AHRQ Tools for Managed Care
Research in Action Issue 11
To ensure quality care, managed care plans need ready access to evidence-based clinical information and clinical performance measures and need to be aware of the most recent preventive care recommendations. The Agency for Healthcare Research and Quality (AHRQ) has funded research and development of clinical performance measures and preventive care recommendations.
This report describes these tools and how they have been used and provides information on where to learn more about them.
By Mark W. Stanton, M.A.
Managed care organizations (MCOs) are responsible for ensuring that persons enrolled in their plans receive quality health care. In addition, MCOs publicly funded through the Medicare and Medicaid programs are required by State and Federal governments to meet certain quality standards.
To fulfill their responsibilities, MCOs need ready access to a comprehensive array of evidence-based clinical information and other clinical performance measures to enable them to evaluate their providers' performance and identify areas where improvement is needed. They also need to know how their members feel about the care they receive and the way they are treated. Finally, they need to ensure that both their providers and members are aware of the most recent preventive care recommendations.
Valid, reliable, and cost-effective measurement tools must be available to make such determinations, but these tools have not always been available. Furthermore, because the science of performance measurement is relatively new, additional measures need to be developed and those that have been developed can be improved. Therefore, to ensure that their enrollees in MCOs receive high-quality care, MCOs need a reliable source to provide the most current and scientifically sound tools.
In response to this need, the Agency for Healthcare Research and Quality (AHRQ) has funded research to compile a database of evidence-based clinical guidelines and to develop clinical performance measures, member satisfaction surveys, and preventive care recommendations that can help MCOs meet their responsibilities. Additionally, AHRQ funds research and develops performance measures and guidelines that MCOs, insurers, providers, and consumers can trust.
This report describes these tools and how they have been used and provides information on where to learn more about them.
Around one-half of insured Americans are enrolled in some form of managed care. However, as the number of persons enrolled in MCOs increased in the 1990s, health care purchasers, policymakers, and other stakeholders became concerned about the potential for health care quality to diminish. In their view, the policies and practices imposed by MCOs to reduce what MCOs define as unnecessary care might result in patients not receiving needed care. Therefore, MCOs faced accreditation systems and other requirements to ensure that patients were receiving the most appropriate care.
More recently, MCOs have had to address other emerging concerns such as: Rapid introduction of new technologies, Data showing unexplained variations in the provision of care, Severe cost pressures.
These factors have provided additional motivation to MCOs to develop systematic ways of preserving and enhancing health care quality and cost-effectiveness.
Evidence-based practice guidelines and performance measures were developed to help ensure that patients always receive the most appropriate care. These guidelines and measures are based on thorough reviews of the relevant medical and health services research as well as on the collection and analysis of detailed data about the clinical and administrative aspects of care.
By using systematic, valid, and reliable methods for providing quality care, measuring the extent of their success, and reporting the results, MCOs are able to demonstrate to policymakers as well as institutional and individual health care purchasers the extent to which the care furnished to its members has been maintained and improved. They can also use those results to assist in internal quality improvement programs, viewed by managed care professionals as an integral part of their responsibilities.
Furthermore, individual and corporate purchasers of health care also view quality improvement as essential because they are seeking the best care that they can afford to buy, and they believe that high-quality care could cost them less because they are not paying to correct mistakes. Purchasers, in particular, believe that improved health care leads to healthier and more productive employees. Also, as health care evolves toward a more patient-centered model that considers consumer and patient preferences, MCOs need to learn more about patients' perspectives on various aspects of their care.
To meet the multiple challenges facing MCOs in the 21st century, AHRQ-funded researchers have developed, tested, and helped to implement a sophisticated array of tools. These tools include:
- The National Guideline Clearinghouse™ (NGC)—an online database of clinical practice guidelines.
- National Quality Measures Clearinghouse™ (NQMC)—an Internet-based resource of evidence-based health care quality measures.
- Patient Outcome Research Teams (PORTS)—clinical performance measures, including those for heart attack treatment and diabetes care.
- Q-SPAN—expanded quality of care measures, including a screening measure for chlamydia.
- Child Health Toolbox—a listing of measures specifically intended to be used to measure the quality of care provided to children.
- Consumer Assessment of Health Plans (CAHPS®)—patient satisfaction surveys on health plans and health care.
- U.S. Preventive Services Task Force (USPSTF)—an independent panel of private-sector experts in primary care and prevention. The Put Prevention Into Practice Program (PPIP) implements USPSTF recommendations by issuing a series of consumer-oriented publications on various aspects of preventive care.
