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“Accountability” is a candidate for
recognition as the most overused word in health
policy this year. Yet a Google search produces
an abundance of scholarly papers proving that
there is no consensus on the meaning of the word,
which has been called a “chameleon”
and “a subjective construct, informed by
experience of it, and one that changes with context,
as much as it is a formalized process of reckoning.”
For purposes of the discussion below, let us agree
that “accountability” entails participating
in a performance measurement system and accepting
the results of public disclosure of one’s
ratings.
The purpose of this discussion itself is to challenge
ASA members to suggest ways of holding health
plans accountable.
Leaders in the field of health care Pay-for-Performance
(P4P) are calling for accountability among various
providers, which in practical terms signals a
shift in emphasis from monetary incentives to
public reporting. “Publicity for Performance”
does not offer much in the way of reward to most
anesthesiologists, whose referral base consists
of surgeons and hospitals to a far greater extent
than it depends on patient choice. Public reporting
is, however, an effective way to hold primary
care physicians and health care organizations
accountable, since it permits comparative rankings.
High-ranking providers may attract more patients
than those at the bottom of the list. The value
of comparative performance information has been
the premise of numerous publications, including
the feature articles on “America’s
Best Hospitals” that began appearing in
U.S. News & World Report nearly 20
years ago.
What about accountability for health plans and
not just for physicians and hospitals? There are
consumers who have options among the Blues and
the Cignas and local HMOs, particularly if they
are employed by a very large organization such
as the federal government. A health plan can include
the area’s finest physicians on its panel,
but if it incentivizes them to adhere to questionable
clinical guidelines or prevents them from providing
high-quality care through too-restrictive payment
policies, consumers may want to enroll elsewhere.
Shouldn’t health plans, like physicians
and health care organizations, be given incentives
to promote quality health care?
Some health plans are in fact being ranked very
publicly. In 2005 the National Committee for Quality
Assurance (NCQA) collaborated with U.S. News
& World Report to place in front of 10
million people its ranking of 75 HMOs and point-of-service
organizations (PSOs) that contributed standardized
performance data. Figure 1 shows the type of information
available to consumers who wish to compare HMOs
and PSOs of interest.
The executive summary to NCQA’s corresponding
“State of Health Care Quality 2005 Report”
argues that “regular measurement and public
reporting drive improvement.” NCQA’s
own data are of limited value, however, if the
measures on which health plans are measured may
not be valid or meaningful or representative of
overall quality. The quality of the measures used
is a fundamental issue in all performance-incentive
programs.
What if NCQA or another accreditation organization
were to measure and report physicians’ evaluation
of managed care plans? U.S. News & World
Report bases its hospital rankings on three
major elements, one of which is “reputation.”
In a survey sent to a large random sample, physicians
are asked to list the five hospitals they feel
are best in their specialty for difficult cases,
without consideration of cost or location. The
number reported for each hospital represents the
percentage of responding physicians who named
the hospital among their top five. Physicians’
opinions of the health plans paying for significant
numbers of their patients might likewise be of
interest. One domain on which doctors could provide
unquestionably valuable information would be whether
the health plan covered all indicated services
and procedures in their respective specialties.
Another question could ask physicians how likely
they were to be participating in the given plan
two or three years from now.
Taking this idea one step further, consider whether
the target audience for public reporting of anesthesiologists’
perceptions of the quality of their managed care
plans should include anesthesiology practices.
Potential measures include appropriate medical
policies and incentives to patients and physicians,
fair and honest contract negotiations, lack of
attempts to change contract terms during the term
of the agreement and prompt payment of claims.
If the president of NCQA is correct in saying
that the process of measuring and reporting causes
performance improvement, and she probably is right,
health plans that sacrifice quality to profits
may find it harder to compete. Patients and physicians
stand to benefit from this form of accountability.
Source Materials:
• U.S. News & World Report
articles and statistics on best hospitals and
health plans: <www.usnews.com/usnews/health/best-hospitals/tophosp.htm>.
• The State of Health Care Quality 2005.
National Committee for Quality Assurance 2005
<www.ncqa.org/Docs/SOHCQ_2005.pdf>.
New Manual Available on Ambulatory
Surgical Centers
Robert E. Johnstone, M.D., Chair of the Committee
on Practice Management, is proud to announce the
publication of the latest manual in ASA’s
Practice Management series. Display copies will
be available at the Practice Management booth in
the ASA Resource Center at McCormick Place during
the 2006 Annual Meeting in Chicago.
There were 239 ambulatory surgical centers (ASCs)
in the United States in 1983, the year Medicare
recognized them. By 2005 there were 4,900, and this
year, the number of ASCs will probably exceed the
number of hospitals (4,919 at last count). Surgeons
and patients like ASCs. Their rapid, market-driven
growth is a prime reason anesthesiologists should
understand them.
A new ASA monograph titled “Ambulatory Surgical
Centers: A Manual for Anesthesiologists” provides
extensive and useful information about ASCs. Judith
Jurin Semo, Esq., who specializes in representing
anesthesiologists and serves as outside counsel
for ASA, authored the monograph in consultation
with the Committee on Practice Management.
The manual is available in electronic format only
as a file with 254 pages divided into 12 chapters
and nine appendices. It contains numerous sample
documents, informative tables and practice pointer
boxes. The manual has 367 references and hyperlinks
to many outside sources. Headings and subheadings,
as well as bolded and underlined passages, make
finding and identifying important information easy.
It is written so well that it could be read from
beginning to end, although it is primarily designed
as a reference resource. Table 1 shows the basic
organization of the manual.
Ms. Semo describes the goal of the manual as to
aid anesthesiologists in understanding the practical
and legal issues associated with ASC practice and
the regulatory environment in which ASCs operate.
The manual includes practical considerations involved
in evaluating an ASC opportunity and contracting
with ASCs, the regulation and accreditation process
for ASCs, the Medicare payment structure for ASCs,
federal and state laws that apply to physician investments
in and practice at ASCs, medical-legal issues relating
to ASC practice, benchmarking ASC performance and
performance standards in the ASC arena.
Members of the Committee on Practice Management
who reviewed the text uniformly praised it. Michael
W. Champeau, M.D., wrote, “Overall I think
it’s superb. Ms. Semo really hits the nail
on the head when discussing the political realities
of surgeon-owned ASCs.”
Randall P. Maydew, M.D., notes, “The chapters
are very thorough and complete … Semo’s
work is always excellent.” Karl E. Becker,
Jr., M.D., agrees, “It is extremely well written,
comprehensive and complete.” Asa C. Lockhart,
M.D., adds, “As always, Semo excels.”
ASA members can purchase the monograph through the
ASA Web site for $150. The cost for nonmembers is
$350. Find it under “Continuing Education
Resources” or go directly to
<www.ASAhq.org/continuinged.htm>.