A Publication of the
Jacobs Institute of Women's Health
Volume 6, Number 3, September 1998
Measuring the Quality of Managed Care
Elizabeth McGlynn, PhD, director of the Center for Research on the Quality of Health Care at the RAND Corporation, discussed her paper, "Quality of Care for Women: Where Are We Now and Where Are We Headed?," and Patricia J. Venus, MA, of the Center for Health Care Policy and Evaluation of United HealthCare discussed her paper "Quality of Care in the Eyes of the Beholder: Perceptions of Women Enrolled in Medicaid Managed Care," which she wrote with her coworker Regina Levin, MPH.
McGlynn explained her work researching clinical measures of quality to evaluate health care. Much of the information available comes from managed care organizations, she noted. "There is an assumption that we don't need to worry about fee-for-service plans. We should leave that assumption behind." How good is the health care being delivered today? "The bottom line is it depends on who you are and where you go for care," said McGlynn. The factors affecting the evaluation of quality of care include voluntary reporting of data, th e lack of benchmarks against which to judge performance, variations in access to care, regional differences in standards of care, and patient preference.
McGlynn described efforts funded by the Health Care Financing Administration (HCFA) and the Agency for Health Care Policy and Research (AHCPR) to seek out more data and evaluate more complex indicators of care. She hoped these initiatives would focus attention on women's health care specifically and look beyond diagnosis and treatment to the whole continuum that makes up health care. The biggest challenge, she points out, are the information systems. "We've been hearing about computerized medical records for years, but they still don't exist," she says.
Finally, she pointed out that the demand for data on quality is increasing, and if users of health care services want more information about quality, they should be more willing to provide information about their experiences to help researchers make assessments.
Venus stated that measures of quality differ widely depending on whose perspective is used to do the measuring. In addition to measuring the processes of care given, as McGlynn described, it is also important "to address the goals and values of the people served," said Venus. However, "there is no clear reliable standard on how to evaluate the perceptions of the beneficiaries," she said. "All plans are doing their own evaluations, and it's hard to make comparisons across states."
The Consumer Assessment of Health Plans (CAHPS), developed by the AHCPR, RAND, and others, is a new tool designed to gauge the experiences of Medicaid and Medicare patients in both managed care and fee-for-service plans, said Venus. "It was created to help consumers make choices, but it also gives purchasers and policymakers a source to monitor and can be used by plans for reporting requirements."
Venus noted the most important question to answer was why there is a difference in use of health care services. "It's important to us because one of the largest concerns is inappropriate control of use and denial of access to care. In an optimal system, use is driven by need: those with high needs should not see barriers, and low use should be because of low need."
The results of her study showed that high users had greater health care needs than low users, but even low users reported having a condition that lasted over three months and required prescription medicine. "Low users said they didn't get to see specialists or get tests when they thought they needed them. Either they're experiencing barriers to care, their expectations are not being met, or the system is functioning appropriately by limiting unneeded use." Even in the latter case, she said, "The health care system should better explain why specialists or tests were not needed, so these users don't feel their expectations are not being met." This particular evaluation is just one example of how CAHPS data can be used to suggest improvements.
A number of panelists presented their own views on measuring the quality of managed care, beginning with Carol Weisman, PhD, professor of health management and policy at the University of Michigan School of Public Health and member of the Jacobs Institute's Board of Governors (see story on page 3). Weisman also serves as chair of the Advisory Committee for the Jacobs Institute's Women's Health and Managed Care project and cochair of the Women's Health Measurement Advisory Panel of the National Committee for Quality Assurance (NCQA). "Standard instruments that measure patient experiences, satisfaction, and quality of life have generally been developed without respect for gender issues," said Weisman. "They don't include items specific to women's experiences or assess what is most important to women." A study she conducted tackled this issue and found, for example, women would like to be able to get routine gynecologic exams and recommended clinical preventive services at one time or in one place.
"As a researcher," said Weisman, "I'm concerned that there is little research explaining variations across plans and models. There is no research investigating the extent to which variation comes from organizations and their management, sociodemographic issues, or other factors. What are the differences between plans that are performing well and those that are not?" In addition, Weisman noted, "We need to prioritize the health conditions of women that account for a lot of mortality and morbidity and may be future indicators for HEDIS [the Health Plan Employer Data and Information Set], such as heart disease, osteoporosis and resulting fractures, unintended pregnancy, breast cancer, and mental health issues."
