Quality of Care

Quality of care can be measured by the quality of doctors and facilities in the network, staffing levels and staffing mix, preventive services and outcome measures, patient satisfaction and utilization standards.

Selection of Providers

Unfortunately, some networks are comprised of any and all doctors willing to charge the fees established by the plan. Criteria for inclusion in the network should go beyond just a willingness to charge the negotiated fees. Critical issues include the following:

Q. What standards are used to credential direct care staff, and who performs the credentialling process? What types of practitioners are evaluated? Are credentials verified? How often does recredentialling take place? Are doctors with a high number of elderly or sick patients excluded? Does the plan make on-site visits to doctors’ offices?

A. It is important to compare credentialling standards among plans. If a plan excludes providers or facilities that treat a lot of elderly or sick applicants, they may well exclude medically necessary care to plan participants. The purpose of on-site visits is to verify that the information supplied in writing by the plan is accurate.

Q. Are physicians certified by the American Board of Medical Specialties (ABMS), or in the process of becoming certified? If so, are they practicing medicine in the specialty within which they are certified?

A. ABMS-certified physicians have successfully completed a residency program and passed an exam in their specialty area. Currently, about 65 percent of all physicians are certified (more in urban areas and often less in rural areas). Information on board certification can be found in the ABMS directory, available in many public libraries, or by calling 1-800-776-2378.

Q. Are physicians required to notify the plan if they have had hospital privileges limited? Is the plan then required to notify patients of the limitation?

A. Hospitals may limit privileges for any number of reasons. The illegal use of prescription drugs or conviction of a felony may result in limitations of privileges. Patients of a physician with limited hospital privileges should be notified immediately.

Q. What retraining is required of physicians who change specialties? Does the plan encourage continuing education for all health care personnel?

A. Today’s health care market depends more on primary care physicians and less on specialists than in the past. As a result, physicians who have been practicing as specialists for years are now becoming primary care physicians, sometimes without any retraining.

Staffing Levels

Q. What is the ratio of primary care doctors to patients?
What is the ratio of primary care doctors to specialists?
What is the ratio of nurses to patients in network hospitals?
What is the ratio of management to staff?

A. While there are no hard and fast rules about how many doctors or nurses a network should include, or how many managers it should employ, a higher rate of doctors and nurses per patient will mean easier access to care and more staff who have time to spend with patients.

Q. For hospitals in the network, is a registered nurse assigned to each patient during each shift to coordinate and monitor care? How many other patients is that nurse responsible for? What is the skill mix ratio (mix of RNs, LPNs, and unlicensed nursing staff) in network facilities?

A. Some experts believe that there should be one RN for every two intensive care patients and one RN for every six patients in most other areas of the hospital. However, staffing needs will vary depending on a number of factors. For example, a hospital with a high number of very ill patients will need more licensed staff than one with fewer such patients.

Q. Is a physician on duty at plan facilities during all office hours?

A. In many managed care plans, patients are examined by a physician assistant, rather than a physician. It is important that the patient also has access to a plan physician, if necessary.

Worker Protections

A plan with employees who are well treated is likely able to provide better health care than one where employees are treated unfairly.

Q. Do workers of the plan have a safe and healthy work environment?

A. If health care workers are protected from toxic exposures, violent assaults and infectious agents, patients are also likely to be protected. Conversely, if infection control procedures are inadequate, a patient could acquire disease while being treated. The following are indicators of a safe and healthy work environment for workers and patients:

• infection control plans that include protocols for preventing transmission of bloodborne, airborne and dermal diseases;
• hazard communication programs and exposure control plans;
• a joint labor/management health and safety committee;
• a violence prevention policy; and
• evidence that staff are not working excessive overtime.

Q. Are workers in the provider network unionized? If not, does management discourage union organizing efforts?

A. Since much of the health care sector is not unionized, the union may not want to rule out a plan because its workers are not organized. A plan that is actively anti-union, though, should not get our business. By the same token, unionized employers are major purchasers of health care and have tremendous clout in the market. We should more effectively use that clout to “buy union” health care.

Q. Does the plan contract out for certain services? If so, why? What proportion of temporary or agency workers does the plan (or its facilities) use?

A. Ask the plan to provide a written description of any services contracted out and how the plan accounts for the quality of those services. Also, the plan should provide information concerning the use of temporary employees. Contracted services or temporary or agency employees do not provide the same continuity of care as permanent employees.

