coverage (Kaiser/HRET, 2002).

The last decade has seen measurable improvement in quality of care, yet large gaps remain between the care people should receive and the care they actually do receive in all types of health plans (Jencks et al., 2000; Schuster, McGlynn, & Brook, 1998), entailing excess costs and poor health outcomes. It is expected that quality improvement (QI) will remain a necessary function of any health plan, but the trend toward open access* has important implications for how these activities are implemented and accomplished. Certain PPO characteristics create challenges for measuring and improving quality that are not as problematic in traditional HMOs. The chief obstacles to clinical quality measurement and improvement in PPO plans are (1) weak provider accountability processes and (2) lack of information structure and detail, such as access to clinical data supportive of quality measurement. As the health plan market evolves, these issues are no longer limited to PPOs, but are also seen in newer HMO models that employ larger provider networks and relaxed medical management controls. Thus, the trend toward open access has implications for the ability of all health plans to achieve QI goals.

The processes and methods for measuring and applying evidence-based medicine were built predominantly on the traditional HMO gatekeeper model. Such QI technology must now be transferred to PPOs and open-access insurance products. For these plans, the imperative derives more from customer demands than accreditation agencies that have begun to measure quality of care in PPOs only recently. Healthcare purchasers maintain a focus on clinical quality in all health plans offered to employees. With double-digit premium price increases, health plans that balance cost and quality have a competitive market advantage.

This article discusses quality measurement and QI in an open-access insurance environment, based on the experience of Blue Cross Blue Shield of Michigan (BCBSM), the largest insurer in Michigan, where more than 4.3 million members (i.e., 90% of membership) are enrolled in some type of open-access plan. Examples of studies conducted by BCBSM’s Center for Health Care Quality and Evaluative Studies illustrate ways of overcoming the challenges of measuring and improving quality in these plans.

Overcoming the Accountability Challenges in Open-Access Insurance

Promoting beneficial evidence-based medicine and limiting overuse or inappropriate use of services underlies QI initiatives. Health plans use information feedback on physician practice and performance to achieve these objectives.

Identification of the individual physician best able to receive and act on quality information is a defining difference between HMO and PPO models and is the primary challenge facing open access plans. Although many PPO and indemnity plan members have a regular provider, this relationship is not part of the members’ insurance or membership records, making attribution difficult, though not necessarily impossible. It is important to overcome this challenge, because the value of conducting quality studies and using claims information for QI is enhanced greatly when that information is collected across patients and presented to the physician providing care.

Administrative data may be used to make inferences about such relationships. Claims for office visits are usually used to assign patients to responsible providers for the purpose of receiving feedback information or profiles. Claims for consultative, emergency department, and one-time services are not used because these visits seldom reflect ongoing care for a particular disease. When study patients are identified through claims for services other than office visits, they are included only in the study population to determine the aggregate rates for quality indicators. This group of patients is categorized as a “nonaffiliated” subgroup in the study results and their individual results are not included in the feedback report to an individual physician. Conversely, when a study population member who received a test or service is affiliated with a physician through one or more claims, all physicians who filed claims for that patient during the period with the study diagnosis receive “credit” for the service or test, regardless of who ordered it. This “one to many” relationship permits physician feedback of individual patient results in the spirit of information for quality-of-care improvement despite the lack of an accountable primary care provider (PCP) in the traditional HMO sense of the term.

A second challenge to implementing im-provement occurs because open-access plans traditionally operate as insurers, not care managers. Confidentiality provisions can be stricter than those of HMOs, creating impediments to the sharing of clinical information between health plan and providers. The difference in privacy protection occurs because HMOs and PCPs are responsible contractually for managing member care. Members of HMOs are made aware of this and consent to this when enrolled.

BCBSM shares with individual physicians the list of their patients identified as having a specific medical condition (e.g., diabetes, persistent asthma, and so on) and balances confidentiality with the need to divulge QI information. Details regarding services that individual patients did or did not receive based on claims from other providers is not shared, because this would be a breech of confidentiality. In open-access plans whereby members may see any provider without referral, the plan may not divulge to another provider the services provided. Because care management in open-access products is self-directed, there are few contractual incentives or requirements for care management. There is not a specific physician care manager with whom the patients’ decisions to act (or not act) need be shared.