Thomas Purdon, MD, associate professor of clinical obstetrics and gynecology at the University of Arizona Health Sciences Center and medical director of University Physicians, Inc., the University of Arizona's faculty health plan, said he represented the providers and allied health personnel who deliver the care. "In models of care, patient satisfaction is important, and so is outcome-they both feed into the overall quality of care," he said. "Patients, clinical processes, and outcomes all need to be interrelated."
Purdon stated member surveys have shown users want lower costs, more access to specialists, and more quality time with their health care providers. Further, "members forgive delays, difficulty getting appointments, or time spent waiting for appointments if they get good quality time with the physician. This is an important point because it overrode all other indicators," said Purdon. As an example, Purdon pointed to counseling regarding menopause: "If we advance in our counseling and this leads to more hormone replacement therapy combined with initiatives to stop smoking, this would have more impact in advancing women's health than all other indicators combined."
Robin S. Richman, MD, vice president and medical director for quality improvement and women's health at Tufts Health Plan, brought up some of the obstacles she confronts in determining quality of care. "Accountability is a big issue for us," she said. "Should it be assigned across health plans? Across medical groups? Among individual physicians?" Data have also presented a problem, for example, when combining information from several managed care organizations to share data from providers who have several contracts. "Why is the data different from one doctor with several contracts?" she asked. Beyond that, she noted, "Information systems used now were designed for plans with only 90,000 members. That doesn't account for combined plans or mergers that result in one million people in a plan, and there are no systems out there to replace these systems." Finally, the issue of consent to share data from medical records has posed a problem. "Traditionally, one person signs off for permission for the whole family," said Richman. "Does a husband have the authority to give up his wife's records?" she asked.
Final comments came from Joanne L. Hustead, JD, director of legal and public policy at the National Partnership for Women and Families in Washington, DC. Her organization "is looking at managed care from a woman's perspective and translating that into public policy. The focus on quality as opposed to access by consumers and purchasers is a relatively new phenomenon," she said. Hustead echoed Weisman's concerns that both researchers and health care plans should pay close attention to gender differences. She cited a study that found women of all ages were less likely than men to receive beta blockers after suffering a heart attack. "Plans would be encouraged to collect and report data on women if HEDIS and the NCQA required gender-specific reporting and information," she posited.
In terms of public policy, the National Partnership for Women and Families has identified a number of health care goals to protect all consumers, but particularly women. They include direct access to an ob-gyn and to family planning clinics, better coverage of prescription drugs, and more women taking part in clinical trials. "We're not trying to legislate quality," Hustead remarked. "We're trying to set standards that ensure people get the right care."
Audience members posed several questions to the speakers. One asked about data on the relationship of preventive services to overall costs. McGlynn pointed out that specific benefits are selected by individual purchasers (employers who provide health benefits to employees), and purchasers have to be willing to take responsibility for those choices. Another audience member agreed with McGlynn, saying purchasers should be called upon to explain why cost is so important in choosing health care plans. She pointed out that companies whose workforce is predominantly women "need to be made accountable for what they provide."
Over the past two years the managed care series has yielded eight symposia covering 15 commissioned papers, as well as Insights, a series of in-depth briefing papers distributed in advance of each symposium. Support for the initiative was provided by The Commonwealth Fund, the Kaiser Family Foundation, the Lilly Center for Women's Health, and Wyeth-Ayerst Laboratories. With a new grant from The Commonwealth Fund, the Jacobs Institute will convene meetings with purchasers and insurers to discuss strategies for implementing the findings from the managed care series (see story on page 4).
The papers commissioned for this symposium are being published in Women's Health Issues, the bimonthly journal of the Jacobs Institute. Audiocassettes of the series are available; for more information, call the Jacobs Institute at 202-863-4990.
Because our population is aging, more women than ever are experiencing menopause-the time around age 50 when the ovaries cease producing estrogen. The lack of estrogen results in an increased risk of heart disease and osteoporosis. Because we are living longer, preventing the debilitating effects of lack of estrogen has become a major public health issue.
