Relationship between low quality-of-care scores and HMOs' subsequent public disclosure of quality-of-care scores

Context  Public disclosure of quality data on health maintenance organizations (HMOs) might improve public accountability, inform consumer decision making, and promote quality improvement. But, because disclosure is voluntary, some HMOs could subvert these objectives by refusing to release unfavorable data. Objective  To determine the association between HMO quality of care and withdrawal from public disclosure of quality-of-care data the subsequent year. Design and Setting  Retrospective cohort study of administrative and quality-of-care data on HMOs from the National Committee for Quality Assurance (NCQA) annual Quality Compass databases for 1997, 1998, and 1999, including Health Plan Employer Data and Information Set (HEDIS) quality scores. Main Outcome Measure  One-year rates of HMO withdrawal from public disclosure of HEDIS scores for plans in the highest and lowest tertiles of HEDIS scores, adjusted for method of data collection and plan model type. Results  Of the 329 HMOs that publicly disclosed HEDIS scores in 1997, 161 plans (49%) withdrew from public disclosure in 1998. Of the 292 HMOs that disclosed their scores in 1998 (including 130 newly participating plans), 67 plans (23%) withdrew from public disclosure in 1999. Plans whose scores ranked in the lowest-quality tertile were much more likely than plans ranking in the highest-quality tertile to withdraw from public disclosure in 1998 (odds ratio [OR], 3.6; 95% confidence interval [CI], 2.1-7.0) and 1999 (OR, 5.7; 95% CI, 2.7-17.7). Conclusion  Compared with HMOs receiving higher quality-of-care scores, lower-scoring plans are more likely to stop disclosing their quality data. Voluntary reporting of quality data by HMOs is ineffective; selective nondisclosure undermines both informed consumer decision making and public accountability.      

Paying for national health insurance--and not getting it

The threat of steep tax hikes has torpedoed the debate over national health insurance. Yet according to our calculations, the current tax-financed share of health spending is far higher than most people think: 59.8 percent. This figure (which is about fifteen percentage points higher than the official Centers for Medicare and Medicaid Services [CMS] estimate) includes health care-related tax subsidies and public employees' health benefits, neither of which are classified as public expenditures in the CMS accounting framework. U.S. tax-financed health spending is now the highest in the world. Indeed, our tax-financed costs exceed total costs in every nation except Switzerland. But the sub rosa character of much tax-financed health spending in the United States obscures its regressivity. Public spending for care of the poor, elderly, and disabled is hotly debated and intensely scrutinized. But tax subsidies that accrue mostly to the affluent and health benefits for middle-class government workers are mostly below the radar screen. National health insurance would require smaller tax increases than most people imagine and would make government's role in financing care more visible and explicit.     

Health care administration in the United States and Canada: micromanagement, macro costs.

A decade ago, U.S. health administration costs greatly exceeded Canada's. Have the computerization of billing and the adoption of a more business-like approach to care cut administrative costs? For the United States and Canada, the authors calculated the 1999 administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies; they analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies; they used census surveys to explore time trends in administrative employment in health care settings. Health administration costs totaled at least dollar 294.3 billion, dollar 1,059 per capita, in the United States vs. dollar 9.4 billion, dollar 307 per capita, in Canada. After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian. Canada's national health insurance program had an overhead of 1.3 percent, but overhead among Canada's private insurers was higher than in the U.S.: 13.2 vs. 11.7 percent. Providers' administrative costs were far lower in Canada. Between 1969 and 1999 administrative workers' share of the U.S. health labor force grew from 18.2 to 27.3 percent; in Canada it grew from 16.0 percent in 1971 to 19.1 percent in 1996. Reducing U.S. administrative costs to Canadian levels would save at least dollar 209 billion annually, enough to fund universal coverage.     

Taking care of business: HMOs that spend more on administration deliver lower-quality care.

The authors analyzed health maintenance organizations' administrative costs and quality measures from the National Committee for Quality Assurance's Quality Compass database for the years 1997-2000. HMOs with higher administrative overhead had consistently worse quality scores in univariate analysis. Multivariate analyses controlling for geographic region (all years) and HMO model type (1997 and 1998 analyses only) confirmed that higher administrative costs were associated with lower quality. Excess HMO bureaucracy is not only wasteful but harmful.