Although many of these AHRQ-funded tools have been developed in managed care settings, they are applicable to other settings as well.q-span
Links to AHRQ Tools on the Internet
The NGC Acts as a Comprehensive Database of Clinical Practice Guidelines
Before MCOs can evaluate whether patients are receiving the right care at the right time, they must identify acceptable practices. The NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by AHRQ in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP).1
Cosponsorship by the major national trade association representing managed care plans is a clear indication of the value of these guidelines in achieving the quality goals of managed care. The NGC provides health plans, health care providers, integrated delivery systems, purchasers, and others user-friendly access to objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.
As of December 2002, the Clearinghouse included 917 guidelines on diseases and conditions, 648 guidelines on analytical, diagnostic, and therapeutic techniques and equipment, 377 guidelines on chemicals and drugs, and 111 guidelines on behavioral disciplines and activities. Key components of NGC include:
- Structured abstracts (summaries) about the guideline and its development.
- Ability to compare attributes of two or more guidelines side-by-side.
- Syntheses of guidelines that cover similar topics, highlighting areas of similarity and difference.
- Links to full-text guidelines, where available, and/or ordering information for print copies.
- An electronic forum, NGC-L, for exchanging information on clinical practice guidelines, their development, implementation, and use.
- Annotated bibliographies on guideline development methodology, implementation, and use.
Impact of NGC
Over the last 2 years, the NGC has had over 2 million visitors, processed over 23 million requests, and received over 42 million hits.
Here is what some people are saying about NGC:
"[The NGC] provides a valuable framework from which to continue our guideline development or renewal process. Because of their credibility, MDs buy into these guidelines as accepted standards of care. Therefore more effort can be given to implementation and compliance monitoring of the guidelines. Since the guidelines are updated as necessary, we don't have to pull teams of MDs together for multiple sessions to consider relevant modifications."
"Downloading guidelines [from the NGC] and adapting them to our local Swiss health care environment is essential for us, an HMO, to provide managed care; in addition we profit from work done in a much bigger country such as the U.S. It makes me stop and consider if I have current evidence for my practice."
The NQMC replaces CONQUEST
AHRQ recognized the essential link between clinical practice guidelines, quality measures, and the need of MCOs and others to find efficient and reliable methods for measuring quality health care. Therefore, in 1998, AHRQ initiated a 4-year project to develop the NQMC, a Web-based resource of evidence-based health care quality measures. AHRQ's purpose in establishing the NQMC is to promote widespread access to quality measures by MCOs and other members of the health care community.2
The NQMC, available in February 2003 and replacing CONQUEST, is designed to be a database for information on specific health care quality measures and measure sets. Quality measure summaries will be retrievable by many parameters including topic, target population, and setting of care. Users of NQMC will be able to search the NQMC and the NGC simultaneously.
PORTs Provided Basis for Development of Clinical Performance Measures
To accurately gauge whether providers in an MCO are providing quality care, the performance measures and clinical guidelines used should be based on scientifically proven treatments. From 1989 to 1997, AHRQ sponsored a series of 14 research projects designed to answer critical questions about the medical and cost effectiveness of available treatments for common clinical conditions such as acute myocardial infarction, diabetes, prostate disease, cataract, and low birthweight.3
The PORT findings led to the development of performance measures that can determine whether patients receive appropriate care.
The PORTs consisted of multidisciplinary teams of researchers ranging from health economists and clinicians to quality-of-life experts and epidemiologists. PORT investigators were instructed to answer questions about what treatments work, at what cost, and why variation exists in the use of treatments. The PORT projects represented an essential start to defining and refining the methods for producing outcomes and effectiveness measures.