The ideal drug to treat symptoms of menopause and estrogen loss would provide all the positive effects of estrogen and none of the negative ones. Are SERMs- selective estrogen receptor modulators that mimic estrogen in some respects but not in others-the wonder drugs we've been seeking for postmenopausal women?
At a breakfast seminar June 25 in Washington, DC, Preston C. Sacks, MD, tackled the question by elucidating what we do and don't know about raloxifene, a SERM that is currently approved by the FDA for osteoporosis prevention. The seminar was the fourth in the series "New Science for Age-Old Problems," sponsored by Monsanto Company and Searle. In short, raloxifene is a promising drug, but its long-term effects are not yet known.
Current methods of hormone replacement therapy (estrogen alone or combined with progestin) may pose an increased risk for breast cancer. At present, women who seek hormone replacement therapy must weigh their individual risk for breast cancer, heart disease, or osteoporosis. Sacks pointed to population-based calculations that more use of hormone replacement therapy could yield a 41% overall reduction in mortality by reducing the incidence of heart disease and osteoporotic fractures. That percentage takes into account that such use of hormone replacement therapy would likely increase the incidence of breast cancer, endometrial cancer, and gallbladder disease. Observational studies have demonstrated a 30-35% reduction in mortality with hormone replacement therapy.
Over the years, experience with hormone replacement therapy shows that it significantly reduces fractures at the hip, wrist, and vertebrae. While raloxifene prevents bone loss (although not as effectively as estrogen), no data are available yet to show that it results in fewer fractures. Sacks said he believes the data on raloxifene will eventually confirm a decrease upon further study.
The other "hole" in the picture is the cardiovascular protection provided by raloxifene, Sacks noted. Again, hormone replacement therapy clearly lowers the rates of cardiovascular disease and death, presumably by lowering low-density lipoprotein (LDL) cholesterol. Raloxifene and other SERMs lower LDL and yield positive changes in blood vessels and vascular smooth muscles in animals. This may result in reduced cardiovascular risk in women, but that has not been confirmed. As Sacks put it, despite the data showing raloxifene reduces LDL, "we don't have clinical data to show this will result in improving mortality."
In animal studies, raloxifene had no effect on the uterus, which Sacks calls "the most encouraging part of SERM studies." Further, he notes, "With raloxifene, breast pain (often a marker of breast tissue stimulation) is lower." In fact, Sacks said, raloxifene's ability to stop breast tissue growth may be even more potent than that of tamoxifen, another SERM currently used to treat and, in some women, prevent breast cancer. Sacks said the possibility that raloxifene may be superior to tamoxifen is one aspect of raloxifene that continues to spark significant interest.
"Preliminary data on raloxifene is positive, but it would be unwise to suggest that it does in fact reduce breast cancer," said Sacks. "Even though news reports have said that it does [reduce breast cancer], from a clinical standpoint, we shouldn't translate that to our patients. Two years of data is not enough to determine the long-term effect."
After Sacks concluded his presentation and opened the floor for questions, a psychiatrist in the audience asked if any data had been gathered on SERMs' effects on anxiety or depression. Sacks replied he had seen only one allusion to such effects but agreed the issue is important. "Data from the last few years on estrogen have been positive. If you had to make a prediction today, you would say SERMs will probably not be like estrogen in that respect," he said.
Another audience member commented that despite all the medical data on various menopause treatments, "real women don't know what this means. Every day they see something different" in the news. Sacks agreed that this was a tough area. "Every woman should get a personal discussion of risks and benefits. We're woefully inadequate in this area," he said. But, he stated, "I think you'll see dramatic changes in this area as a matter of public health policy; we know if you provide adequate treatment in the beginning, it saves an enormous amount of money by preventing hospital admissions for major treatments."
Sacks serves on the staff of Washington, DC's Columbia Hospital for Women and the Georgetown University Hospital. He is a clinical instructor for the Department of Obstetrics and Gynecology at George-town University School of Medicine and a member of the clinical faculty at the Washington Hospital Center.
September 24-25, Ovarian Cancer National Alliance Advocacy Conference: SILENT NO MORE, at the Embassy Square Hotel in Washington, DC. For more information, call 202-452-5910 or visit the Alliance's web site at www.ovariancancer.org.
