HMOs are poised to lead; health plans and employers have fostered reform by developing report cards and standardizing data - health maintenance organizations - Perspective - Column

Real momentum for national health care reform has come about because we now realize that the dismal state of the U.S. economy and the unsustainable rise in health care costs are intertwined.

Working together over the past 20 years, employers and HMOs have already achieved a reform a revolution really-that has laid the foundation for the upcoming changes in our health care system. For the first time in our history, more than haft of the people with employer-sponsored health care coverage are enrolled in a managed care plan, such as an HMO.

Far-sighted employers have been pivotal to HMO development through their selection of health plans. In the early 1970s, for example, General Mills formed an employer coalition in Minneapolis that helped to make that section of the country one of the top HMO markets.

Working together. employers and the HMO industry have achieved major breakthroughs. Today, HMOs benefit most from the sophistication and support of prominent employers that are playing a major role in burgeoning fields, such as continuous quality improvement, outcomes measurement, and public reporting of data.

Take for example, Xerox Corp. in Stamford, Corm. Patricia Nazemetz, Xerox's benefits director, has been instrumental in the development of the National Committee for Quality Assurance, a national accreditation organization in Washington. Nazemetz was also the first in the employer community to mandate accreditation for the HMOs that contract with her company. Her innovative benefits program, which is based on HMOs, has been viewed as a model for a market-based health care reform.

It is an exciting time. The report card project proposed to President Clinton (including 30 major employers and GHAA as sponsors) and the Health Plan/Employer Data and Information Set are two of many projects to measure health plan performance.

Many of these efforts grew out of earlier initiatives, like the Washington Business Group on Health/GHAA reporting form of the mid-1980s, the time when employers first began to clamor for data on cost--and then on quality.

Initially, the HMO industry was reluctant to comply with some requests. Often HMOs did not have the necessary reporting systems. Or they feared the data would be used to ratchet down prices. Most of the time, HMOs simply were overwhelmed with requests from various sources for data, none comparable to the other.

But there am now concerted efforts to standardize the data received from health plans. Employers that have so strongly supported the development of high NCQA standards, the report card project, and HEDIS must continue to support a single standard.

There are numerous organizations that have begun to ask for and publish "quality" data from plans that publish the data in formats of their own creation. The resulting lack of standardization could confuse purchasers at a time when unfamiliar data on a complicated subject are available to the public for the first time.

Many in our industry believe that the cost savings that are to be wrung from the system will come about because we will learn to do things the right way, and then better, over time. Strategies, such as identifying and treating high-risk women and preventing premature births, improve infant health and save thousands of dollars. HMOs have such strategies in place.

And became merely offering a benefit isn't enough, over 70% of health plans have instituted outreach programs. A number of efforts have been initiated to encourage parents to bring in their children for immunizations. Those efforts promote good outcomes and save money, and can be done only in organized medical systems.

The message is that quality comes first, and that cost savings will follow.

Unless we convince policymakers and comers of our intention to make quality a priority, they will not support the passage of reform based on managed care. Indeed, the success of reform will ultimately depend on our commitment to quality.

James Doherty is the former president and chief executive of Group Health Association of America, in Washington.

COPYRIGHT 1994 A Thomson Healthcare Company
COPYRIGHT 2004 Gale Group