Ensuring managed health care quality: areas of consensus and debate

CLINICAL THERAPEUTICS®/VOL. 19, NO. 6, t997

Ensuring Managed Health Care Quality: Areas of Consensus and Debate Stephen Joel

Coons, PhD, and JoLaine R. Draugalis, PhD Centerfor PharmaceuticalEconomics and Department of Pharmacy Practiceand Science, Collegeof Pharmacy, The Universityof Arizona, Tucson,Arizona

CONFERENCE OVERVIEW This supplement includes papers from a conference titled "Ensuring Managed Health Care Quality: Areas of Consensus and Debate," held January 20-22, 1997, in Tucson, Arizona. The topic was selected because of the dramatic changes occurring in the financing and delivery of health care in the United States, and the increased interest in the resulting quality of the medical care provided. Many individuals and organizations are talking about quality, but no consensus exists as to what it is, how to measure it, and what to do with the information that is collected. As the shift of patients to various forms of managed care continues in response to cost pressures, will maintaining and even improving quality remain on the agenda? A major concern is that by focusing on cost 1520

reduction, health care quality is being sacrificed. Individual experiences and a number of high profile cases have shaken the public's confidence in the ability of managed care to balance effectively the apparent trade-off between cost and quality. Thomas Bodenheimer, a physician at the University of California at San Francisco School of Medicine, wrote a Sounding Board article in The New England Journal of Medicine in November 1996 titled "The HMO Backlash--Righteous or Reactionary? ''1 He discusses what he suggests is an angry and determined backlash against health maintenance organizations (HMOs) that is spreading across the United States. He cites several manifestations of that backlash, including federal and state legislation, lawsuits naming HMOs as defendants, statewide electoral initiatives, horror stories in the mass me-

0149-2918/97/$3.50

S.J. COONS AND J.R. DRAUGALIS

dia, the emergence of physician-run HMOs to compete with HMOs run by corporate executives, and a drive for medical savings accounts to draw patients away from HMOs. As health care delivery changes to a predominantly managed care system, how can we ensure that quality of care remains a top priority? Although many studies indicate that the majority of managed care enrollees are satisfied with the quality of medical care provided by their health plan, a number of high-profile cases have called that view into question in the public's mind. Ensuring the delivery of high-quality health care will require a great deal of work. Every conference attendee has a stake in that process. The goal of this conference was to identify mechanisms for measuring health care quality, and methods for reporting those measures in such a way that they provide effective input to a variety of decision makers. The conference was designed for directors of pharmacy services, medical directors, and other administrators in managed care organizations, pharmaceutical company representatives, and academicians. The program offered the opportunity to address relevant issues from a variety of perspectives. The overall objectives of this conference were as follows: • to describe various approaches for ensuring the quality of managed health care; • to debate the relative merits of current accreditation approaches; • to discuss the implications of quality measurements for the consumers, purchasers, and providers of managed health care services; • to describe how collaboration among managed care organizations (MCOs), purchasers, and the pharmaceutical industry

can enable MCOs to measure and ensure quality more effectively; and • to discuss pharmacy performance standards and describe their role in ensuring managed health care quality. Although not all of these objectives are addressed in the selected papers that follow, our aim was to provide an overview of a number of issues critical to managed health care quality. ACKNOWLEDGMENTS This conference was funded through unrestricted educational grants from the following firms: Abbott Laboratories (Abbott Park, Illinois), Boehringer Ingelheim Pharmaceuticals Inc. (Ridgefield, Connecticut), Boehringer Mannheim Corporation (Gaithersburg, Maryland), BristolMyers Squibb Company (Princeton, New Jersey), Ciba Pharmaceuticals Division (Summit, New Jersey), Dupont Merck Pharmaceutical Company (Wilmington, Delaware), Eli Lilly and Company (Indianapolis, Indiana), Hoescht Marion Roussel (Kansas City, Missouri), Janssen Pharmaceutica (Titusville, New Jersey), Merck & Co., Inc. (West Point, Pennsylvania), Pfizer Inc. (New York, New York), Pharmacia & Upjohn Company (Kalamazoo, Michigan), Rh6ne-Poulenc Rorer Pharmaceuticals, Inc. (Collegeville, Pennsylvania), and Sandoz Pharmaceuticals (East Hanover, New Jersey). We thank all the participants and presenters for their part in making this conference a success. We appreciate the editorial assistance of Shilo Creek and Marty Kelley in the preparation of these selected proceedings. The efforts of Lynne Mascarella and Denise deGeus in planning and conducting this conference are gratefully acknowledged. 1521

CLINICALTHERAPEUTICS*

Address correspondence to: S.J. Coons, PhD, College of Pharmacy, PO Box 210207, The University of Arizona, Tucson, AZ 85721-0207.

REFERENCE 1. Bodenheimer T. The HMO backlash-Righteous or reactionary? NEJM. 1996; 335:1601-1604.

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