Correspondence
Quality-of-Care Data from Managed-Care Organizations
N Engl J Med 1997; 336:443-444February 6, 1997
- Article
To the Editor:
In the United States, an increasing number of Medicare and Medicaid patients are enrolling in managed-care organizations, either voluntarily or because of state Medicaid reforms. Data on the use of health care by these patients and on outcomes should be collected and evaluated continuously. Previously, large state and federal data bases facilitated the tracking of use of services, outcomes, and costs among these patients. Currently, managed-care organizations maintain information on patients, but it may not be reported consistently by the various plans.
The system with which the Health Care Financing Administration (HCFA) follows Medicare transactions is being revamped to accommodate managed-care data. Currently, the system can identify only recipients and payments forwarded to health maintenance organizations (HMOs). It does not contain detailed information on health status or interventions. The HCFA requests encounter data from HMOs for Medicare patients, but the data are often incomplete and unreliable, as are data on the managed care provided under Medicaid. Moreover, these fragmented data on encounters and costs may not be available in time for prompt assessment of the quality of care.
Current and complete data on interventions and outcomes are essential. Creating the necessary technological infrastructure is a challenge to Medicare and state Medicaid programs. The HCFA and state Medicaid agencies should establish uniform data fields or standardized data-collection forms. They should require managed-care organizations to submit data that are at least as comprehensive as those previously reported by fee-for-service providers. The HCFA's present policies and procedures of assessment are inadequate to ensure that data are specific enough to permit the evaluation of outcomes.1,2 For state Medicaid reform under Section 1115 demonstration waivers of the Social Security Act, the secretary of Health and Human Services has broad discretion to require more specific data from managed-care organizations caring for Medicare and Medicaid patients.
2 ReferencesFrancis B. Palumbo, Ph.D., J.D.
C. Daniel Mullins, Ph.D.
University of Maryland, Baltimore, MD 21201Author/Editor Response
The administrator of the Health Care Financing Administration replies:
To the Editor: We agree that gathering data on Medicare and Medicaid beneficiaries enrolled in managed-care plans is essential. We also know that there is a great deal still to learn about how best to collect and use such data. We have begun working aggressively to collect data from managed-care plans, even as we work actively to answer a range of questions on types of data, measurement tools, and methods of collection.
In 1997, the HCFA will require all Medicare health plans to report on their performance using Health Plan Employer Data and Information Set measures. These measures were developed jointly by the National Committee for Quality Assurance and the HCFA. We are commissioning a plan-by-plan survey of Medicare beneficiaries to see whether they are satisfied with their access to care and the quality of the care they receive. We will also test measures of outcomes for chronic disease that have been developed by the Foundation for Accountability, an association of large public and private health care purchasers and consumer representatives.
No single type of data answers all our questions, however. Even data on Medicare fee-for-service claims must be supplemented by surveying beneficiaries for information on functional status and the use of non-Medicare services. Managed care presents a greater challenge, since there are no insurance claims. We are testing the collection and uses of encounter data in managed care in several demonstration projects, including a pilot program in Washington State (where we are working with health plans to develop a mutually acceptable data set) and our Medicare Choices demonstration project (in which we are studying the use of various options for the delivery of managed care to Medicare beneficiaries). We are also requiring that encounter data be submitted as part of the Medicaid waiver demonstrations. We hope to build a consensus on what information to collect, how to collect it, and how to use it.
We at the HCFA believe that managed-care data are vital to high-quality, cost-effective care for Medicare and Medicaid beneficiaries. When it comes to the collection and use of such data, however, the devil is in the details. We are working to get those details right.
Bruce C. Vladeck
Health Care Financing Administration, Washington, DC 20201
