Comprehensive health data systems spanning the public-private divide: the Massachusetts experience

As systems of health care delivery have evolved from claims-based fee-for-service to capitated or managed care, with its emphasis on cost-effectiveness, quality, and performance measurement, some states have begun to experiment with new ways to collect, organize, and share health information. In many cases, the drivers of these changes have been purchasers of health care, including large and small private employers and public agencies such as Medicaid. One of the results of these changes is the increased interest in the sharing of health information, between health plans and employers, and, in some instances, between private plans and public agencies such as public health. Massachusetts, which has one of the highest rates of managed care penetration in the United States, has brought together the various parties involved in the collection and utilization of health information, to craft agreements on standards and protocols that will allow the sharing of health data. While much of the activity involves business transactions between private sector health plans, the Department of Medical Assistance (Medicaid) has joined with its private sector purchasing partners in demanding cost-effective, high-quality care; it is these demands that have helped stimulate the need to reorganize previously proprietary health information systems. The activities of two public-private coalitions, the Massachusetts Healthcare Purchaser Group and the Massachusetts Health Data Consortium, have been critical in initiating and supporting the complex processes that have led to significant changes in state-based systems of health information.

Vendor management: a model for collaboration and quality improvement

BACKGROUND

The Massachusetts Medicaid agency, also known as the Division of Medical Assistance, has developed a quality-driven approach for managing its managed care suppliers. Such an approach has, as its foundation, principles of continuous quality improvement (CQI). Suppliers participate in an annual process whereby CQI goals are negotiated between the division and its suppliers. The division then works with suppliers to achieve such goals. A cornerstone of the division's approach is the notion that data can highlight an unlimited number of opportunities for improvement and that pursuit of such opportunities will ultimately result in meaningful improvements in the health status of recipients who are served by the division.

COLLABORATIVE APPROACH

The agency's approach involves five key steps: 1) the development of contractual terms and purchasing specifications; 2) the identification of improvement priorities; 3) the negotiation of improvement goals; 4) efforts directed at meeting improvement goals and measurement of success; and 5) collaboration to achieve mutual objectives.

BENEFITS AND CHALLENGES

Overall, suppliers report many benefits of collaborative participation in CQI activities with the division. Suppliers have enhanced their understanding of the importance of meeting the needs of the customer and have further accrued benefits resulting from discussions with managed care vendors throughout the site regarding benchmarking of efforts and CQI efforts. Conversely, suppliers are challenged by the need to balance and allocate resources to meet increasing demands, which are not always consistent, from various purchasers, including the division. The division has been challenged in the evolution of its contract management strategy by an uneven level of knowledge among managed care vendors regarding CQI; goal setting and measurement issues; the length of time and level of effort required to develop good relationships with suppliers; and the critical importance of comparable, valid, and timely submission of data.

RESULTS

Over the last three years, the division has seen a dramatic increase in the responsiveness of managed care suppliers to meet its needs as a purchaser. Specifically, this has been expressed through supplier ability to meet mutually negotiated improvement goals. The division is also pleased that it is beginning to achieve some measurable improvements in outcomes of care.

Reporting and using health plan performance information in Massachusetts

BACKGROUND

In 1993, 27 corporate and government health care purchasers formed the Massachusetts Healthcare Purchaser Group (MHPG). Sixteen health plans submitted 1992 data on six clinical indicators-mental health inpatient days per patient and inpatient readmission, blood pressure screening, prenatal care, mammography screening, cesarean section (C-section) rates, and asthma admission rates-developed in an earlier pilot effort in response to the quality portion of MHPG's "Cost/Quality Challenge."

DATA COLLECTION AND ANALYSIS

Detailed data specifications developed in the pilot to ensure uniform data collection were used, with a requested sample size for chart-reviewed measures of 220. A "clinically significant average range" was defined. Health plan performance was summarized for each indicator in a report released in March 1994. REPORTING OF CLINICAL INDICATOR RESULTS: For the six indicators, each plan had a unique pattern of variation from the average range. For prenatal care, mammography, and hypertension, many plans had opportunities for improvement. SURVEY OF PURCHASERS: Most of the purchasers MHPG surveyed in October 1994 about their assessment and use of the Cost/Quality Challenge Report found it useful. RESPONSES TO THE REPORT: To promote quality improvement activities among health plans, MHPG showed purchasers how to pursue performance issues with health plans, held a Best Practice Forum on C-section, and created a follow-up endeavor, the Coordinated Purchasing Initiative.

SUMMARY AND CONCLUSIONS

In spite of potential problems posed by technical deficiencies, costs of data acquisition and quality efforts, and unintended effects of public reporting, purchaser/plan initiatives such as the Cost/Quality Challenge can provide valuable information to purchasers.

Development of clinical indicators for performance measurement and improvement: an HMO/purchaser collaborative effort

This article describes a collaborative effort between a major health care purchaser, three area health maintenance organizations, and a state Medicaid agency to develop clinical indicators as the basis for a comparison database. Some of the difficulties in developing a "common yardstick" of quality and value are candidly discussed.