Overcoming Information-Structure Challenges

The QI process begins with selection of clinical study topics in accordance with generally accepted QI theory. Selection criteria include high cost and/or prevalence of disease or condition, existence of evidence-based clinical guidelines, availability of benchmarks, evidence of a strong positive correlation between processes and outcomes of care, and opportunity to act on the study results. Even though open-access plans are not commonly accredited by the National Committee for Quality Assurance (NCQA), they will often begin with Health Plan and Employer Data Information Set (HEDIS®) measures, as these are well-established and widely accepted methodologies for quality measurement.

In an open-access plan environment, the choice of study topic is highly influenced by the ability of information systems to provide necessary information. Because these plan managers rarely have contractual access to patients’ medical records and other clinical data for quality assurance, open-access plan managers are only able to collect and use administrative data, comprising primarily inpatient, outpatient, and pharmacy claims files and enrollment records. Given that the primary purpose of an insurance claim is for reimbursement of services rendered, the practical reality of using these sources of data for secondary analytic purposes introduces several opportunities for error and other difficulties that must be recognized and accommodated for in the analysis. Examples are provided in Table 1. A second challenge is that these data may provide an incomplete medical profile of a patient. Common sources of these limitations are described in Table 2.

Administrative data may be useful for QI if limitations are explicitly recognized and creative thought is used to modify HEDIS or other measurement methods. Examples of modifications used at BCBSM follow. Al-though these modifications preclude comparison to the pure NCQA HEDIS benchmarks, they are meaningful for investigation, reporting, and benchmarking of QI on the health plan level.

1. Information gaps are controlled by limiting the study population to members with known and relevant benefit coverage. Filtering may preclude accounting for the entire population; however, it ensures that findings are accurate and actionable.
   • Example 1: Controlling for benefit coverage is a concern when the quality of diabetes care is assessed according to evidence-based guidelines. Important services are carved out to external vendors, such as laboratory and vision benefits, both of which have a significant effect on the ability to collect data on hemoglobin HbA1c, lipid testing rates, and retinal examinations. The best way to measure the quality of diabetes care accurately is to exclude these members and focus on those known to have full coverage with the insurer. The disadvantages are the exclusion of known diabetics from the overall study denominator and the potential bias it may create. In smaller health plans, rate calculations can be unreliable, if numbers become small enough. Similar issues occur in measuring other benefits that are often carved out, such as mental health/substance abuse care and prescription drugs.
   • Example 2: Study populations are also limited to control for the presence of other insurance payment. Findings from BCBSM studies show that quality of care measures are typically lower for dependents than for contract holders within a family group, indicating a possible absence of claims due to the coordination of additional insurance benefits from other family members. To control for this potential information bias, the study population is analyzed and reported by subgroups of contract holders and dependents. This small adjustment helps control for the presence of other insurance and the degree of variation.
2. Guideline measurement methodology is modified. The HEDIS methodology for hypertension measurement and guidelines recommended by the Joint National Committee on Prevention, Evaluation and Treatment of High Blood Pressure require that blood pressure readings be obtained from medical records. Like many open-access plans, BCBSM contracts allow medical record review for fraud and utilization management purposes, but exclude quality of clinical care measurement. To address quality in this area, BCBSM devised an alternative case-finding algorithm that combines medical and pharmacy claims to identify people with hypertension.
3. Guideline measurement methodology is extended. Studying drug treatment continuation, the next level of evaluation after determining the presence/ absence of a prescription, again presents a challenge for open-access products that do not allow user access to medical record data. In such cases, BCBSM begins with the specific evidence-based methodology for adequacy of therapy and enhances it with other indicators that can be measured with administrative data. For example, HEDIS defines adequate treatment of depression as a scenario whereby the patient has enough medication to last at least 67% of the first 84 days of treatment. BCBSM applies an additional criterion: The patient must be taking the minimum daily dose of medication at the end of the 84th day, based on guidelines from the American Psychiatric Association for antidepressant drug classes. Again, the tradeoff is one of a smaller, but more accurately defined study population. Because of high enrollment, this still represents a large number of patients.
4. Validity of findings are tested. To validate the results of quality studies using administrative data, random sample medical record review is used in the initial year of major new studies to validate the study methodology and the results through comparison of administrative data with medical record data. Administrative data alone tend to slightly overcount the denominator (i.e., the study population) and slightly undercount the numerator (i.e., the desired event), resulting in undercounting of the rate. In other words, there is a degree of error expected in rates based on administrative data, resulting in conservative results—understated rather than overstated.

