5. The California Experience: Implementing the Research and Action Agenda in Practice
In developing the recommendations included in the Research and Action Agenda, members of the Work Group on Consumer Information were keenly aware of the experiences of a handful of sponsors throughout the country that had already implemented programs designed to provide consumers with action information on health care quality.
Nowhere are the lessons from these experiences more evident than in California, where the California HealthCare Foundation (CHCF) has been instrumental in putting elements of the Research and Action Agenda into practice. Ann F. Monroe, M.A., director of the Quality Initiative for CHCF in Oakland, California, drew upon these experiences by offering insights into how the recommendations of the Research and Action Agenda can be used to make a meaningful difference in a marketplace.
Background: The California Environment
California is often thought of as a laboratory for the rest of the country, particularly when it comes to health care. Many experiments have been attempted in the state, only some of which have worked. And even those that have worked may not be right for another state. As a result, Ms. Monroe urged audience members to "take what makes sense and leave the rest."
How California Demographics Affect the Health Care System
Home to over 33 million people, California is unique in its diversity. Not only are residents spread out over a wide geographic area, but they also comprise a broad spectrum of racial and ethnic backgrounds. No single racial or ethnic group makes up a majority of the population, although almost one in three Californians is Hispanic.
Over 22 percent of nonelderly California residents lack insurance. Almost one in three people living in Los Angeles County is uninsured, a level that puts significant pressure on the health care system. In addition, over five million low-income Californians are covered by Medi-Cal (the state's Medicaid system), with another 500,000 children eligible for coverage but not yet enrolled.
The large uninsured and Medi-Cal population, combined with the ethnic diversity of the state's residents, combine to create significant challenges with respect to providing information to consumers on the quality of health care in the state. For example, the Department of Health Services (DHS) prepares all of its written materials in 10 different languages.
The California Market
As in many other areas, California's health plan market is relatively consolidated, with the top five plans controlling about 70 percent of the market. But unlike in other markets where a Blue Cross plan might enjoy 60 percent to 70 percent market share, no one plan has more than 25 percent share in California. This fragmentation has created intense competition among plans for market share, and very tense relationships between plans, medical groups, and hospitals as they negotiate pricing and other issues. (The situation is so tense that the California Medical Association sued the major health plans, charging them with racketeering.) Not surprisingly, these uneasy relations make it difficult to forge collaborative efforts in the area of quality of care.
To complicate matters further, with the exception of Kaiser, most health plans contract with most of the hospitals and medical groups in their market; they have also delegated extensive risk to the medical groups, so that decisions about what is and is not covered are often made at the provider rather than plan level. (Interestingly, the medical groups have managed to avoid the public backlash over managed care, as consumers still blame the plans if they are denied care.)
This contract-with-everyone approach raises interesting issues with respect to quality measurement, as it is not clear what role the health plan plays in assuring quality services are provided, given that they all offer the same basic set of providers. Consumers in California are beginning to wonder if it matters which health plan they join, as long as they have access to the doctor(s) they want. A patient can expect pretty much the same set of services from a given group practice, regardless of the health plan that he or she chooses.
Ms. Monroe believes that even in this environment the health plan plays some role in ensuring quality care, especially with respect to access. The challenge, however, lies in trying to define the role that each party plays and to develop measures that hold both plans and providers accountable for their respective contributions to quality.
The Regulatory Environment in California
California recently reorganized the regulation of health care in the state by setting up a new department dedicated to overseeing managed care. Up to this time, the state's emphasis was more on consumer protection (e.g., safeguarding appeals processes, regulating disputes) than on advancing quality. The recent reorganization has brought preventive regulation, public accountability, and consumerism to the forefront.
But because the reorganization has just occurred, health plans are not yet sure what these new regulations really mean. In particular, there appears to be a lack of clarity around the regulation of medical groups, as no one is really sure to what degree these groups fall under the purview of the new department. In response to a number of financial failures among medical groups (due primarily to an inability to manage delegated risk), the state government is currently emphasizing the issue of solvency standards for such groups.
Against this backdrop, quality measurement and reporting remains primarily a voluntary endeavor, which has an impact on what kind of measurement will work. The state is planning to issue report cards on commercial health plans and those serving the Medi-Cal population. For its part, the legislature seems fixated on criticizing health maintenance organizations (HMOs), although most legislative solutions focus on isolated problems with payment and provision of care (e.g., "body part" legislation) rather than taking a more global look at quality of care.
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How CHCF Operates in This Environment
CHCF is one of several organizations promoting quality measurement and improvement in California. Others include:
- The Pacific Business Group on Health (PBGH), a coalition of major purchasers that is very active in the field.
- The California Cooperative Healthcare Reporting Initiative (CCHRI), a group of health plans that have come together to collect HEDIS data.
- The Office of State Health Planning and Development (OSHPD), which produces quality information on acute conditions such as heart attacks.
Unfortunately, OHSPD data are often 3-5 years old at the time of release.
