Do health plans influence quality of care?

OBJECTIVE: To investigate the relative impact of physician groups and health plans on quality of care measures. DESIGN: Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included. SETTING: Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997. MAIN OUTCOME MEASURES: Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate. RESULTS: There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with. CONCLUSIONS: There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.     

Choosing quality of care measures based on the expected impact of improved care on health.

Consumers, payers, and policymakers are demanding to know more about the quality of the services they are purchasing or might purchase. The information provided, however, is often driven by data availability rather than by epidemiologic and clinical considerations. In this article, we present an approach for selecting topics for measuring technical quality of care, based on the expected impact on health of improved quality. This approach employs data or estimates on disease burden, efficacy of available treatments, and the current quality of care being provided. We use this model to select measures that could be used to measure the quality of care in health plans, but the proposed framework could also be used to select quality of care measures for other purposes or in other contexts (for example, to select measures for hospitals). Given the limited resources available for quality assessment and the policy consequences of better information on provider quality, priorities for assessment efforts should focus on those areas where better quality translates into improved health.     

Primary health services in Ecuador: Comparative costs, quality, and equity of care in ministry of health and rural social security facilities

This study of costs, quality and financial equity of primary health services in Ecuador, based on 1985 data, examines three assumptions, common in international health, concerning Ministry of Health (MOH) and Social Security (SS) programs. The assumptions are that MOH services are less costly than SS services, that they are of lower quality than SS services, and that MOH programs are more equitable in terms of the distribution of funds available for PHC among different population groups. Full costs of a range of primary health services were estimated by standard accounting techniques for 15 typical health care establishments, 8 operated by the MOH and 7 by the rural SS program (RSSP), serving rural and peri-urban populations in the two major geographical regions of Ecuador. Consistent with the conventional premise, MOH average costs were much lower than RSSP costs for several important types of services, especially those provided by physicians. Little difference was found for dental care. The lower MOH physician service costs appeared to be attributable primarily to lower personnel compensation (only partially offset by lesser productivity) and to greater economies of scope. Several measures of the quality of care were applied, with varying results. Based on staff differences and patterns of expenditures on resource inputs, notably drugs, RSSP quality appeared higher, as assumed. However, contrary to expectation, a questionnaire assessment of staff knowledge and procedures favored the MOH for quality. Program equity was judged in terms of per capita budgeted expenditures (additional measures, such as the likelihood of receiving necessary care, would have required household survey data beyond the scope of this program-based study). The results support the assumption of greater MOH financial equity, as its program reveals less variation in budgeted expenditures between different population groups covered. Additional evidence of equity, using other indicators, would be helpful in future research. The paper's findings have policy implications not only for Ecuador's health sector but also for policy-makers in other countries at similar levels of socioeconomic development. These implications are spelled out in order to guide officials wrestling with issues of efficiency, quality, and equity as they search for the best use of scarce resources to promote health.     

Provider Perceptions of Reproductive Health Service Quality in Jordanian Public Community Health Centers

Enhancing the quality of reproductive health care delivery in developing countries is a key prerequisite to increased utilization and sustainability of these services in the target population. Our objective was to assess the perception of quality of reproductive health (RH) care services provided by Jordanian Ministry of Health community-based centers from the perspective of service providers in these settings. A purposeful nationwide sample of 50 primary health care providers took part in five focus group discussions with the purpose of exploring their perceptions of the quality of care provided by their centers and perceived barriers to the provision of quality RH care. Health care providers felt that the quality of RH care provided by their centers was suboptimal. Focus group participants reported numerous barriers to the provision of high quality-care in the clinical setting. These included issues related to patient overload, patient and physician characteristics, as well as problems inherent to supervisory and administrative functions. Exploring and aligning goals and expectations of RH care providers and administrators may result in improvements in the quality of RH care service delivery and morale in public health settings in Jordan, which is a requirement for public sector reform.     

