PPO Leaders Discuss Approaches to Quality Reporting: Quality Reports Must Meet Member And Payer Needs

As more employers enroll workers in managed health care programs, measuring the quality and satisfaction of those plans becomes increasingly important. During the last 10 years, standards of care and provider performance have been promulgated by health plan accreditation organizations, most notably the National Committee for Quality Assurance.

But while health maintenance organizations are commonly reviewed for quality, preferred provider organizations, which enroll more Americans than any other health care delivery system, until recently had no standard method of quality measurement and reporting that allows for comparison of different PPOs.

The American Accreditation HealthCare Commission, a leading accreditor of PPOs, recently convened leaders of the PPO industry to discuss approaches to quality measurement and reporting in PPOs.

The American Accreditation HealthCare Commission is also meeting with employer representatives to discuss what information employers need from PPOs to enable them to evaluate quality and whether they are willing to pay higher administrative costs to obtain such information.

A small number of PPOs now report on their performance using a variety of tools, including both national and company-specific reporting tools. National performance assessment techniques used by PPOs include URAC accreditation and the NCQA's Consumer Assessment of Health Plans Survey. A few integrated PPOs are able to report modified HEDIS data. Many PPOs also report specific information requested by payers, such as: customer service, patient access to care, rates of complaints and grievances, and rates of utilization.

The American Accreditation HealthCare Commission convened the PPO industry leaders to discuss what, if any, standardized measures of performance are of value and are feasible to produce. The organization encouraged PPOs to consider the informational needs of payers, regulators and patients, and to identify a core set of information that could be reported in a standardized way. PPO leaders did not reach consensus on the need for standard measures of PPO performance. They noted that purchasers, regulators and patients have different demands for information.

The "PPO Leadership Meeting on Performance Reporting" is meeting with PPO leaders, consumer organizations, and employers to discuss strategies for improving information available about PPO quality.

More than a dozen PPOs and national organizations were represented at the meeting, including the American Association of Health Plans, the American Association of PPOs, Blue Cross Blue Shield Association, HealthLink and others.

The group heard presentations from the Agency for Health Care Policy and Research and several PPOs that report different quality measures. Garry Carneal, president and CEO of the American Accreditation HealthCare Commission. "We are very pleased that so many organizations sent representatives to this meeting. (The commission) has designed the "PPO Quality Initiative" to bring together ideas and data from all parts of the PPO system in order to improve the quality and efficiency of health care delivery."

At the meeting, Carneal asked the PPO leaders to comment on the value of adopting standardized tools to report on PPO performance. Although there was no unanimous agreement on most issues, several general themes emerged from the discussion.

• PPOs are extremely diverse in their structure and operations.

• State, federal, or employer-driven reporting requirements should account
for this diversity.

• There are fundamental differences between PPOs and HMOs in financing and delivering health care. Employers, regulators, and consultants will need more education to understand fully these differences.

• Reports on PPO quality must be meaningful to payers and consumers.

• Quality reporting could include such areas as cost, access, satisfaction, provider credentialing, and management of grievances and complaints.

• Performance information should be of use to the PPO in improving PPO performance, as well as to external audiences seeking to evaluate PPO performance.

Karen Greenrose, President of the American Association of Preferred Provider Organizations said, "One of the major tasks PPOs face is communicating the important differences between PPOs and HMOs and showing the benefits of PPOs. PPOs offer a cost efficient delivery option with wide network access--this is the sort of thing we should address when we evaluate PPO performance."

In The American Accreditation HealthCare Commission 's earlier meeting with consumer organizations, the organizations expressed a strong desire for more information on PPOs. The representatives of consumer organizations expressed particular interest in learning about how PPOs operate and how they address specific patient care and customer service issues.