Continuous Improvement and the Expansion of Quality ... - NCQA

18
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
members. Purchasers that want to expedite performance gains may want to create incentives
around measures where there has been little progress.
Public reporting alone might not be a strong enough incentive to lead to change. The record on overuse
measures is disappointing, and suggests other factors are at play. for example, we have seen virtually
no change during the six-year history of Use of Imaging Studies for Low Back Pain. And although
overuse of antibiotics leads to development of antibiotic-resistant strains of bacteria, performance on
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis has worsened, falling from almost
29 percent (successful avoidance) to 22.5 percent for commercial HMos in 2010. one reason for this
might be that providers have difficulty resisting patients’ demand for a pill to address symptoms.
Implications: a vision of High-value Health Plans
In the 1990s, many policy makers thought health plans were the vehicle to better quality of care
and lower costs. The notion of “managed competition” underpinned the Clinton health reform
proposals. Proponents envisioned that health plans would compete on cost, and drive consumer
choice through transparency. HMos would combine their insurance function with active
management of patient care. Advocates saw opportunities to avoid emergency room use and
hospital care by improving benefit design, networks and other programs.
What happened instead was “managed care backlash”: members rebelled against limited
provider networks and utilization review. 1 And the rise of self-insured employers led to increased
contracting with PPo networks, rather than with full-risk-bearing HMos.
one big difference between earlier ideas about health reform and the 2010 Patient Protection
and Affordable Care Act (PPACA) is an expectation that change should happen in the health
care delivery system. The locus is the clinician’s office—and, to a lesser extent, the hospital.
Programs like PCMH and the Meaningful Use of Health Information Technology (HIT) initiative
push small practices to track patients’ care over time and across settings and to report and
benchmark their performance against quality measures derived from medical evidence.
The ACo program reflects this vision on a larger scale. The model involves a collection of
clinician practices (and possibly hospitals) taking collective responsibility for improving patient
care and lowering costs.