Provider perceptions of reproductive health service quality in jordanian public community health centers

Enhancing the quality of reproductive health care delivery in developing countries is a key prerequisite to increased utilization and sustainability of these services in the target population. Our objective was to assess the perception of quality of reproductive health (RH) care services provided by Jordanian Ministry of Health community-based centers from the perspective of service providers in these settings. A purposeful nationwide sample of 50 primary health care providers took part in five focus group discussions with the purpose of exploring their perceptions of the quality of care provided by their centers and perceived barriers to the provision of quality RH care. Health care providers felt that the quality of RH care provided by their centers was suboptimal. Focus group participants reported numerous barriers to the provision of high quality-care in the clinical setting. These included issues related to patient overload, patient and physician characteristics, as well as problems inherent to supervisory and administrative functions. Exploring and aligning goals and expectations of RH care providers and administrators may result in improvements in the quality of RH care service delivery and morale in public health settings in Jordan, which is a requirement for public sector reform.     

Integrating the Financing and Delivery of Medical and Supportive Services for People Living With Dementia

The number of people living with dementia (PLWD) is expected to grow considerably in the coming years. PLWD often have substantial medical and supportive service needs and face fragmentation of services across payers and across health and social service systems; recently, efforts have been made to achieve greater integration of care and financing. This article considers issues related to integrating long-term services and supports (LTSS), medical care, and financing for PLWD; reviews the policy context and key clinical and delivery system challenges to these efforts; and describes key lessons regarding integration learned from examples in the field. Recommendations are provided and include the following: (1) assess carefully whether integration of medical and LTSS is required to achieve the intended outcomes of an intervention or program targeted at PLWD; if integration is needed, select carefully the types of medical and LTSS to integrate and the mode of integration; (2) use measures that evaluate quality across LTSS settings in which PLWD receive care; (3) assess whether and how eligibility and payment policies pose barriers to PLWD from receiving services they need, and evaluate ways in which policies might be reformed to meet beneficiaries’ needs; and (4) conduct research examining the potential of value-based payment efforts to improve the quality and efficiency of care received by PLWD, including their potential impact on out-of-pocket expenses and caregiving burden for PLWD and their families.     

Predicting and comparing patient satisfaction in four different modes of health care across a nation

This study aims to inform strategic policy makers and managers about the value of general population surveys by determining and comparing dimensions of satisfaction in four different health services in Scotland: general practice, domiciliary care, outpatients and inpatients (including day cases). The research design involved secondary data analysis of a national telephone survey conducted to inform the development of a national health plan. The database was created using a stratified quota sample of 3052 people of 16 years and above resident in Scotland in 2000. The main outcome measures investigated were overall measures of patient satisfaction with each type of service. Principal components analysis was used to determine the dimensions. Interest was in the extent to which patients, many of whom were the same (having used more than one service), evaluated different services in similar ways, as well as those factors specific to each service. Using logistic regression, the results demonstrate that interpersonal care and information, and desired improvements in service were universal and key explanatory dimensions in all services, followed by a combination of access, physical facilities, time and quality of food, depending on relevance to the service. These factors, particularly interpersonal care and information, distinguished well the highly satisfied from the others, with age providing further discrimination between non-hospital patients, while gender added to discrimination between inpatients. In conclusion, despite the limitations of telephone interviews, it is feasible to ask about several services at the same time and for the answers to reflect common underlying dimensions of evaluation found in more exhaustive research within each service. These factors offer a set of summary measures by which services can be easily evaluated at a strategic level and point to where efforts to increase patient satisfaction can be maximised.     

A criterion-based review of preventive health care in the elderly. Part 1. Theoretical framework and development of criteria.

The magnitude of health care resources devoted to care for the elderly is increasing; however, little is known about the efficacy of the services purchased with those resources. This is especially true in the area of preventive health care. In the absence of a consistent and comprehensive definition of health for the elderly population, it has been difficult either to establish criteria for evaluating preventive services or to assess the impact of those services. This article extends criterion-based review to the assessment of preventive services for the elderly. Health in the elderly can be defined by three related factors: the absence of disease, the maintenance of optimal function, and the presence of an adequate support system. Based on this definition of health, goals for preventive care should include compression of morbidity in addition to prevention of disease, and will require that quality of life be measured to completely assess the value of services. Unfortunately, existing measures of quality of life are difficult to apply to the elderly population, and there are no consistent societal values on which to base a new definition for quality of life. Because existing sets of criteria for the evaluation of preventive services do not address the distinctive health issues affecting the elderly, we have constructed a set of six criteria designed specifically for the well elderly population. In a companion article, we will apply these criteria to candidate preventive services for the elderly population to develop a geriatric health maintenance protocol for use in clinical practice.     

