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NCQA Report Shows Health Care Quality Up, But Enrollment Down In Plans That Report On Performance


WASHINGTON, Oct. 3 -- Health care quality improved markedly in many key areas in 2004, but only about 21.5 percent of the industry now reports publicly on its performance, according to NCQA’s annual State of Health Care Quality report, released today. To help support consumers’need for information this open enrollment season, NCQA and U.S. News & World Report have collaborated to create new rankings of America’s Best Health Plans.

The good news in this year’s report is striking: among the 289 commercial health plans that reported their data, average performance improved on 18 of 22 clinical measures. Medicare and Medicaid plans reported smaller gains. The report shows that as many as 67,000 deaths have been prevented to date as a result of improvements recorded over the past six years (see Table 2). Especially notable this year were improvements in measures related to high blood pressure control (up 4.6 points to 66.8 percent) and cholesterol control for people with diabetes (up 4.4 points to 64.8 percent).

“This is a positive trend that can continue indefinitely, but the price is that we have to pay attention and reward accountability,” said NCQA President Margaret E. O’Kane. “The new mantra for health care purchasers needs to be, ’show us your data.’ Why trust your family’s health to an organization that operates behind closed doors?”

The improvements noted in the report are enjoyed by only about 64.5 million Americans, the number covered by publicly reporting plans. This represents a decline of 4.5 million from a year ago, due largely to shifting enrollment patterns. Enrollment in PPOs and high deductible (consumer-directed) health plans is up sharply; with few exceptions, these plans tend not to measure or report on their performance.

“Any kind of health plan might potentially be an excellent plan, but realistically, only the ones that measure quality are going to achieve excellence,” said O’Kane. “Today we see a lot of health plans that aren’t measuring anything. The right response as a consumer to these plans is simply, don’t buy them.”

America’s Best Health Plans

The print version of the U.S. News/NCQA America’s Best Health Plans rankings includes 50 commercial, 25 Medicare and 25 Medicaid health plans, but virtually every plan in the nation is included online at (see Table 5 for commercial plans list).

The rankings are based on clinical performance, member satisfaction and NCQA Accreditation information. Visitors to the U.S. News Web site will be able to “drill down” to view more detailed information about each plan. “We’re excited to be working with NCQA to offer the America’s Best Health Plans rankings,” said Brian Duffy, Editor, U.S. News & World Report. “Together we’re providing people with the information they need to make informed choices during this year’s open enrollment season.”

Persistent Variation, Quality Gaps

NCQA’s report shows that huge variations in quality remain commonplace. Different regions of the country often have wildly different rates on the same measure. In New England, about 71 percent of patients with hypertension have their blood pressure under control. In the Mountain region however, the rate is only about 62 percent. Virtually every measure shows similar variations.

“If you are a Medicare enrollee living in Fort Wayne, Indiana, you are five times more likely to get a spine fusion than a similar enrollee in Terre Haute. If you live in Elyria, Ohio, you are four times more likely to get a heart revascularization than a similar patient in Cleveland,” said Elliott Fisher, M.D., M.P.H., Dartmouth Medical School, who has done extensive research into how and why clinical practice varies from region to region. “These remarkable differences in practice show that that what’s best for the patient isn’t always what drives clinical decisions.”

The report also estimates that between 39,000 and 84,000 Americans die each year due to commonplace failures to provide recommended care (Table 3). For example, it is recommended that diabetics receive medication and support to control their blood sugar, but only about 70 percent actually have their blood sugar controlled. This results in nearly 12,000 avoidable deaths each year. The cost to employers is significant as well; businesses lose $13 billion in productivity annually because workers and their families don’t get the care they should. (See Table 4)

Pay for Performance

One of the reasons for the health care system’s routine failure to apply best practice care is that current payment practices inadvertently discourage it. Physicians and hospitals are often compensated based on the amount of care they provide, not the quality of that care.

Large employers, health plans and three of the nation’s largest physician advocacy organizations have all recently endorsed pay for performance. Medicare has also been a strong advocate of pay for performance, with nearly a dozen different pilot projects presently underway. The Medicare Payment Advisory Commission (MedPAC) a panel that advises Medicare on payment policies, recommends expanding such programs.

“Right now Medicare pays by volume instead of quality,” said Glenn Hackbarth, J.D., Chairman, MedPAC. “As a result, we buy a great deal of care of uneven quality. Expanding pay-for- performance gets the dollars flowing in the same direction as our desire for higher quality. As things now stand, Medicare often pays more for care of poor quality than it does for high quality care.”

Pay for performance is also a popular private sector strategy, with well over 100 pilot projects currently underway. Blue Cross Blue Shield of South Carolina recently established such a program -- it pays physicians who earn recognition under the NCQA/American Diabetes Association Diabetes Physician Recognition Program a lump sum of $5,000.

“The financial incentive makes it possible for physicians to invest in themselves and in their practices so that they can deliver even better care to their patients,” said John Little, M.D., Chief Medical Officer, Blue Cross & Blue Shield of South Carolina. “We want to encourage these types of efforts by physicians to improve the care processes for patients with chronic diseases----leading to better clinical outcomes and, ultimately, lower costs.”

