A report released today 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," said 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."
In the report NCQA calls on Congress to: reform payment systems that undermine efforts to improve care; expand quality measurement to the 60% of Americans not currently covered by accountable health plans; invest in measure 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. But 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. And, the report noted, several key areas of care have seen little progress in several years. For example:
-- Only 46.4% of people taking anti-depressant drugs are monitored by their physicians; -- 34.1% of children prescribed medications for attention deficit hyperactivity disorder (ADHD) are seeing a doctor for follow-up care; -- Half of patients previously hospitalized for mental illness see a physician for a follow-up visit; -- 45.3% of people are receiving colon cancer screening at the appropriate age; and -- 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," said O'Kane.
NCQA's 2009 State of Health Care Quality Report examines quality data submitted by an all-time high 979 health plans across the country that collectively cover 116 million Americans -- a 9 percent increase over 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 6 months. Provision of these drugs greatly reduces the possibility of a second, often fatal, attack; -- Near universal high-quality care for Americans with asthma. An estimated 30 million Americans have asthma; and -- Substantial gains in helping Medicaid beneficiaries stop smoking. This is of particular importance as 1 in 3 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 failed to appreciably improve on key quality measures. Among Medicare Advantage plans, only 5 of 36 measures (14%) showed a statistically significant improvement; in Medicaid, 18 of 50 measures (36%) showed a statistically significant gain, and most of these improvements were 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," said 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 Boom generation becomes eligible.
Care quality in Medicare Advantage health plans was 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.