Performance Measure for Beta-Blocker Treatment After a Heart Attack Helps Improve Care of Heart Patients
One result of the PORT reviewing cardiac conditions was development of a measure to determine whether patients received beta-blockers when appropriate. Beta-blockers are drugs that help prevent heart attacks by acting to stabilize the heart. A 1997 study of elderly Medicare patients reported that the mortality rate among those that received beta-blockers was 43 percent lower than among those who did not. Although research has shown that beta-blockers substantially improve survival in elderly people who have had a heart attack, AHRQ researchers found that only one of five patients received them, thus doubling their risk of death. Furthermore, beta-blocker recipients were rehospitalized 22 percent less often than nonrecipients. Also, treatment with beta-blockers after a person suffers a heart attack reduces the chance of a subsequent attack between 20 and 30 percent.5
Performance Measure for Beta-Blocker Treatment After Heart Attack Is Being Used by MCOs and Accrediting Bodies
Since 1996, the National Committee for Quality Assurance (NCQA), the organization that accredits health plans, has included a measure for prescribing beta-blockers in the Health Plan Employer Data Information Set (HEDIS®). HEDIS® is a set of standardized performance measures that allows a managed care plan to measure its performance and compare it to that of other managed health care plans. The HEDIS® Beta Blocker Treatment after a Heart Attack measure estimates the percentage of members aged 35 years and older who were hospitalized and discharged from the hospital after surviving a heart attack (defined as an acute myocardial infarction [AMI]), and received a prescription for a beta blocker.
Health plans are using the beta-blocker indicator in their public reports to NCQA, employers, States, and others. These reports provide annual updates on a broad range of clinical performance and consumer satisfaction measures. Furthermore, as required by NCQA accreditation standards, plans are using the indicator as part of their efforts to improve quality. The latest NCQA report on managed care quality reported that the average HEDIS®-participating managed care plan increased its beta blocker treatment percentage from 87 percent in 1999 to 92 percent in 2000. The five-point increase means that over 2,000 additional people received beta-blocker treatment in 2000, reducing their risk of subsequent heart attack. 4
UnitedHealthcare, which represents 7 million commercial members, 430,000 Medicare members, and 500,000 Medicaid members, has made information on the use of beta-blockers a part of its physician education program. Programs such as these have probably been partly responsible for the strong increase in the percentage of heart attack patients receiving beta-blockers.
Comprehensive Diabetes Control Measures Help Improve Care of Diabetes Patients
AHRQ's PORT on diabetes care developed a comprehensive, prospective, longitudinal database that addressed costs, quality, and outcomes of care for patients with Type II diabetes. It assessed the value of specific known interventions, such as preventive eye care, and tested the usefulness of new tools for disease management. Performance measures developed as part of this PORT have been used as indicators or tools to assess the level of care provided within systems of care to patients with diabetes.
For example, in 1998, the Diabetes Quality Improvement Project (DQIP), a coalition of public and private entities, developed the initial set of diabetes-specific performance and outcome measures.6 These measures replace a number of conflicting standards and are being used by MCOs, professionals, and health insurance purchasers to compare diabetes care in and across health care settings. In formulating these measures, DQIP members reviewed the literature on clinical effectiveness along with data collected for quality-of-care studies for patients with diabetes. This material, including published and unpublished data from AHRQ's Diabetes PORT, was used as part of the evidence base that guided DQIP's decisionmaking.
Health plans, health care professionals, purchasers of health care, and consumers are gradually making greater use of the DQIP measures, which focus on blood sugar (Hb A1c) testing, eye and foot exams, blood pressure control, and monitoring for kidney disease. According to NCQA, diabetic members of managed care plans reported increases in blood sugar testing, kidney disease screening rates, and eye exam rates between 1999 and 2000 (Table 1).
Table 1. Clinical Performance Measures for Diabetes Care Track Improvements
|Blood sugar testing||75%||78%|
|Kidney disease screening||36%||41%|
Q-SPAN Strengthens Performance Measures and Develops New Ones
MCOs are looking continually for new or better measures that will assist them in their quality assurance and quality improvement efforts. As a result of this and other factors, AHRQ is constantly working on strengthening the scientific basis of quality measurement while expanding the scope and availability of validated, ready-to-use measures.
Q-SPAN is an AHRQ-funded project involving Harvard, RAND, and NCQA that focuses on the expansion of quality-of-care measures.7 It builds on past work in quality measurement by public and private organizations through cooperative agreements to develop and test additional clinical performance measures for specific conditions, patient populations, and health care settings. In addition, once the new measures are ready for use, they will be added to the more than 1,200 performance measures included in the NQMC.