CHCF and the Quality Initiative in Brief
CHCF came into existence when the Blue Cross plan in California converted from not-for-profit to for-profit status. (It was one of two foundations formed from the conversion.) CHCF's Quality Initiative was launched two years ago and works in collaboration with other organizations in the state. In creating this program, CHCF leaders hoped to provide resources—including manpower and money-that would serve as a catalyst for change by assisting with the initiatives already under way in the state and by stimulating new initiatives to fill the gaps.
Putting the Research and Action Agenda into Practice
CHCF provides a real-life example of the Research and Action Agenda in practice, as exhibited in the Quality Initiative's four-step approach to quality measurement and improvement:
- Step 1. Increase the supply and dissemination of salient, objective information on quality performance (which relates directly to Tasks 2 and 3 from the Research and Action Agenda). Most data that previously existed in California were relevant to the quality community rather than to consumers.
- Step 2. Stimulate consumer and purchaser demand for such information (which relates directly to Tasks 1 and 4 from the Research and Action Agenda).
- Step 3. Create an environment that demands and supports quality (which relates to Task 1 of the Research and Action Agenda).
- Step 4. Build a prairie fire for quality. Ms. Monroe recently added this step, which she sees as necessary for building momentum for quality among key stakeholders. Although this is not explicitly a part of the Research and Action Agenda, Ms. Monroe would like to see it added as a sixth task area.
The remainder of this section talks about each of these steps.
Step 1. Increasing the Supply and Dissemination of Quality Information
CHCF's Quality Initiative is working toward the goal of having data available publicly on both clinical effectiveness and patient experiences with care at multiple levels of the health care system. As shown in Figure 4, much work needs to be done to reach this goal. At present, data on both clinical effectiveness and patient experiences are available primarily at the health plan level (for commercial and Medicare enrollees). At the provider level, data on patient experience is available only for medical groups, while information on clinical effectiveness can be found for hospitals.
CHCF is involved in several California-focused initiatives designed to help reach this goal, as outlined below:
- The PEP-C project, a standardized survey developed by The Picker Institute that measures patient experiences in over 100 (out of 350) California hospitals.
The first public report is due out in the middle of 2001. CHCF used every tool at its disposal—including "begging"—to convince hospitals to participate. The organization was criticized for running advertisements giving credit to those who participated, as it was perceived as being critical of those not participating. Ms. Monroe is hopeful that publicity surrounding release of the report will encourage more hospitals to participate next year.
- A nursing home survey, the first publicly disclosed comparative survey of nursing home quality, which is due out in early 2002.
This report will measure quality issues of critical importance to nursing home patients, such as risk-adjusted rates of pressure sores and hospital admissions. All data used in this report are already submitted by nursing homes to the government; CHCF is working with researchers to ensure that the information is valid and useful.
- A Consumers Union review of Medicare managed care plans, which will incorporate HEDIS measures and other data.
This information will be useful to seniors and their families if it can be made relevant and easily accessible.
- Risk-adjusted coronary artery bypass graft (CABG) surgery outcomes, due out in 2001.
This is a voluntary effort of PBGH, hospitals, thoracic surgeons and OSHPD.
- Government-issued report cards by Medi-Cal and the Department of Managed Care.
These report cards were due out in the summer of 2001.
- A consumer assessment survey of medical groups, using a hybrid version of CAHPS® and the Physician Value Check Survey (PVCS).
The first results will be available in Fall 2001.
Step 2. Generating Consumer and Purchaser Demand for Information
As a precursor action to encouraging consumer demand for information on quality, CHCF embarked on an initiative to better understand California health care consumers' views on the subject. This effort made use of 22 focus groups and a survey of 4,000 Californians that was conducted in collaboration with the RAND Corporation.
As with the KFF/AHRQ survey, the results showed that information about the quality of health care is reaching a limited number of consumers. That said, consumers think that comparison information on quality is valuable. In particular, consumers indicated that they want the following:
- Useful, salient, current, objective information on quality the way consumers define it.
Less educated consumers expressed a preference for summary information with simple ratings, while those with more education also wanted more detailed information for comparison.
- Information about that part of the health care system that is relevant to their concerns.
For example, individuals about to undergo major surgery want to look at comparative data on hospital performance, ideally with respect to the particular procedure in question. Most people express a desire for information about their doctor.
Timely information, available upon request when the consumer wants it.
Information that is communicated by a trusted source.
- Information that takes into account the consumer's "specialness."
Consumers want information that recognizes who they are as people, as most individuals see themselves as special and unique in a positive way. This desire could translate into data specific to a particular gender, age, or ethnicity. If general, aggregated data are all that is available, consumers will likely ignore it.
Ms. Monroe believes that these findings have important implications for those individuals and organizations such as CHCF that are trying to provide useful information to consumers. In particular, such information needs to be communicated in a variety of languages and formats, with dissemination being broad and through trusted sources. It is also critical to capitalize upon teachable moments, such as right before an individual is eligible for Medicare, or when a woman is newly pregnant.
CHCF has tried to follow these lessons in its efforts to stimulate demand among consumers for quality information:
- Placing supplements in the Los Angeles Times and in La Opinión, the largest Spanish-language newspaper in the State.