October, National Breast Cancer Awareness Month. For a promotion kit with information, brochures, and posters in English and Spanish, call the National Breast Cancer Awareness Month Board of Sponsors toll-free at 1-877-88-NBCAM.
November 2, Advances in Women's Health Research, the Society for the Advancement of Women's Health Research's Eighth Annual Scientific Advisory Meeting, at the Sheraton City Centre Hotel in Washington, DC. For more information, call 202-223-8224 or visit the Society's web site at www.womens-health.org.
November 15-19, Public Health and Managed Care, the American Public Health Association's Annual Meeting in Washington, DC. For more information, call 202-789-5600 or visit the Association's web site at www.apha.org.
December 6-9, National STD Prevention Conference, sponsored by the Centers for Disease Control and Prevention, in Dallas, TX. For more information, call the CDC at 404-639-8260.
Women's Health Care: Activist Traditions and Institutional Change, by Carol S. Weisman, PhD, reveals how women have been "the perennial health reformers in the United States, due to their unique position as both providers and consumers of health care services." The book looks at historical issues in the context of contemporary policies for improving women's health care. It is published by the Johns Hopkins University Press. Copies are $19; to order, contact Darlene Gregory of the Association for Health Services Research by phone at 202-223-2477 or by e-mail at
Addressing Domestic Violence and Its Consequences, a policy report from The Commonwealth Fund Commission on Women's Health, presents the findings of a national survey along with recommendations for addressing this significant public health issue. For a free copy, call 1-888-777-2744 or order directly from the group's web site at www.cmwf.org.
The Health of Mid-Life Women in the States, a report by the Women's Research and Education Institute funded by the Merck Company Foundation, provides state-by-state data on women ages 45-64 years to help policymakers create programs to prevent health problems among women as they age. Copies are $4.95 plus shipping; to order, call 202-628-0444 or visit the Institute's web site at www.wrei.org.
Into a New World: Young Women's Sexual and Reproductive Lives, by the Alan Guttmacher Institute, provides data from 53 developed and developing countries on young women's reproductive health needs. The report is $30; to order, call 212-248-1111 or order directly from the Institute's web site at www.agi- usa.org.
Hospital Mergers and the Threat to Women's Reproductive Health Services: Using Antitrust Laws to Fight Back, from the National Women's Law Center, provides explanations of applicable antitrust laws and practical tools for fighting hospital mergers that would result in cutting off some reproductive health services, such as abortion. The Center's legal staff will also provide assistance to local advocates implementing the strategies. Copies of the executive summary are free; the full guide is $15. For more information, call 202-588-5180.
"Sleeping: It Does a Body Good" was the topic of the May/June issue of Facts of Life, an issue briefing from the Center for the Advancement of Health. Each issue focuses on a single topic and provides an overview, interviews with experts, background on new research, and more. To order copies of Facts of Life, call 202-387-2829, or visit the Center's web site at www.cfah.org to see current and archived issues online.
"Women's Decision Making about Hormone Replacement Therapy" is the topic for this year's Jacobs Institute of Women's Health Leadership Award, a manuscript competition established by Women's Health Issues, the Jacobs Institute's journal. Author of the best submission receives a $1,000 prize. Manuscripts should address patient, physician, or other influences on women's decisions regarding use or non-use of hormone therapy. The deadline for the award is March 31, 1999. For details, call the Jacobs Institute at 202-863-4990.
Martha Romans, executive director, recently attended a meeting of the Gynecologic Oncology Group, a national research consortium seeking better treatments for gynecologic cancers. She serves as a public member of the Data Safety Monitoring Committee and the Human Research Committee.
Warren Pearse, MD, FACOG, editor of Women's Health Issues, attended the biennial Congress of the Royal College of Obstetricians and Gynecologists in Harrogate, England, in early July. Dr. Pearse and his daughter, Kathryn, also took time to tour castles in northern England and museums and sights of London.
Carol S. Weisman, PhD, professor in the Department of Health Management and Policy and director of the Interdepartmental Concentration in Reproductive and Women's Health at the University of Michigan's School of Public Health, has joined the Jacobs Institute's Board of Governors. Weisman chaired the Advisory Committee to the Jacobs Institute's project on women's health and managed care and co-chairs the Women's Health Measurement Advisory Panel of the National Committee for Quality Assurance. She is also associate editor of the journal Women's Health Issues.
