Abstract

The increase in healthcare cost without direct improvements in health outcomes, coupled with a desire to expand access to the large uninsured population, has underscored the importance of quality initiatives and organizations that provide more affordable healthcare by maximizing value.

To determine the knowledge of managed care organizations about quality organizations and initiatives and to identify potential opportunities in which pharmaceutical companies could collaborate with health plans in the development and implementation of quality initiatives.

Introduction

Many of today's healthcare concerns focus on the concept of value, which can be defined as a composite of cost, quality, and access. Expanding access through affordable healthcare insurance will only be possible if healthcare costs are contained through a focus on quality. Poor care quality results in costly errors, complications, and re-work. Conversely, high-quality care, namely, the right treatment at the right time, results in more cost-effective care. This emphasis on value is underscored by a lack of correlation between the increase in healthcare spending in recent years and health outcomes, which is often the result of a lack of information and tracking systems to determine the value of different treatments.

A survey of 36 pharmacy directors and 15 medical directors of different plans during a Managed Care Network meeting in 2008. The represented plans cover almost 74 million lives in commercial, Medicare, and Medicaid programs, or a combination of them.

Methodology

MCOs' interaction with each quality organization is different. Both NCQA and URAC issue health plan accreditations, whereas the relationship of MCOs with other quality organizations is more collaborative. NCQA was the organization with whom MCOs had the strongest relationship, with 74% of the respondents being or planning to be accredited by it. Furthermore, 34% of the plans were currently participating in other programs offered by NCQA. This again shows a great difference with URAC, with only 30% of plans being or seeking accreditation from URAC.

To further understand the reasons behind some of our observations, in January 2009 we conducted a follow-up online survey of the MCN meeting attendees on why the NCQA and URAC where best known and most referenced for quality initiatives. Many respondents commented that the NCQA is seen as almost “mandatory or expected,” and sometimes listed as a requirement from employers to consider a health plan. Some respondents commented on the NCQA accreditation requirement by Medicare and some Medicaid state programs.

However, even though pharmaceutical companies were mainly not considered as quality improvement partners, 36% of MCO directors express moderate to very high interest in getting more support and partnership from pharmaceutical companies. Specifically, pharmaceutical companies were viewed as more valuable in providing support in patient compliance/adherence programs, and in appropriate drug utilization programs.

Conclusion

The high increase in healthcare costs in the past decade is starting to build a focus on quality as an integral part of addressing cost-containment without lowering health outcomes. By creating their own quality metrics and systems that allow the development of clinical guidelines, and by collaboration with external quality improvement organizations, health plans can more efficiently allocate their resources to maximize health outcomes for their members.

Regards
Rutherford
Managing Editor
Journal of Pharmacy Practice and Education