Ten years later: Ellwood's challenge still unmet
Ten years later: Ellwood's challenge still unmet
AMGA experience reveals progress, obstacles
Ten years ago, Paul Ellwood, MD, who is regarded as the father of the managed care movement, issued a challenge to the medical community to manage outcomes and share the results with the public. He envisioned a health care market in which medical groups would compete on quality as well as cost.1
Why haven't we realized that vision? What must we do to make quality a guiding factor for medical groups, health plans, consumers, and purchasers?
Those questions are before the American Medical Group Association (AMGA) in Alexandria, VA, which had scheduled an address from Ellwood at a July meeting of its Outcomes Management Consortia in Jackson Hole, WY.
AMGA took on Ellwood's challenge by launching its outcomes management efforts in 1990, when its president, Kermit Knudsen, MD, urged the organization (then the American Group Practice Association) to expand its mission from its focus on national legislation. In 1991, with a grant from the Kaiser Family Foundation, AMGA began a feasibility study in which six group practices organized to collect data on total hip replacement.
"It was a sentinel event," says Julie Sanderson-Austin, AMGA's vice president for operations and quality management and research. "We were the first organization to respond to Paul Ellwood's challenge to be accountable for medical care."
Today, many organizations, from specialty medical societies and the Medical Group Man-agement Association (MGMA) in Englewood, CO, to state or federal agencies, have set up quality improvement projects and outcomes databases. But the early days of outcomes management reflected the paradigm shift that physicians and others in health care needed to make to achieve Ellwood's dream.
Terms such as "outcomes" and "accountability" brought blank stares, and computer systems were the exclusive province of the billing and scheduling staff.
Alfredo Czerwinski, MD, an internist who is now a health care consultant with Lawson & Associates in Sacramento, CA, recalls how he became a co-chair of a work group on total hip replacement. At that time the medical director of Kelsey-Seybold Clinic in Houston, Czerwinski was intrigued by the AMGA foray into "outcomes management."
"I managed to garner interest - not from the chief of orthopedics [at Kelsey-Seybold] but from his physician's assistant [PA]," recalls Czerwinski. "That PA got very excited and started getting data. Then the PA took another job, and that was the end of that. At that point, I had already committed Kelsey-Seybold."
At first, medical groups were overwhelmed by technical issues. Some didn't even have personal computers, which were more expensive and less functional than those available now. The work groups produced their own data collection tools, and some of them were interminably long.
"The No. 1 hypothesis we asked ourselves at the beginning was, 'Could diverse multispecialty groups from different markets around the country share data and do anything consistently in a useful way?'" he says. "The first three years were preoccupied with that issue."
Meanwhile, bringing research methods into a clinical practice presented challenges, recalls Maggie Gunter, PhD, a health care researcher who is vice president and executive director of the Lovelace Clinic Foundation, a nonprofit research and education institute affiliated with the Lovelace Health System in Albuquerque, NM.
"It was more difficult than any of us had anticipated to collect the data on a regular basis [and obtain] really good data," says Gunter, who is chairwoman of the national steering committee of AMGA's Outcomes Management Consortia. "It wasn't easy to integrate it into clinical practice. There was so much going on, it did take real resources to do that [outcomes] work."
Some 95 medical groups have now contributed data on seven different diseases to AMGA databases - a sizeable number, but still just a portion of the association's total membership. The project has moved from its struggle with data collection and other technical issues to these broader issues of outcomes management:
r How can measures address the need for internal quality improvement as well as external accountability to such groups as the National Committee for Quality Assurance (NCQA) in Washington, DC, and the Foundation for Accountability in Portland, OR?
r How can outcomes management become not only more feasible but a business imperative?
The answers, says Sanderson-Austin, lie in finding common denominators for quality. In his Shattuck lecture, delivered to the Massa-chusetts Medical Society and published in 1988 in the New England Journal of Medicine, Ellwood referred to a "central nervous system" of quality information.
"It's been very difficult for us to find out how to enable medical groups to collect one core set of data to use for internal quality improvement and for external accountability," says Sanderson-Austin, who was president and CEO of Ellwood's Interstudy think tank before joining AMGA in 1990. "That's been the most important challenge."
Slowly, AMGA has been reviewing its measures to ensure they fulfill the various goals. For example, AMGA's diabetes protocol now complies with FACCT, HEDIS, and the American Diabetes Association's Provider Recognition Program. Medical groups can collect data through four phases, from measuring just the essentials to tracking indicators that fully portray the patient's experience and clinical outcomes.
Still, to attain Ellwood's vision, Sanderson-Austin asserts that medical groups will need to make yet another technological leap forward into electronic medical records.
"We cannot expect physicians to collect information for the medical record and separate information for quality databases and then information for external accountability," she says. "We have to get to the point where a physician encountering a patient quickly documents that information for all of the external and internal requirements, without violating patient confidentiality."
"Performance measurement," as defined by accrediting bodies such as NCQA, also needs to focus on the patient's care and experience, not just isolated markers of physicians' processes, says Sanderson-Austin.
"Outcomes [management] will not take off until we see the margins disappear on cost and people compete on quality," she says. "I don't mean how many mammograms you give. I mean what are you going to do about [the results]? That's quality."
Making outcomes measurement more cost-effective is also a major goal of MGMA, says Neill Piland, research director for the MGMA's Center for Research on Ambulatory Health Care Administration. MGMA is concentrating its efforts on making data measurement by physician practices more cost-effective and in setting common industry benchmarks.
Incentives are possible
"For the largest portion of the medical care delivery sector, the generation of quality improvement and outcomes data will remain sketchy as long as the cost of generation of these data remains high. The real key will be the acceptance of performance and outcomes measures that can be generalized across all delivery organizations," Piland says.
"For many groups and systems, this remains beyond their means, especially in this increasing competitive arena. [The center] is currently designing patient satisfaction and health care benchmarking systems aimed at the cost-effective generation of information useful for a broader range of medical practices," Piland adds. "The cost of information needs to be reduced drastically before you can expect these measures to have a great impact on the overall quality of care delivered to the vast majority of the public."
Could Lovelace represent the incentives that are possible with fully implemented outcomes management? An integrated health care delivery system with a health plan, multispecialty practice, hospital, and physician network, Lovelace has benefited from years of work in outcomes and disease management.
For example, hospital admissions and emergency department visits have declined for pediatric asthma patients, as have workdays lost for the children's caregivers. Lovelace began presenting that information to employers. That apparently influenced significant growth; from 1996 to 1997, the health plan grew from 160,000 to 208,000 covered lives.
"It shows that employers do care about both cost and quality, but we have to show them [the data]," says Gunter. "The pressure to improve and demonstrate improvements in cost and quality is not going to go away."
Reference
1. Ellwood PM. Shattuck Lecture - Outcomes management: A technology of patient experience. New Engl J Med 1988; 318:1,549-1,556.
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