A review of the 'welfare state' and alternative ways of delivering health care.

There was no such thing as a public policy for quality health care in the inception of what we now address as the 'welfare state'. The main objectives of those supporting the idea, epitomized by the 'freedom from want' that Beveridge postulated in his now famous November 1942 Report on Social Insurance and Allied Services, was to extend the benefits of social insurance, that is access to services such as health care, to every individual. In the same fashion, post World War II initiatives in Latin America somewhat disregarded the intrinsic quality of health care services, provided they were distributed equally, at least among the urban people. Therefore, it is licit to ascertain that the main, albeit implicit, quality feature of health care was access, that is the ability to reach the entire population with the available services. The health care reform movement following the welfare state crisis, from the Jackson Hole group and Einthoven's managed competition in the United States to the internal markets proposals in different European countries, started when universal coverage had been achieved where it had been pursued, and disregarded elsewhere. In other words, access as a measure of health care quality was not the point. Instead, the subject of both academic research and administrative initiatives was the quality of the health services effectively provided to the population. Furthermore, the World Health Organization in its World Health Report 2000 explicitly excluded access as an item to be assessed in the process of evaluating health systems, although many countries had not achieved, nor were even near, universal coverage. Therefore, notwithstanding the relevance of the continuous quality improvement of the health services actually delivered to the people, access should always be the first quality concern to those health systems lacking universal coverage of the population they are supposed to serve.     

The impact of the introduction of user fees at a district hospital in Cambodia

Proponents of user fees in the health sector in poor countries cite a number of often interrelated rationales, relating inter alia to cost recovery, improved equity and greater efficiency. Opponents argue that dramatic and sustained decreases in service utilization follow the introduction of user fees, highlighting evidence that user fees reduce service utilization when they fail to result in improved quality of care and/or when services are priced higher than those charged by private health care providers. Utilization of public health services in Cambodia is low. Supply-side factors are significant determinants of such low public sector utilization, including low official salaries of service providers (forcing many to seek additional income in the private sector), and operations budgets which are erratic and often insufficient to cover running costs of service delivery outlets. The Cambodia Ministry of Health (MOH) encourages user fee schemes at operational district level. By allowing revenue to be retained at the health facility level, the MOH aims to improve health care delivery--and consequently service utilization--through increased salaries to health facility staff and increases in operations budgets. This case study of the introduction of user fees at a district referral hospital in Kirivong Operational District in Cambodia, using the findings from empirical research, examines the impact of user fees on health-careseeking behaviour, ability to pay and consultation prices at private practitioners. The research showed that consultation fees charged by private providers increased in tandem with price increases introduced at the referral hospital. It further demonstrates--for the first time that we are aware of from the available literature--that the introduction and subsequent increase in user fees created a 'medical poverty trap', which has significant health and livelihood impact (including untreated morbidity and long-term impoverishment). Addressing the medical poverty trap will require two interventions to be implemented immediately: regulation of the private sector, and reimbursing health facilities for services provided to patients who are exempted from paying user fees because of poverty. A third, longer-term initiative is also suggested: the establishment of a social health insurance mechanism.     

Retention of health workers in Malawi: perspectives of health workers and district management

Background  

Shortage of human resources is a major problem facing Malawi, where more than 50% of the population lives in rural areas. Most of the district health services are provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialists. As this cadre and the cadre of enrolled nurses are the mainstay of the Malawian health service at the district level, it is important that they are supported and motivated to deliver a good standard of service to the population. This study explores how these cadres are managed and motivated and the impact this has on their performance.     

Facing the cuts: a health authority's experience of rate-capping.

Health and social services in Britain are both publicly funded, but health care is provided centrally by the National Health Service while social services are provided by local government. Central government has sought to limit overall public spending by limiting the income of local authorities from rates (property taxes)--a policy known as rate-capping. In the face of this policy, one inner London local authority was forced to cut its social services budget in 1988/89 by 17%. We have compared the actual social service reductions with the perceptions, expressed in semi-structured interviews, of 69 health and social services staff. There was a perceived deterioration in social service provision, and indicators were suggested which would help health service staff to monitor these changes. There were also recent and more long-standing difficulties of communication between the two services, which limited joint working. The increasing emphasis on community care requires health authorities to cooperate more closely with social services at the local level.     

