Health maintenance organizations, clinical quality measurement, and market competition: Demand and supply side incentives for quality improvement
Open Access
- Author:
- Lee, Woolton
- Graduate Program:
- Health Policy and Administration
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- December 18, 2008
- Committee Members:
- Dennis Patrick Scanlon, Dissertation Advisor/Co-Advisor
Dennis Patrick Scanlon, Committee Chair/Co-Chair
John Raymond Moran Jr., Committee Member
Peter Kemper, Committee Member
Dennis G Shea, Committee Member
Mark John Roberts, Committee Member
Peter Cm Molenaar, Committee Member - Keywords:
- health care quality
health plan quality measurement
HMO cost functions
insurance competition - Abstract:
- Several well known studies and reports have documented serious problems with the quality of health services provided in the United States (U.S.). These problems range from failure to provide preventive, chronic or acute health care services almost half the time they are needed to mistakes in the inpatient hospital setting which are estimated to result in 44,000-96,000 preventable deaths annually. The Institutes of Medicine (IOM) groups these quality problems into three categories: 1) failure to provide health services of proven benefit (i.e. underuse); 2) the delivery of medical care in the absence of evidence that it could help the patient receiving care (i.e. overuse); and 3) failure to execute clinical care plans and/or procedures properly (i.e. misuse). Many analysts believe that misaligned medical care demand and supply incentives are an important causal component of quality problems in the U. S. health care system. This thesis is organized into three papers that examine demand and supply side quality incentives in HMOs and similar health plans. HMOs have historically exhibited greater potential to bring about changes in medical care delivery, are often involved in the coordination of health services among different providers and utilize a variety of clinical and non-clinical arrangements designed to incentivize quality improvement in hospitals and physician organizations. Many government and private purchasers of insurance now provide public reports of health plan quality to prospective consumers. It is hoped that these reports will sensitize consumers to quality differences among health plans and help to realign medical care producer incentives for quality. The first paper (chapter 2) of this thesis makes use of mandates in the Balanced Budget Act of 1997 (BBA97) requiring the collection and public reporting of clinical quality information of Medicare + Choice (now Medicare Advantage) health plans. This paper examines whether changes in insurance competition among Medicare HMOs caused by the BBA97 caused improvements in cardiovascular disease (CVD) and diabetes quality during the period 1998-2002. Publicly reporting quality information is viewed by many policy makers as an important component in realigning producer incentives for quality improvement. The Health Effectiveness Data and Information Set (HEDIS) alone, contains over 60 measures of the quality of clinical care provided under HMOs and similar health plans. These measures are often collapsed into composites of health plan quality in report cards used to inform consumers. However, the methods used to derive HEDIS composites varies widely and analysts have found instances where ratings assigned to health plans using different methods are contradictory. The second paper develops composites of HMO quality measures and examines statistical relationships among alternative approaches used to combine health plan quality measures. Some analysts have argued that government reimbursement may be necessary to incentivize quality improvement in health insurers such as HMOs. Others have argued that improving quality may result in savings resulting from reductions in medical expenditures. To date, only a few studies have examined this question and consequently, understanding about the cost of improving health care quality in HMOs is limited and may inadequately account for member case severity differences or differences in the relationship between a plan and its network physicians. The last paper of this thesis estimates quality adjusted HMO cost functions, and seeks to further elucidate the relationship between quality and costs in HMOs.