Download this year’s report from NCQA’s Web site. The report includes complete results showing year over year performance on each measure. Printed versions of the report can be purchased at (888) 275-7585.

Editor’s note: NCQA makes plan-specific HEDIS results available to the media at no charge. Please contact the NCQA Communications Department at (202) 955-3518 to discuss data needs.

NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA measures and reports on quality at all levels of the system, from individual doctors to medical groups to health plans. NCQA also manages the evolution of HEDIS(r), the tool the nation’s health plans use to measure and report on their performance. NCQA is committed to providing the market with access to health care quality information in order to help consumers make more informed health care choices.


Table 1. Selected Results (a): Commercial, Medicare and Medicaid Health Plans, 2004

Measure: Antidepressant Medication Management - Acute Phase, Medicare: 56.3, Medicaid: 46.4, Commercial: 60.9

Measure: Antidepressant Medication Management - Continuation Phase, Medicare: 42.1, Medicaid: 30.5, Commercial: 44.3

Measure: Asthma Medication Use - All Ages Combined, Medicare: n/a, Medicaid: 64.5, Commercial: 72.9

Measure: Beta-Blocker Treatment After a Heart Attack, Medicare: 94.0, Medicaid: 84.8, Commercial: 96.2

Measure: Breast Cancer Screening, Medicare: 74.0, Medicaid: 54.1, Commercial: 73.4

Measure: Childhood Immunization Status - Combo 1, Medicare: n/a, Medicaid: 65.4, Commercial: 76.4

Measure: Cholesterol Management - Control (LDL less than 130), Medicare: 69.8, Medicaid: 40.7, Commercial: 68.0

Measure: Cholesterol Management - Screening, Medicare: 82.1, Medicaid: 61.8, Commercial: 81.8

Measure: Comprehensive Diabetes Care - Lipid Control (LDL less than 130), Medicare: 71.7, Medicaid: 51.0, Commercial: 64.8

Measure: Comprehensive Diabetes Care - Monitoring Nephropathy, Medicare: 58.5, Medicaid: 46.7, Commercial: 52.0

Measure: Comprehensive Diabetes Care - Poor HbA1c Control-(aa) , Medicare: 22.5, Medicaid: 48.6, Commercial: 30.7

Measure: Controlling High Blood Pressure, Medicare: 64.6, Medicaid: 61.4, Commercial: 66.8

Measure: Follow-Up After Mental Illness - 7 Days, Medicare: 40.2, Medicaid: 38.0, Commercial: 55.9

Measure: Follow-Up After Mental Illness - 30 Days, Medicare: 60.7, Medicaid: 54.9, Commercial: 76.0

(a) - The results above show what percentage of members get recommended care in various areas. Thus, the Commercial rate of 73.4 for the Breast Cancer Screening measure indicates that 73.4 percent of enrollees in commercial plans who should have received a mammogram (in the past two years) actually received one. (aa) - Lower is better for this measure.


Table 2: Cumulative Lives Saved Due to Improvements Among Publicly Reporting Plans Since Measure Inception: Commercial and Medicare

Measure: Beta-Blocker Treatment After a Heart Attack; Cumulative Lives Saved: 3,700 - 4,700; Since: 1996

Measure: Cholesterol Management After a Heart Attack; Cumulative Lives Saved: 3,300 - 5,600; Since: 1999

Measure: Controlling High Blood Pressure; Cumulative Lives Saved: 31,800 - 55,200; Since: 1999

Measure: Poor HbA1c Control (a); Cumulative Lives Saved: 1,300-2,200; Since: 1999

Total -- Cumulative Lives Saved: 40,000 - 67,000


Table 3: Estimated Deaths Attributable to Failure to Deliver Recommended Care: Selected Measures/Conditions (U.S. Population)


MEASURE: Beta-Blocker Treatment; AVOIDABLE DEATHS: 800 - 1,200

MEASURE: Breast Cancer Screening; AVOIDABLE DEATHS: 150 - 600

MEASURE: Controlling High Blood Pressure; AVOIDABLE DEATHS: 12,000 - 32,000

MEASURE: Cervical Cancer Screening; AVOIDABLE DEATHS: 650 - 850

MEASURE: Cholesterol Management (Control); AVOIDABLE DEATHS: 3,400 - 7,200

MEASURE: Diabetes Care - HbA1c Control; AVOIDABLE DEATHS: 5,300 - 11,700

MEASURE: Smoking Cessation; AVOIDABLE DEATHS: 8,300 - 13,200

MEASURE: Prenatal Care; AVOIDABLE DEATHS: 1,000 - 1,750

MEASURE: Colorectal Cancer Screening; AVOIDABLE DEATHS: 4,100 - 6,200

MEASURE: Flu Shots (65-and over); AVOIDABLE DEATHS: 3,500 - 7,500

Total -- AVOIDABLE DEATHS: 39,200 - 83,600


Table 4: Estimated Avoidable Sick Days & Lost Productivity Due to Sub-optimal Care in Selected Areas (U.S. Population)

Condition: Sick Days(b): Lost Productivity:

Condition: Depression; Sick Days(b): 8.8 million; Lost Productivity: $1.4 billion

Condition: Asthma; Sick Days(b): 15.3 million; Lost Productivity: $2.5 billion

Condition: Diabetes; Sick Days(b): 18.2 million; Lost Productivity: $3.0 billion

Condition: Heart Disease; Sick Days(b): 12.5 million; Lost Productivity: $2.0 billion

Condition: Hypertension; Sick Days(b): 28.3 million; Lost Productivity: $4.6 billion

Total -- Sick Days(b): 83.1 million; Lost Productivity: $13.5 billion

(b) Includes ’presenteeism’ experienced when sick employees report to work but work at a reduced capacity.


