Report finds gaps in health care quality

The National Committee for Quality Assurance's recent annual report found that between 42,000 and 79,000 avoidable deaths are caused by gaps in health care quality.

But the report contained a bit of good news as well: For the fifth year in a row, NCQA's measures indicated that more physicians were following evidence-based guidelines in areas such as managing chronic conditions, administering recommended immunizations, screening for cancer and providing beta-blocker treatment after heart attacks.

The NCQA study includes information on the use of its Health Plan Employer Data and Information Sets (HEDIS) measurements by 563 reporting health plans covering more than 69 million people. Gains of about 4% were reported for evidence-based guideline adherence in several key measures such as controlling high blood pressure and controlling cholesterol. In all, improvements were seen in 41 out of 43 measures.

Although some may view adherence to guidelines as a threat to physician autonomy, some doctors who have received NCQA recognition report that the guidelines help them with self-assessment and with patient compliance with treatment recommendations.

The result of these improvements, said NCQA President Margaret E. O'Kane at a recent press conference, was that "a lot of lives were saved and [a lot of] misery prevented."

O'Kane added that there is a huge differential between the best performing plans and the rest and that there are no data available for the 45 million Americans without health insurance.

For those people, she feared the worst. "We've documented how terrible the quality of care is when you don't have insurance," she said.

One key to improving quality, according to the report, is to get the plans that are lagging to match the performance of the top 10%. If this were done for hypertension, NCQA reports that between 15,000 and 26,000 deaths could be avoided. If diabetes were better managed, the report states that more than 14,000 heart attacks and strokes could be prevented.

To foster better adherence to evidence-based guidelines, the NCQA, a health plan accreditor, recommends that more health plans use pay-for-performance plans and that more patients use Internet directories developed by the NCQA with the American Diabetes Assn. and the American Heart Assn./American Stroke Assn. These directories list physicians who follow the evidence-based guidelines for diabetes, heart disease and general practice, and NCQA recommends that patients see these physicians because they have a proven track record of giving quality care.

The largely physician-owned Touchpoint Health Plan has consistently ranked near the top of NCQA's list of the best performing plans.

Based in Appleton, Wis., Touchpoint ranked in the top 5% for 19 "effectiveness of care" measures, including giving patients a beta-blocker after a heart attack, eye exams for diabetic patients, and kidney function and HbA1C testing for diabetics.

Physician-adopted guidelines

Because these guidelines were adopted by physicians and not imposed on them from above by corporate administrators, Greg Long, MD, medical director for physician services in Touchpoint's ThedaCare division, said there was more "buy-in" among the plan's medical staff.

"We are they," Dr. Long said when explaining how with "mild arm twisting," most physicians were willing to participate in the program because they were in control of the plan.

The key, he said, is practicing proactive disease management instead of episodic care.

To do this, Dr. Long said, "case management triggers" have to be built into a practice's patient record system to make sure that patients with chronic diseases make regular appointments or receive intensive follow-up care after hospitalization.

For this system to work, he recommends that doctors delegate much of the calling and test-tracking work to their administrative staff, leaving them time to make medical decisions.

Although he said it's still tough to track patient outcomes for conditions such as asthma and depression, Dr. Long said they now have internal data suggesting an overall improvement in their patients' hospitalization rates.

Robert R. Kahnk, MD, the only Nebraska doctor on the ADA/NCQA physician recognition database, said his use of evidence-based guidelines for diabetes care has helped make his patients more involved and more interested in their care.

"There are a lot of farmers and ranchers who work very hard, and their health is not as important to them as getting the job done," said Dr. Kahnk, a Broken Bow-based family physician. "When they have time -- or their spouses make them -- they take care of health matters."

He said there was a lot of upfront time spent educating patients as he incorporated the ADA/NCQA measures into his practice, but he believes it will pay off in the long run.

"You have something to show the patient and you can tell them, 'This is why we're doing this,' " Dr. Kahnk said. "Patients tend to be more compliant when they understand the reason why things are being done."