Use of Chlamydia Measure
An example of a clinical performance measure developed by the Q-SPAN project is the chlamydia screening measure. Chlamydia is the most common sexually transmitted disease, with an estimated 3 million cases annually.8 The chlamydia measure assesses the proportion of sexually active women between the ages of 15 and 25 who received a screening test for chlamydia within the past year. Screening for chlamydia is especially important because 60 to 70 percent of women with chlamydia do not experience any symptoms. Consequences of the disease can be serious, often including pelvic inflammatory disease, heightened risk of ectopic pregnancy (development of the fertilized egg outside of the uterus), or even infertility. Fortunately, therapies are inexpensive and offer cure rates approaching 100 percent.9
Child Health Toolbox
Because children's health care needs differ from those of adults, AHRQ has collected various measurement sets to help MCOs and others assess the performance of child health programs. These measurement tools have been put into AHRQ's Child Health Toolbox, which can be accessed on the Agency's Web site.10 This online resource can help MCOs, policymakers, and others develop plans that reliably measure health care performance in child health programs such as whether children are receiving quality health care and whether a health program is functioning effectively. Specifically, this Web site has links to tools and information on how to measure performance, access, quality, and health service delivery, as well as concepts, tips, and tools for evaluating health care service programs for children. Information about how to develop performance guidelines can also be found at this site.
CAHPS® provides Valuable Information About Consumer Perspectives
For health plans to improve the quality of their services, it is important for them to assess their members' experiences with the health care they receive. CAHPS® (formerly the Consumer Assessment of Health Plans) is an easy-to-use kit of survey and report tools that provides reliable and valid information on consumer perspectives on their health plans and health care.11 The kit contains a set of questionnaires that ask consumers about their experience with their health plans, sample formats for reporting results to consumers, and a handbook to help implement the surveys and produce the reports.
Consumers are asked about:
- Whether they received the care they needed in a timely manner.
- The quality and promptness of their care.
- The quality of provider communication.
- Courtesy and helpfulness of office staff, and quality of the customer service.
They are also asked to rate their physicians, health care, and health plan.
By providing the consumers' view of the quality of care and services they experience with their health plans, CAHPS® offers to health plans useful information that assists MCOs with quality monitoring and improvement.
Impact of CAHPS®
CAHPS® is being used currently by the NCQA in the Health Plan Employer Data Information Set (HEDIS®) and is required for health plan accreditation. By reporting important information from the patients' perspective, CAHPS® complements the clinical performance measures in HEDIS®.
The Centers for Medicare & Medicaid Services (CMS) is using a specially developed version of CAHPS® to survey 130,000 Medicare enrollees in managed care plans. The results of the Medicare survey were released in February 1999 to aid CMS' 39 million beneficiaries who were selecting a health plan.
Many health plans, including Mercy Health Plan, Harvard Pilgrim Health Care, and Health Plus of Michigan, conduct CAHPS® for commercial, Medicare, and/or Medicaid populations and use the results for quality improvement initiatives.
In 1997 and 1998, the UnitedHealthcare Corporation (UHC) surveyed Medicaid plans and Medicare plans not being surveyed by CMS. The data were used by the health plans to report their performance to State and Federal regulators.
One of the MCO's stated goals is to foster preventive health care practices among providers and enrollees. A panel managed by AHRQ is assisting MCOs and other sectors of the health care system by providing updated comprehensive preventive care recommendations. Using these recommendations, MCOs can evaluate whether their providers are delivering appropriate services.
The U.S. Preventive Services Task Force (USPSTF), an independent panel of private-sector experts in primary care and prevention, managed since 1998 by AHRQ, systematically reviews the evidence on the effectiveness of clinical preventive services. These include screening tests, counseling, and immunizations.12 The mission of the Task Force is to evaluate the benefits of individual services, to create age-, gender-, and risk-based recommendations about services that should routinely be incorporated into primary medical care and to identify a research agenda for clinical preventive care.
AHRQ's Put Prevention Into Practice (PPIP) program works to implement Task Force recommendations and to increase the appropriate use of clinical preventive services through a variety of resources and tools for clinicians, health care systems, patients, and the public.13
USPSTF recommendations have been used by numerous health plans and have been endorsed by AAHP, as a guide to what services should be regularly delivered to MCO members. The recommendations also have been used by major primary care specialty organizations (including the American Association of Family Practice, the American College of Physicians, and the American Society of Internal Medicine) as a basis for their prevention guidelines. Finally, Task Force assessments of the evidence supporting individual services are often used in the development of HEDIS® measures. Through the USPSTF Web site (http://www.uspreventiveservicestaskforce.org/), users can access USPSTF recommendations, age- and sex-specific tables about recommended preventive services, and reports describing in detail the evidence considered by the USPSTF for each service. In addition, PPIP develops additional materials to translate and disseminate the work of the USPSTF for both clinicians and patients.