- Working with PBGH on an outreach program to make its Web site, known as HealthScope, more visible and available.
- Launching several other outreach projects to consumer or patient organizations.
Step 3. Creating an Environment That Demands and Supports Quality
CHCF is working in collaboration with other organizations on a variety of projects designed to create the type of environment that demands and supports quality. For example, CHCF is working to do the following:
- Reduce the burden on provider organizations, through a joint project with PBGH and the National Committee for Quality Assurance, known as the Provider Organization Accountability Project.
Providers face a large burden with respect to quality monitoring and oversight. A single medical group contracting with 10 different health plans across multiple products could easily face 50-60 audits in a single year. CHCF is trying to reduce this burden, and therefore free up more resources for quality measurement and improvement. For example, they are considering ways for different accrediting bodies to embark on their activities on a joint basis, and for health plans to conduct audits collaboratively.
Increase the size and scope of the quality community through the following initiatives:
- A 2-day retreat for consumer and patient leaders (held in February 2000).
- Working with the California Federation of Labor on health care purchasing and information dissemination projects focusing more on quality.
- Leading a pan-ethnic discussion of how to improve surveys of patient experience and satisfaction, to take into account differences among ethnic groups.
Step 4. Building a "Prairie Fire for Quality"
CHCF is trying to build momentum for quality by taking advantage of the fact that consumers want to get health information from people like them. As demonstrated in Figure 5, patients seeking health information turn to people with similar conditions, as well as to friends and family. Many of the sources traditionally touted by the quality community, including Web sites, quality reports, and the general media, appear far down this list.
The idea of such efforts is, by creating quality champions and supporting allies, to capitalize on the fact that consumers turn to other individuals for health information. To that end, CHCF is working to find common ground with other organizations that are not typically thought of as being a part of the quality community. CHCF leaders are taking the time needed to build trust with these organizations, in part by having a dialogue about what quality means to their constituents. As Ms. Monroe noted, quality of care means different things to different people, as a wide variety of contributing factors lead to optimal health care outcomes (select for Figure 6).
CHCF is currently exploring a variety of the factors noted in this chart, primarily by allocating grant funds to organizations in high-priority areas. Based on responses to an RFP (request for proposal), CHCF has funded eight community-based organizations that are very effective with their own constituencies. The grants cover five different areas related to quality, including the following:
- Increasing consumer awareness of health care quality problems.
- Increasing consumer/patient awareness and use of existing quality measurement tools.
- Promoting the use of evidence-based treatment guidelines by consumers.
- Improving patient interactions with providers and health care systems.
- Developing and implementing appropriate health care policy.
Ms. Monroe believes that these types of activities have the potential to be very effective. They show what can happen if an organization steps outside of its comfort zone with respect to quality by partnering with organizations not typically considered a part of the health care quality movement, such as churches, consumer advocacy groups, and other community-based enterprises. The key, she noted, is to frame the quality agenda in terms relevant to them. In other words, to build our agenda into their organization's agenda.
"The key is to build a quality agenda into other organizations' agendas."
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Questions for the Future
Ms. Monroe concluded her remarks by raising a series of questions that CHCF and other California stakeholders must address as they seek to promote quality measurement, reporting, and improvement in the state.
- What is the appropriate role of regulation in a state where disseminating quality of care information is voluntary (and therefore difficult to achieve)?
Ms. Monroe suggested that—at a minimum—regulators should require health care organizations to disclose data to the public as a condition for doing business in the State.
- What is the better strategy for consumers and patients—having regulations that set a floor on quality, or using a market strategy?
Ms. Monroe believes that a mix of the two approaches is probably needed. Regulation can help to ensure that no organization that offers very poor quality is allowed to stay in business. But the market helps to encourage innovation and competition based on quality and quality improvement.
- How many consumers is enough for change to occur?
Not everyone who buys a car reads Consumer Reports. Similarly, not all health care consumers are going to check quality rankings before making decisions. But the good news is that quality will matter as long as enough consumers use quality information to create the potential for market share shifts. More important, perhaps, all consumers will benefit from this focus on quality, not just those who use the data.
- How can individualized information be created that takes into account the diversity of consumers and their priorities?
Ms. Monroe sees technology as being critical to producing personalized report cards.
- What is the goal of measurement at each level (e.g., health plan, provider) in a system like California's? How can one determine who contributes what to quality?
Ms. Monroe believes that the providers have the biggest impact on quality, although she does believe that health plan outreach efforts and other programs can make a difference, particularly with respect to ensuring timely access to needed services. But she cautioned that health plans need to standardize their methodologies for measuring provider quality, as inconsistencies across different plan-sponsored report cards tend to confuse consumers.
For the future, CHCF plans to continue to sponsor many activities in this field in an effort to bring whole new groups to the "quality table." Some may work, while others will not. Ms. Monroe encouraged audience members to try new and creative ways to engage others in the quality discussion, to broaden the circle of champions and allies for quality measurement and improvement.
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AHRQ Publication No. 02-0014
Current as of September 2002
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