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National Committee for Quality Assurance

Health Care

Quality of U.S. Health Care Stuck in Neutral

Analysis shows spending unrelated to quality improvement.

Published: Monday, October 26, 2009 - 15:53

(NCQA: Washington) -- “The State of Health Care Quality 2009,” an annual report, now in its 13th year, provided by the National Committee for Quality Assurance (NCQA), finds that the quality of U.S. health care was virtually stagnant in 2008, a disturbing slowdown after a decade of improvements. The across-the-board trend was seen in care provided to people with private insurance coverage as well as in Medicare and Medicaid. The report also examines the link between higher health care spending and quality and finds little to no connection, a finding with significant implications for health care reform efforts.

“As Congress works to shape a final health reform bill, lawmakers must be certain that the legislation includes significant provisions to improve the quality and efficiency of care,” says NCQA president Margaret E. O’Kane. “This includes requiring quality reporting by all health plans and providers, not just those who do so voluntarily today.”

Accountability expanding, but care remains uneven

In the report, NCQA calls on Congress to: reform payment systems that undermine efforts to improve care; expand quality measurement to the 60 percent of Americans not currently covered by accountable health plans; invest in measurement development, implementation, and maintenance to expand what we know about quality; and revitalize the nation’s primary care system. Many of these issues are addressed by the health reform bills now being debated in Congress, but the outcome of those debates remains uncertain.

Improving health care quality would have significant benefits beyond the health care system itself. NCQA estimates that were all health plans able to perform at the level of the top 10 percent of plans, the U.S. would avoid up to 115,000 thousand deaths and save at least $12 billion in medical costs and lost productivity every year.

Despite the disappointing trends, there were a few notable improvements in areas such as keeping heart attack patients on life-saving beta blocker drugs and delivering flu shots. However there were disquieting declines in several measures related to mental health, diabetes care, the overuse of imaging for low back pain, and breast cancer screening. Also the report noted several key areas of care have seen little progress in several years. For example:

• Only 46.4 percent of people taking anti-depressant drugs are monitored by their physicians.

• Among the children who are prescribed medications for attention deficit hyperactivity disorder (ADHD), only 34.1 percent are seeing a doctor for follow-up care.

• Half of patients previously hospitalized for mental illness see a physician for a follow-up visit

• The percentage of people who are receiving colon cancer screening at the appropriate age is 45.3 percent.

• Only 42.6 of patients with alcohol or drug dependency are entering into treatment.


“Hundreds of health plans have made the commitment to measure and report on the quality of care provided to their members. Those plans have made remarkable progress in improving care. But they cannot do this alone. It is time for all plans and providers to step up to the plate and do the right thing for their members,” says O’Kane.

NCQA’s report, “The State of Health Care Quality 2009,” examines quality data submitted by an all-time high of 979 health plans across the country that collectively cover 116 million Americans—a 9-percent increase from 2008. Plans submit data using NCQA’s Healthcare Effectiveness Data and Information Set, or HEDIS, a set of measures that assess how often patients receive care that conforms to evidence-based guidelines. While the data show that the system has hit a performance plateau, some bright spots were noted:

• A 12-percentage point jump in the provision of beta-blocker drugs to Medicare patients who had a heart attack within the previous six months. Provision of these drugs greatly reduces the possibility of a second, often fatal, attack.

• A near universal high for quality care of Americans with asthma. An estimated 30 million Americans have asthma.

• Substantial gains in helping Medicaid beneficiaries to stop smoking. This is of particular importance as one in three Medicaid beneficiaries in health plans are smokers.

Care for vulnerable populations fails to improve

For the third year in a row, NCQA found that the performance of health plans serving Medicare and Medicaid patients fail to appreciably improve on key quality measures. Among Medicare Advantage plans, only five of 36 measures (14%) show a statistically significant improvement; in Medicaid, 18 of 50 measures (36%) show a statistically significant gain, but most of these improvements are small.

“More than 100 million Americans depend on Medicare and Medicaid for their care and that number is growing. Three years of little or no improvement in care quality is truly surprising, and should be unacceptable,” says Vernon K. Smith, Ph.D., Health Management Associates, one of the nation’s leading experts on Medicaid. “The health plans need to focus on this immediately, because we know there is room for improvement. With these results, I would expect federal and state policy makers to take action quickly to jump-start quality improvement.” Enrollment in Medicaid grew in 2008 due to the declining economy and all of the reform bills before Congress envision greater expansions in the future. Medicare enrollment will also grow as the baby boomer generation becomes eligible.