Table 5: U.S. News/NCQA America’s Best Health Plans Ranking (commercial plans)

Rank -- Plan Name (bb) --- State

Rank: 1; Plan Name (bb): Harvard Pilgrim Health Care; State: MA

Rank: 2; Plan Name (bb): Harvard Pilgrim Health Care of New England; State: NH

Rank: 3; Plan Name (bb): Preferred Care; State: NY

Rank: 4; Plan Name (bb): Tufts Health Plan (HMO); State: MA

Rank: 4 (c ); Plan Name (bb): Tufts Health Plan (POS); State: MA

Rank: 5; Plan Name (bb): Independent Health Association (HMO); State: NY

Rank: 6; Plan Name (bb): ConnectiCare; State: CT

Rank: 7; Plan Name (bb): Care Choices (HMO); State: MI

Rank: 8; Plan Name (bb): Blue Cross and Blue Shield of Massachusetts; State: MA

Rank: 9; Plan Name (bb): Capital District Physician’s Health Plan (HMO); State: NY

Rank: 10; Plan Name (bb): Health Alliance Medical Plans; State: IL

Rank: 11; Plan Name (bb): Security Health Plan of Wisconsin (HMO); State: WI

Rank: 12; Plan Name (bb): Excellus BlueCross BlueShield; State: NY

Rank: 13; Plan Name (bb): Anthem Blue Cross and Blue Shield; CT

Rank: 14; Plan Name (bb): Univera Healthcare; NY

Rank: 15; Plan Name (bb): Geisinger Health Plan; PA

Rank: 16; Plan Name (bb): Capital Health Plan (HMO); FL

Rank: 17; Plan Name (bb): Fallon Community Health Plan; MA

Rank: 18; Plan Name (bb): Oxford Health Plans of Connecticut; CT

Rank: 19; Plan Name (bb): Health New England; MA

Rank: 20; Plan Name (bb): MVP Health Care; NY

Rank: 21; Plan Name (bb): ConnectiCare of Massachusetts; MA

Rank: 22; CIGNA HealthCare of New Hampshire; NH

Rank: 23; Group Health Cooperative of South Central Wisconsin (HMO); WI

Rank: 24; Priority Health (HMO); MI

Rank: 25; BlueShield of Northeastern New York; NY

Rank: 26; Physicians Health Plan of Mid-Michigan; MI

Rank: 27; HealthGuard of Lancaster (POS); PA

Rank: 28; BlueCross BlueShield of Western New York; NY

Rank: 29; Blue Cross & Blue Shield of Rhode Island (POS); RI

Rank: 30; Aetna - Southern New Jersey; NJ

Rank: 31; Dean Health Plan (HMO); WI

Rank: 32; Network Health Plan (HMO); WI

Rank: 33; Keystone Health Plan West; PA

Rank: 34; HealthGuard of Lancaster (HMO); PA

Rank: 35; UPMC Health Plan; PA

Rank: 36; Physicians Health Plan of South Michigan; MI

Rank: 37; SummaCare; OH

Rank: 38; Anthem Blue Cross and Blue Shield of New Hampshire; NH

Rank: 38 (c ); Matthew Thornton Health Plan (HMO); NH

Rank: 39; Keystone Health Plan Central (HMO); PA

Rank: 40; CIGNA HealthCare of Colorado; CO

Rank: 41; Aetna - Connecticut; CT

Rank: 42; Unity Health Plans Insurance Corporation; WI

Rank: 43; Aetna of the Carolinas; NC

Rank: 44; HealthAmerica Pennsylvania; PA

Rank: 45; HealthPlus of Michigan; MI

Rank: 46; CIGNA HealthCare of Massachusetts; MA

Rank: 47; Excellus Health Plan (HMO); NY

Rank: 48; Medical Associates Health Plans; IA

Rank: 48(c); Medical Associates Health Plan of Wisconsin; WI

Rank: 49; Kaiser Foundation Health Plan of Hawaii (HMO); HI

Rank: 50; Plan Name (bb): Aetna; State: Maine

(c) -- Repeated rankings (e.g., 4, 4 or 38, 38) indicate a tie score between two plans. Tie scores sometimes occur when two or more related entities (e.g., an HMO and an affiliated POS plan) undergo a joint survey and share HEDIS and CAHPS results.

(bb) -- All plans are HMO/POS combined except as noted. POS refers to and organization’s Point of Service plan


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