QI

In spite of such challenges, many health plans are developing and implementing a number of member-focused interventions that work in an open-access environment. At BCBSM, study results and related health-education information are published in member and provider publications and on the BCBSM Web site. An Internet-based member-driven health information system is available to provide information that members may search and tailor to their own needs. Care and disease management programs are also available as additional tools for reaching individual members and improving quality of care.

Because physicians are key players in QI, it is important to seek opportunities to develop interventions that involve the provider community. Market share and number of pro-viders contracted are important advantages in terms of type and degree of influence over provider behavior. Consequently, although there may not be the financial incentives found in managed care provider contracts, open-access products do have contractual relationships with providers that may otherwise be used to advantage.

There are several provider-focused interventions for improving quality of care in open-access products. As with most health plans, BCBSM disseminates study results and related activities in its provider publications. For selected disease-specific studies, such as diabetes and asthma, BCBSM provides individual physicians with performance reports, or profiles, that display their own rates compared to guideline recommendations, specialty group peers, and best in class. In the initial year of profiling a study topic, a provider feedback survey is included. The profiles are sent solely as information for use in individual practice assessment and QI activities. Although the overall results of a quality study may be accurate, individual physician profiles may be less accurate, so information is provided only for self-assessment and improvement purposes.

In a more active role, BCBSM partners with area health systems and community coalitions on QI initiatives. In each case, BCBSM leverages its large data and analysis resources, which are essential elements for assessing care of chronic illnesses. The health system leadership and clinical experts champion physician QI initiatives at the individual, hospital, and system levels. In these community partnerships, coalition members use the information to support member-focused initiatives with their populations on the local, county, and state levels.

Finally, in the QI spirit, surveys are used to improve study methods and approaches in sharing information with physicians. Survey results were generally neutral to positive; most providers consider the information relevant. Survey return rates have been low (e.g., 17% or less), so care must be taken in generalizing the feedback to the provider population.

Example One: Improving Quality Through a Collaborative Partnership with a Community Coalition
The sample profile was used to support the Michigan Quality Improvement Consortium (MQIC) asthma initiative designed to improve provider compliance with evidence-based guidelines. BCBSM plays a leadership role in the MQIC, a collaboration of regional HMOs, physician organizations, and community health groups with the goal of promulgating statewide consensus-based clinical guidelines and encouraging provider awareness and compliance. The MQIC disease-specific guidelines are mailed to all primary care physicians in the state annually, along with tools to assist in implementation. MQIC members followed up by mailing an asthma care performance-reporting packet (including the profile, shown in Figure 1) to the providers to reinforce the guideline message of optimizing care for members with persistent asthma. A similar initiative was conducted for members with diabetes. Outcomes results are not currently available, although evaluation plans are in place that will track MQIC providers over time and conduct subsequent remeasurement to determine the degree of improvement in guideline compliance as a proxy for improved asthma disease management.

Example Two: Improving Quality Through a Collaborative Partnership with a Multi-Hospital Health System
BCBSM also partners with interested provider systems and groups to support their QI efforts. In one such partnership, BCBSM collaborates with a nine-hospital system to conduct diabetes and asthma quality measurement studies. The results of the studies are used to develop aggregate profiles for each hospital and for the total system, as well as individual profiles for each provider in the system. With the active support of the system’s medical leadership, QI initiatives were launched at both the hospital and provider levels. Subsequent evaluation of these efforts shows measurable improvement in care. Rates of HbA1c testing rose from 46% to 64% from 1996 to 1998 and finally increasing to 70% in 2000. Comparatively, increases over the same period were seen in the total Michigan population, but increases were not as dramatic. In this case, physicians in the health system are independent contractors (not employees), so the data were not accessible to the hospital system. BCBSM was able to fill this gap in their QI efforts by providing data that were not otherwise available, measurement expertise, provision of benchmarks, and high-quality reports.