Care quality in Medicare Advantage health plans is also flat for the third year in a row. Congress is considering making changes to Medicare’s payment system for these plans including the introduction of financial incentives to improve quality.

Variation: The pathology of big differences

The quality of care for Americans continues to vary sharply depending on where people live. NCQA’s analysis of care for several chronic illnesses found that people in some parts of the U.S. were far less likely to receive appropriate care than were people in other parts of the country. Across key measures in diabetes, cancer screening, behavioral health and cardiovascular care, high-performing regions outperformed low ones by 14 percent or more.

Health plans in the New England region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) continued to outpace all others and the quality of care in the South Central region (Alabama, Kentucky, Missouri, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas) tended to lag the most. Among the findings:

• Health plans in New England were 16.3 percent more likely to treat diabetic patients according to accepted guidelines compared with health plans in South Central states.

• Health plans in Mid-Atlantic states were 14.1 percent more likely to adhere to guidelines for treating patients with cardiovascular disease compared with plans in South Central states.

• New England health plans were 19.2 percent more likely to ensure that all patients received all appropriate cancer screenings compared with health plans in South Central states.

• Health plans in Pacific states (Alaska, California, Hawaii, Oregon, and Washington) were 20.8 percent more likely to appropriately treat and follow up with patients with mental health and substance abuse issues compared with health plans in West North Central states (Iowa, Nebraska, Kansas, North Dakota, Minnesota, South Dakota, and Montana).


“The quality of your care should not depend on geography,” says Cristie Upshaw Travis, CEO of the Memphis Business Group on Health. “These quality gaps translate into preventable heart attacks, strokes, and other serious medical events, not to mention billions of dollars in avoidable medical costs.”

Value: Cost, quality, and a bothersome scattergraph

For the third year, NCQA measured the value of health plans by combining quality measures with an assessment of how many resources were used to achieve those results. Data were collected in four key chronic disease areas: diabetes, cardiovascular disease, asthma, and chronic obstructive pulmonary disease. There were wide variations in both spending and quality, and NCQA found essentially no relationship between cost and quality, a disturbing and counterintuitive finding in an economy where price is often used as a proxy for quality.

"Health care doesn't follow the 'pay more get more' rule," said NCQA Executive Vice President Greg Pawlson, M.D. "Areas of the country with higher costs are more likely to have lower rather than higher quality. You can't simply spend your way to better health or to a health care system that delivers high value for the costs."

The rest of the system

Finally, little is known about the quality of care for the roughly 190 million Americans who are not in a health plan that measures and reports on quality. More than half (56%) of commercially insured people are in plans that report HEDIS to NCQA but only 25 percent of Medicaid beneficiaries and 16 percent of Medicare beneficiaries are in such plans. Many of the rest are in fee-for-service-care systems where quality measurement is not measured in a comprehensive manner. Congress has been working in recent years to expand the use of quality reporting in both these programs.

NCQA’s full report, “The State of Health Care Quality 2009,” is available online at www.ncqa.org/sohc. Much of the data from the report is used in NCQA’s online Health Plan Report Card, which allows consumers to compare health plans based on NCQA accreditation results and HEDIS quality scores. To see the Health Plan Report Card, visit http://reportcard.ncqa.org.


About The Author

National Committee for Quality Assurance’s picture

National Committee for Quality Assurance

NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations and manages the evolution of HEDIS®, the performance measurement tool used by more than 90 percent of the nation’s health plans. NCQA is committed to providing health care quality information through the Web and the media in order to help consumers, employers and others make more informed health care choices.


NCQA Rates Neutral - Not Surprising

A lot of the improvements made in the past were due to better data collection by health plans. As an example, by having better electronic health records and database systems, cancer screening rates were improved by capturing a larger numerator vs the denominator of the eligible patient population. Certified software vendors that take the data from health plans and calculate the measures have certainly helped rates improve over the last ten years. In sum, the rates never really changed that much, but the capture of the data improved.

Also, changes in the technical specifications of NCQA has in some cases caused improvement trends to take place when really there wasn't much improvement taking place.

NCQA will need to examine health plan influence on quality of care delivered by provider networks. Are health plans the right entities to promote quality with providers? Maybe if they are integrated with a delivery system??? I would not expect any significant improvements to take place going forward if NCQA holds its current course and methods of measuring quality.