Q. Does the plan have a system under which its doctors and other health care staff can advocate for patients and/or expose quality concerns without fear of retaliation?

A. Although health plan employees may be morally obligated to advocate for patients and legally obligated to report quality concerns, they may be hesitant to do so if whistleblower protections are not in place. Whistleblower protections should apply to employees of the plan and to those under contract with the plan. They should include protections for workers who advocate for patient safety and/or report quality concerns and should prohibit retaliation in any form.

Preventive Services/Outcomes

Q. How does the plan measure quality? What are the results of such measurements? What preventive services does the plan provide?

A. The National Committee on Quality Assurance (NCQA, see Appendix) requires plans to report on the percentage of enrollees receiving preventive services such as:

• childhood immunization
• cholesterol screening
• mammography screening
• cervical cancer screening
• treatment following a heart attack

Other questions include whether the plan monitors the number of low birthweight infants, and the percentage of pregnant women who receive prenatal care in the first trimester. Because early medical treatment reduces the risk of blindness in diabetics and reduces inpatient treatment required for asthma patients, NCQA looks at the plan’s percentage of diabetic enrollees receiving diabetic retinal exams and at the plan’s asthma inpatient admission rate. Statistics on the level of care provided to participants with high-risk factors, such as a family history of heart disease or high blood pressure, are also reviewed. These are strong indicators of a plan actively encouraging enrollees to obtain preventive care, which in the long run will stabilize health care costs.

Many hospitals use the following as indicators of quality problems:

• patient injury rate
• medication error rate
• infection rate
• re-admission rate
• decubitus ulcer (bedsore) rate
• mortality/morbidity rate

Plans should track these measures for hospitals in their network and they should be available to health care purchasers and enrollees upon request.

Currently, there are no universally accepted standards for measuring the outcomes of treatment for serious illness or injury. However, quality plans are likely working to collect and use their own data. Ask that plans report the results of any clinical outcome measurements and any changes in health care as a result of such reviews.

Patient Satisfaction

Another way of assessing the quality of a plan is to survey current participants and those leaving the plan. Most plans conduct their own satisfaction surveys. Because such surveys are not standardized and may not be entirely objective, their value is limited.

Q. Does the plan periodically survey enrollees? If so, are the results available to current enrollees and to those eligible for coverage?

A. Ask for a copy of the survey and past and current results. This information should be provided when a plan is being selected as well as during open enrollment periods.

Q. What percent of enrollees in the plan last year are still in the plan this year? Or conversely, what percent of enrollees left the plan during open enrollment? Were those who left surveyed to find out why?

A. How many people remain with a plan or leave it can be the best indicator of satisfaction. If the number leaving is high, it is important to find out why.

Q. Does the survey include questions about serious illness or injury?

A. Managed care plans are generally very willing to provide preventive care and to treat routine illnesses, but may be less willing to provide more expensive care or care that the plan considers to be experimental. Patients who are unhappy with a plan are frequently those who have suffered a serious illness or injury and feel that they have been treated inadequately or denied medically necessary care.

Q. Is the plan user-friendly?

A. A good plan should educate enrollees about how to use the network in a way that minimizes confusion. For example, plan members should be able to call one telephone number and access all areas of the plan’s administrative services.

Utilization

Plans devise standards — protocols — for everything from when given surgeries are medically appropriate and how long a patient should stay in the hospital to whether someone can be treated in an emergency room. The union should learn as much as possible about what the protocols are, how they are established and how actual utilization and denial of care compares with other plans.

Q. How does the plan develop its clinical guidelines/protocols? Are they provided by an outside firm? Are physicians who practice in the community consulted?

A. The plan should maintain an ongoing process for developing protocols that are relevant to the health characteristics of the plan’s membership.

Q. Are the plan’s medical reviewers permitted to use their own judgment and deviate from the standards?

A. Many guidelines are geared to patients who do not experience problems or complications beyond those typically expected for their particular condition. Medical reviewers should be permitted some flexibility in their decisions.

Q. Will the plan provide statistics on utilization?

A. Here are some statistics that could be compared among plans:

• number of hospital admissions per 1,000 enrollees;
• number of hospital days per 1,000 enrollees;
• average length of stay;
• number of days of hospital care denied; and
• total specialist visits.