Conclusions

Open-access insurance plans allow members to capitalize on a wealth of administrative data by turning data into actionable information for quality of care improvement. The approach differs from that used with HMOs, but its pursuit can nonetheless yield positive results. Success requires creative thinking about the major challenges posed by plan features—physician accountability and information availability—and a maximization of the plan’s strengths, which may include large amounts of data and strong market presence.

At BCBSM, application of HEDIS or other established performance measures is a good start, requiring only some modifications to accommodate the reliance on claims and enrollment data alone. True QI is furthered by collaboration with community and provider partners in the healthcare system. Although BCBSM is unique because of a strong market presence in Michigan, this experience may be readily adapted to other organizations offering open-access insurance products. The formation of regional community health coalitions and employer group purchasing collectives suggest that smaller plans can see similar improvement through those avenues.

As the healthcare insurance market continues to evolve, indications are that PPO plans will continue to grow at a rate outpacing other product types. To the extent that these plans commonly employ fee-for-service reimbursement systems, special attention must be paid to monitoring utilization and minimizing the delivery of unnecessary and inappropriate services that diminish quality of care. The increasing trend toward individual employer group customization and consumer directed health plans will require new techniques for recognizing administrative data limitations while improving care quality. Similarly, more HMOs are offering “less managed” managed care products, blurring the distinction among insurance plans and products further. As these trends continue, it will increase the attention paid to managed care and the need for meaningful and measurable clinical quality of care in open access plans.

*Due to the growth and prominence of PPOs in the healthcare delivery system, the focus of this discussion is on PPO insurance products. However, traditional fee-for-service and indemnity products also offer relatively unrestricted access and provider choice and can be included under the “open access” umbrella.

Acknowledgments
The authors thank David Share, MD MPH, Susan Rubin, MPH, Michael J. Connor, DrPH, and Cheryl Dean of BCCSM and Mary Madison, MPA, Nadine Caputo, MS, of the Blue Cross Blue Shield Association for their assistance in conceptualizing and reviewing many drafts of this manuscript.

References
Holmes, J.S., Shevrin, M., Goldman, B., & Share, D. (2004). Translating research into practice: Are physicians following evidence-based guidelines in the treatment of hypertension? Medical Research and Review, 61(4), 453–473.

Jencks, S.F., Cuerdon, T., Burwen, D.R., Fleming, B., Houck, P.M., Kussmaul, A.E., Nilasena, et al. (2000). Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA: The Journal of the American Medical Association, 24(13), 1670–1676.

Kaiser Family Foundation and Health Research and Educational Trust [HRET]. (2002). Employer Health Benefits, 2002 Summary of Findings. [Online]. Available: http://www.kaisernetwork.org/health_cast/uploaded_files/transcript_kff-hret.pdf

Schuster, M.A., McGlynn, E.A., & Brook, R.H. (1998). How good is the quality of healthcare in the United States? The Milbank Quarterly, 76(4), 517–564.

Authors’ Biographies
Huda Fadel, PhD MPH, is the manager of Health Services Research in the Center for Health Care Quality and Evaluative Studies at BCBSM, Detroit, MI. Her previous positions were at the University of Michigan Health System, Pfizer, and in the Department of Veterans Affairs. She received her doctorate from the University of Michigan School of Public Health.

Kathy Laing, MBA RN CPHQ, is a project manager in the Center for Health Care Quality and Evaluative Studies at BCBSM. She spent 13 years in a variety of clinical and administrative positions in settings across the healthcare continuum, including acute care, long-term care, behavioral health, and public health. Laing is also a former chair of the Healthcare Quality Certification Board of NAHQ.

For more information on this article, contact Huda Fadel by phone at 313/225-7175 or by e-mail at hfadel@bcbsm.com.