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NCQA: Health Care Quality Improving, but Key Lapses Remain

Eastman, Peggy

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doi: 10.1097/01.EEM.0000296449.37069.f4

    Americans enrolled in health care plans that voluntarily report their patient quality data to the nonprofit National Committee for Quality Assurance (NCQA) reaped the benefits of overall higher quality care in 2005, according to NCQA President Margaret E. O'Kane. But there are still lapses that contribute to a quality differential between the U.S. health care system as a whole and the top-performing health plans, she noted.

    Those gaps exist in adult influenza immunization, breast cancer screening, and mental health care, for example. Health care that is not high quality costs lives and money, and NCQA estimated that lapses in care account each year for 37,600 to 81,000 unnecessary deaths, more than $10 billion in lost productivity, and nearly 65 million avoidable sick days.

    At a news briefing in Washington, D.C., at which NCQA's annual quality results on reporting health plans were revealed, Ms. O'Kane said Health and Human Services Secretary Michael Leavitt “has been playing a strong role in health care quality, and we feel that what we do is complementary to that.” The new NCQA report, “The State of Health Care Quality 2006,” covers 76.4 million Americans enrolled in private plans, Medicare, and Medicaid. Statistics released at the news briefing did not cover 12 million Americans enrolled in 80 preferred provider organizations reporting data to NCQA for the first time.

    The quality of U.S. health care is of critical importance to emergency physicians because patients who don't receive high quality medical care regularly are more likely to end up in the ED. Coincidentally, the NCQA report was released on the same day, Sept. 27, that Frederick Blum, MD, the president of the American College of Emergency Physicians, was participating in a roundtable discussion on the future of ED care on Capitol Hill in Washington. Recent reports by the Institute of Medicine and the U.S. Centers for Disease Control and Prevention have highlighted the crisis of ED overcrowding, often due to use of the ED for nonurgent conditions. The CDC report found ED overcrowding most severe in urban hospitals.

    On the plus side, the new NCQA report found improvement in private plans on 35 of 42 clinical quality measurements, the seventh straight year NCQA's annual report has shown progress. In fact, the greatest quality gains in 2005 were achieved by private health plans. These included high blood pressure control (68.8%); childhood immunizations (77.7% of children received recommended immunizations); beta blocker treatment after a first heart attack to prevent a second (96.6%); comprehensive diabetes care through HbA1c testing (87.5%); and medical assistance with smoking cessation (71.2%).

    Beta-Blocker Success Story

    NCQA considers the improvement in administration of beta-blockers an especially dramatic success story, noting that in 1996 only 62 percent of patients who had had a heart attack received beta blockers to prevent a second and often fatal heart attack. NCQA estimates that this clinical quality improvement alone saved between 4,200 and 5,300 lives over the past decade.

    Ms. O'Kane also pointed to blood pressure control as a particularly encouraging sign because elevated blood pressure is without symptoms to many patients. “This takes a lot of work; it takes a lot of convincing of the patient,” she said.

    Medicare's figure for blood pressure control was not far behind private plans at 66.4 percent; Medicaid's figure for blood pressure control lagged somewhat at 61.4 percent. In plans reporting Medicare data, 93.8 percent of patients received beta blocker treatment after a heart attack; for Medicaid that figure was 86.1 percent.

    Also on the plus side is the fact that a new measure — use of disease modifying anti-rheumatic drugs — was used by 81 percent of private health plans on patients with rheumatoid arthritis, which affects 2.5 million Americans, mostly women. “This is remarkable,” said Ms. O'Kane, noting that “early treatment preserves joint function and quality of life” for patients with rheumatoid arthritis. Use of these drugs was lower in Medicare (64.2%) and Medicaid (67.5%) patients.

    On the downside, influenza shots for adults in 2005 dropped, a fact Ms. O'Kane attributed to last year's vaccine shortage. The flu immunization rate last year was 36.3 percent in private plans and 70.3 percent in Medicare, the population most vulnerable to death from influenza. Each year, more than 200,000 Americans are hospitalized for influenza-related complications. An estimated 36,000 Americans die of influenza annually, and 90 percent of these are elderly, according to statistics in the NCQA report. Influenza vaccines can cut hospitalizations in half and prevent 80 percent of deaths due to complications among the elderly, the report noted.

    Screenings Decline

    Breast cancer screenings also declined in private plans from 75.5 percent of women 50 to 69 in 2001 who had had a mammogram in the previous two years to 72 percent in 2005 of those in that age bracket who had had a mammogram in the previous two years. The screening rate for Medicare in 2005 was 71.6 percent and 53.9 percent for Medicaid. “There seems to be quite a bit of confusion” among women about the value of mammography, said Ms. O'Kane. “We speculate that this is due to people reading the newspaper. The case has become clouded.” She urged physicians to intensify their efforts to remind women that mammography does save lives.

    In need of quality improvement was follow-up after hospitalization for mental illness. In private plans, the follow-up figure was 55.8 percent after seven days and 75.9 percent after 30 days. For Medicare, the follow-up figure was 39.1 percent after seven days and 59.3 percent after 30 days. For Medicaid, comparable figures were 39.2 percent and 56.8 percent respectively. The NCQA report noted that mental disorders affect about 57 million Americans over 18, and that mortality rates, primarily from suicide, are as high as 15 percent for the severest forms of depression, making follow-up after hospitalization a critical component of care.

    NCQA recommended an increase in the number of accountable health plans, public and private, that voluntarily report their data to improve the health system overall. “NCQA recommendations are so congruent with what we've been doing in HHS,” said Thomas Barker, JD, counselor to the HHS Secretary, at the Washington news briefing. He noted that in May 2006 President Bush ordered transparency in Medicare, a directive that required CMS to post the price Medicare pays for hospital procedures. Mr. Barker said the executive order President Bush signed in August 2006 directed federal health agencies sponsoring or administering health plans for their employees to provide information on cost and quality to those beneficiaries. Mr. Barker added that along with transparency on reporting health data, HHS considers interoperable health information technology such as electronic health records an important key to improving health quality.

    Ann Easton, the chief of insurance policy for the federal Office of Personnel Management, said at the news briefing that the federal government is “leading by example” in the effort to improve U.S. health care quality. She said the office is asking health plans that serve federal employees to collect data in 2006 on their performance on breast cancer screening, cholesterol control, and diabetes care for reporting in 2007. “We really believe transparency will help employees control costs,” she said.

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    © 2007 Lippincott Williams & Wilkins, Inc.