Assessment of Quality of Care for Managed Care and Fee-For-Service Patients Based on Analysis of Avoidable Hospitalizations

As managed care has grown to dominate the US health care delivery system, questions have been raised about the impact on the quality of care provided to its enrollees. Two important aspects of health care quality are access to care and the appropriateness of care. This analysis evaluated the occurrence of preventable hospitalizations among managed care (MCO) versus fee for service (FFS) populations to compare access to and appropriateness of preventive, primary, and surgical health care services. Rates of preventable hospitalizations associated with ambulatory sensitive conditions (ASCs) were calculated based on all discharges from Massachusetts hospitals in 1995, and categorized by population characteristics including: age, sex, ethnicity, and insurance status. Multivariate logistic regression models were employed to explain the likelihood of having a preventable hospitalization. Rates of preventable hospitalizations for two of the conditions evaluated (perforated appendix and diabetes complications) were lower for MCO enrollees. For two additional indicators (immunization preventable pneumonia and low birth weight), MCO rates were no different from FFS rates. Results for pediatric asthma were inconclusive. For four out of five quality indicators evaluated, individuals in Massachusetts MCOs are doing better or no worse than their counterparts in FFS plans. Until population-based data on managed care enrollees becomes available, and until such data can be linked to utilization and health outcomes information, investigations into the quality of services provided by MCOs compared to FFS plans cannot be definitive.     

6所乡镇卫生院住院病人的服务质量差距评价

目的对乡镇卫生院住院患者期望服务与感知服务的差距进行分析,探索服务质量差距的影响因素,提出弥合裂痕,提高卫生服务质量的措施。方法通过分层整群抽样方法对6个县被调查的乡镇卫生院538例住院患者进行统一的满意度问卷调查,运用服务质量差距模型对住院服务的6个要素和总体满意度进行患者满意度差距分析,并通过Kruskal Wallis秩和检验发现质量差距存在的主要影响因素。结果本次调查住院患者总体满意度的期望值和感受值存在差距,6个住院服务要素的感受值评分均小于期望值评分,且差距具统计学意义(P0.05,α=0.05);患者的年龄和职业是影响总体满意度差距的主要因素。此外,医生诊疗水平、护士服务质量的差距主要受患者年龄和职业因素影响,医生服务质量差距受年龄和生活状况影响,医患交流的质量差距受患者年龄、职业和生活状况的影响。建议目前乡镇卫生院的住院服务质量依然低于期望服务,各服务要素均存在改进的空间,要善于运用期望值和感受值的差距,结合差距存在的影响因素予以综合判断,建立合理的期望,在此基础上对农村基层卫生机构的卫生服务进行评价,制定相应的质量标准和质量控制办法。     

Needs in rare diseases during paediatric age

All rare diseases present a common set of challenges to the sufferers and their families: diagnosis, dealing with symptoms, health information, obtaining helpful medical care, availability of medications, disability and emotional impact. Children with rare disorders are an important population from health care services, and social services perspectives, and families are providing long-term care for these chronically ill children. The impact of rare disorders in children is far-reaching, extending beyond the child to all those with whom he/she has contact. Multiple facets of life are affected including social an family relationships, economical well-being and activities of daily living. The assessment of needs for rare disorders treatment is a critical step in providing high quality care and achieving patients' and families' satisfaction. Findings from different studies show that people with rare diseases have medical and social needs. Social needs are becoming more relevant in developed countries where health care services, even with limitations, have greater availability than social services. Furthermore, it seems that health care and social services for persons with rare diseases need to be improved to address the patients' needs and to provide better support to families. Validated tools with good psychometric properties are still needed to assess quality of care on the basis of patients and family needs.     