Publications emanating from this program include The Clinician's Handbook, Personal Health Guide, and Staying Healthy at 50+. The Clinician's Handbook contains summaries of recommendations on screening tests, immunizations, and counseling for children/adolescents and adults/older adults by major authorities, including the USPSTF.14 The Personal Health Guide helps patients make sure that they get needed tests, immunizations (shots), and guidance to stay healthy.15 The Child Health Guide helps parents to work with the doctor, nurse, or other health care provider to keep their children well.16 The Staying Healthy at 50+ guide describes ways that people aged 50 and older can stay healthy.17 It gives information on screening tests, immunizations, and living habits that have been proven to help prevent certain diseases and conditions.
AHRQ has supported the development of tools such as a clearinghouse for clinical practice guidelines, clinical performance measures, consumer satisfaction surveys, and information about preventive care that is being used by MCOs to make decisions and improve the quality of health care. Because these scientifically valid and reliable tools are available, policymakers, corporate, and individual health insurance purchasers, providers, and MCOs themselves are able to use these tools to help their patients.
For More Information
For information about this synthesis, write Mark W. Stanton (Mark.Stanton@ahrq.hhs.gov).
For information on the following AHRQ tools, contact:
National Guideline Clearinghouse™
National Quality Measures Clearinghouse™
Patient Outcomes Research Teams
AHRQ (main number)
Child Health Toolbox
Denise Dougherty, Ph.D.
U.S. Preventive Services Task Force
Kenneth S. Fink, M.D.
Put Prevention Into Practice
- The National Guideline Clearinghouse™. Fact Sheet. AHRQ Publication No. 00-0047, July 2000. Agency for Healthcare Research and Quality, Rockville (MD); Web site: http://www.ahrq.gov/clinic/ngcfact.htm.
- Measures Sought for National Quality Measures Clearinghouse™. August 2002. Agency for Healthcare Research and Quality, Rockville, MD. Web site:
- Freund D, Lave J, Clancy C, et al. Patient outcomes research teams: contribution to outcomes and effectiveness research. Ann Rev of Pub Health 1999, 20:337-59. Reprints (AHCPR Publication No. 99-R073).
- National Committee for Quality Assurance. The State of Managed Care Quality 2001. Standard version.
- Soumerai SB, McLaughlin TJ, Spielgelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997; 277(2): 115-21.
- Diabetes Quality Improvement Project. DQIP Background. Web site: http://www.ncqa.org/dprp/dqip2.htm. Accessed on April 28, 2003.
- Expansion of Quality Measures (Q-SPAN). Agency for Health Care Policy and Research, Rockville (MD). January 12, 1998. Web site: http://www.ahrq.gov/qual/qspanovr.htm.
- Centers for Disease Control and Prevention. Chlamydia in the United States. April 2001. Web site: http://www.cdc.gov/nchstp/dstd/Fact_Sheets/chlamydia_facts.htm Accessed on January 9, 2003.
- Mangione-Smith R, McGlynn E, Hiatt L. Screening for chlamydia in adolescents and young women. Arch Pediatr Adoles Med 2000;154:1108-13.
- AHRQ Child Health Toolbox. Web site: http://www.ahrq.gov/chtoolbx/ Accessed on January 9, 2003.
- Consumer Assessment of Health Plans (CAHPS®) Fact Sheet. AHRQ Publication No. 00-P047, April 2000. Agency for Healthcare Research and Quality, Rockville (MD); Web site. http://www.cahps.ahrq.gov/.
- About USPSTF. U.S. Preventive Services Task Force, February 2002. Agency for Healthcare Research and Quality, Rockville, MD. Web site: http://www.ahrq.gov/clinic/uspstfab.htm.
- About PPIP. Put Prevention Into Practice, May 2000. Agency for Healthcare Research and Quality, Rockville, MD.
- Clinical Handbook of Preventive Services, 2nd Edition, 1998. Washington, DC; U.S. Department of Health and Human Services.
- Personal Health Guide: Put Prevention into Practice. Consumer Information, April 1998. Publication No. APPIP 98-0027. Agency for Health Care Policy and Research, Rockville, MD.
- Child Health Guide: Put Prevention into Practice. Consumer Information. Publication No. APPIP 98-0026, revised July 2000. Agency for Health Care Policy and Research, Rockville, MD.
- Staying Healthy at 50+. Publication No. AHRQ 00-0002, January 2000.