Weisman is a sociologist and health services researcher with a principal interest in women's health care and policy. In addition to her role at the University of Michigan School, she is an adjunct professor and an associate of the Women's and Children's Health Policy Center at Johns Hopkins School of Hygiene and Public Health.
Author of over 70 publications, Weisman recently penned Women's Health Care: Activist Traditions and Institutional Change (1998, Johns Hopkins University Press). The book grew out of her research on issues in women's health care and on US women's historical and current efforts to change health care institutions and improve quality of care, which she conducted as a 1994-1998 Robert Wood Johnson Investigator in Health Policy Research.
Weisman is a Fellow of the Association for Health Services Research and a 1997 recipient of the National Award for Excellence in Women's Health Research from the National Association of Professionals in Women's Health. "Carol has been such a vital part of so many Jacobs Institute activities, we are delighted she will be joining our Board," said Martha Romans, Jacobs Institute executive director. "I believe the organization will benefit even further from her broad perspective and expertise."
We are currently accepting applications for the 1999 Jacobs Institute-Ortho-McNeil Pharmaceutical Scholar award, a one-year, $30,000 grant. Eligible research will consider the changing health care environment, the unmet need for primary and preventive health services, the historic lack of research on women's health, and the importance of social, cultural, legal, economic, and behavioral factors influencing the financing and delivery of health care to women. The application deadline is October 15, 1998. For more information, please contact the Jacobs Institute at 202-863-4990.
Welcome to the following new members of the Jacobs Institute, who joined from May 1 to July 31, 1998. To become a member, complete the order form below. For more information on membership, call the Jacobs Institute at 202-863-4990.
Toni R. Ardabell
The Jacobs Institute has been awarded a grant from The Commonwealth Fund to continue to bring national attention to women's health issues. Building on the success of its two years of research assessing the impact of managed care on women's health issues, the Jacobs Institute will use a portion of the grant money to convene meetings with health plan medical directors and with health care purchasers to pass on the resulting recommendations and develop strategies for implementing them in health care plans.
In addition to aiding health plans in making real improvements in their delivery of services to women, providing information to purchasers to aid in the selection of plans will ensure that the findings of the earlier work are translated into practice. In a further effort to ensure that the information is disseminated, the Jacobs Institute will publish all of the issues of Insights, a series of briefing papers that accompanied each of eight seminars on managed care, in a supplement to its quarterly journal, Women's Health Issues.
With the aid of grant funding, the Jacobs Institute will also assess the impact of managed care on obstetrician-gynecologists through a national survey of Fellows of the American College of Obstetricians and Gynecologists. Questions designed specifically to determine how managed care affects practice patterns will be included in ACOG's survey of its 30,000 members. Finally, the grant allows the establishment of an annual conference on women's health issues, beginning fall 1999. The Jacobs Institute will work with The Commonwealth Fund to identify conference topics, organize the conferences, and invite leaders in the field of women's health to attend. Proceedings from the annual conferences will be published in Women's Health Issues.
The Jacobs Institute introduces State Profiles on Women's Health, a new publication that describes women's health in each of the 50 states and the District of Columbia, incorporating important information on demographics, health status, insurance coverage, risk factors for illness, and health policy issues of particular relevance to women's health. Information on each state is presented in a standard chart form, allowing comparisons with other states and with national data.
According to Jacobs Institute Executive Director Martha Romans, "Health care policy increasingly is made at the state level, and we find tremendous variations among the states on nearly every indicator. State Profiles on Women's Health will help identify priorities in each state and can serve as a benchmark for measuring changes in women's health status from the growth of managed care, welfare reform, and the like."
State Profiles on Women's Health will aid health care providers, policymakers, program administrators, researchers, teachers, and women's health advocates by offering concise and consistent data on major health issues. State Profiles on Women's Health is made possible through the generous educational support of the Kaiser Family Foundation, Wyeth-Ayerst Laboratories, and Westat. Members of the Jacobs Institute will automatically receive one copy of State Profiles free (individual membership is $55 annually); others can purchase the book for $30 plus $3.50 for shipping. To order, click here.