Assessing structure, process and outcome in palliative day care: a pilot study for a multicentre trial

Palliative day care is an expanding service which remains under-researched. Study designs need to be developed to evaluate the costs and outcomes of the service in ways which are meaningful to patients, clinicians and policy-makers. At the same time, these must be open to the same criteria for rigour and reliability as techniques used elsewhere in health and social service evaluation. To this end, a developmental stage of exploratory research was undertaken at the start of a major multicentre trial of palliative day care to meet two clear aims: to understand more about the structure and processes of palliative day care, and to identify ways in which service outcomes could be evaluated and measured. In-depth observations at five palliative day care centres were undertaken across one health region. This provided a better understanding of the models, outcomes and processes of palliative day care in five different environments. Centres represented the spectrum of medical and social care models and findings were analysed using an organisational systems approach. The findings showed that, despite the lack of a national strategic approach to developing the service, the centres all provided a core set of services which were broadly similar. However, differences in philosophy, ownership, and organisation affected how the services were provided and may have an impact on the costs of the service. The study has provided a more in-depth understanding of palliative day care services in order to design an effective research strategy for evaluating a service which crosses the boundaries of health and social care.     

A consumer-based tool for evaluating the quality of health services in the Israeli health care system following reform

Many countries have reformed their health care systems in the past decade and, as such, the need to monitor health system performance is widely recognized. In this paper we present a method for constructing quality indicators, which were used to evaluate the reformed Israeli health care system, and demonstrate the sensitivity of these indicators to change over time and to differences in quality among health plans and among population groups. The quality indicators were developed based on consumers' reports of their experiences in the health system. The indicators were measured in periodic population telephone surveys conducted between August and October of 1995, 1997, and 1999, using a structured questionnaire in Hebrew, Arabic, or Russian, this ensured the inclusion of all major sub-groups of Israel's population. Between 1080 and 1749 people were interviewed, with a response rate of over 80% each year. Using the theory-based evaluation approach, we specified the plausible causal links among intervention (components of the National Health Insurance Law), intermediate outputs (changes in health plan organizational behavior), and consumer outcomes. This led to the identification of indicators of quality of ambulatory health services, which included measures of accessibility, availability, patient satisfaction, performance of preventive medicine, and utilization of private medical services. The consumer-based evaluation tool presented in this paper was found to be easy to apply, sensitive, and relatively inexpensive. We hope that our approach will be of use to other countries that want to evaluate system-wide change and monitor quality of services over time.     

Gender and the utilisation of health services in the Ashanti Region, Ghana

The survey seeks to structure a model for gender-based health services utilisation for the Ashanti Region of Ghana, and in addition, recommend intervention measures to ensure gender equity in the utilisation of health services. A sample size of 650 covered over 3108 houses, and the main research instruments were the questionnaire and formal interview. A multiple regression model is used for the analysis of the relationship between the complex independent variables and utilisation by gender. Results show that although females have a greater need for health services than males, they do not utilise health services as much. Secondly, whereas quality of service, health status, service cost and education have greater effect on male utilisation than females, distance and income have higher impact on female utilisation. It is recommended that, to ensure equity in health care utilisation, females be empowered through increased access to formal education and sustainable income opportunities. The introduction of a national health insurance scheme is also recommended to ensure adequate access by both sexes.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

Look who's taking notes in your clinic: mystery shoppers as evaluators in sexual health services

Objectives To test the feasibility of professional patients as a tool for sexual health service evaluation. Professional patients are paid to use services specifically for audit or evaluation purposes without disclosing their identity as evaluators. Methods Professional patients visited five large sexual health departments used by 3000 clients per week in two inner London Boroughs with very high rates of sexual ill health. They recorded their experience on a structured evaluation form. Semi‐structured telephone interviews were completed with seven service providers to document their experience of the programme. Results Recruitment and training for professional patients is described. Forty professional patients made 105 visits during two rounds of visits 9 months apart. After 47% (round 1) and 62% (round 2) of visits, the professional patients felt that they would recommend the service to a friend. The professional patients provided detailed and specific feedback on all aspects of service provision. This information was highly valued by service providers who reported few objections from staff to the visits. A small number of examples of very poor care were documented. Conclusions Professional patients are a useful tool for sexual health service evaluation. They provide high quality feedback because they are both ‘experts’ on sexual health service provision and users of sexual health services. This method of evaluation raises ethical issues about the acceptability of deception as part of the evaluation process, the right of staff to anonymity and to refuse to be visited. Professional patient programmes provide an opportunity for regular cycles of user feedback to monitor quality improvement.