Mr. Chairman, I am very pleased to be here to describe how the Health Care Financing
Administration (HCFA) is working to ensure that Medicare and Medicaid beneficiaries receive
high quality health care services. This is a priority for the President and the Administration as a
whole. Mr. Chairman and Rep. Stark, I would like to thank you for the leadership you provided
in passing strong consumer and quality protections for Medicare beneficiaries in last year's
Balanced Budget Act (BBA). Our goal is to become a value-based, beneficiary-centered
purchaser. We are striving to enhance performance and accountability in a quality health care
delivery system -- one that is affordable, effective and safe, while protecting and improving
enrollee health and satisfaction, and responding to the specific health needs of individuals.
As the Nation's largest purchaser of health care, we want to effectively use market forces to
obtain best value for our beneficiaries. We have developed a unified approach in regard to
quality measurement and improvement for both Medicare and Medicaid. We know through our
participation in a variety of public private partnerships that this approach is consistent with the
strategy of many of the large private and public purchasers. However, given that this
Subcommittee has jurisdiction over Medicare, I will focus my testimony on our efforts in regard
to that program. In addition to discussing our quality initiatives, I want to highlight some of the
quality- related consumer protection provisions in the Medicare program. These provisions were
strengthened as a result of the work of this Subcommittee in the Balanced Budget Act of 1997.
The argument for the potential of managed care to improve quality is well known. The capitated
prepayment made to managed care allows plans to organize care and re-allocate resources to
address, in a coordinated and systematic way, the needs of each patient. In managed care, the
organization is accountable for improving the well-being of the patient. This provides both an
opportunity and an incentive to improve the quality of care being furnished and emphasizes
preventive care rather than acute care.
The flip side to the argument is also well known. In managed care, there is the potential for
"under-service" and poor quality, if plans try to maximize short-term profits by not delivering
appropriate care. The goals of our quality initiatives are to measure performance and to hold
plans accountable for their performance and for quality improvement.
We have two approaches towards performance measurement. The first approach is to identify
those clinical intervention processes (tests, medications, procedures, surgeries) that, based on
scientific evidence, we know are linked to desired health outcomes. Examples of these processes
are mammograms for breast cancer screening, flu shots, use of beta-blockers after myocardial
Some (not all) of the measures of these clinical processes can come from plan administrative or
encounter systems. While this approach has limitations (good outcomes is not the sum of known
clinical processes), process measures provide significant insight into the quality of care and
provide opportunities for measurement and improvement.
The second, preferred and potentially the most efficient strategy for clinical performance
measures, is to move toward outcome measures, which reflect the health status of the beneficiary.
The problem is that the science of outcomes measures is in its infancy. The movement towards
better outcomes measures is critical for HCFA, like-minded purchasers, and beneficiaries in
order to hold plans and providers accountable for the care they deliver. HCFA and the Agency
for Health Care Policy Research (AHCPR) have been active in promoting research to identify
these measures. With such measurements in hand, HCFA and the public will be able to
objectively compare managed care plans as well as fee-for-service, and to determine whether
managed care plans are living up to its potential to improve the quality of care.
In June of 1996, a Quality Initiative Team was commissioned within HCFA to develop a
comprehensive quality strategy that would transform HCFA's efforts from that of carrying out a
group of quality-related functions to that of operating an integrated quality program that is
accountable for the health and satisfaction of its beneficiaries. The goal of this strategy is to
improve care consistently across the Medicare and Medicaid programs, for managed care as well
as fee-for-service, and for special populations as well as the beneficiary population as a whole.
Based on the recommendations of the Quality Initiative Team, a permanent Quality Council was
created within HCFA to coordinated implementation of the quality strategy.
Accountability -- Quality Improvement System for Managed Care
Historically, HCFA's review of Medicare managed care plans has focused on structural standards
that looked at a plan's infrastructure and capacity to improve care, as opposed to looking at
whether the plan actually improved care. The trend among purchasers of managed care,
however, is to demand performance measures in order to hold managed care organizations
"accountable." To provide for this accountability within Medicare and Medicaid, HCFA
working though the National Academy of State Health Policy in consultation with State
Medicaid agencies and regulators, quality measurement experts, managed care plans and
beneficiary groups has developed the Quality Improvement System for Managed Care (QISMC).
QISMC will help us to assure that care is improving and that plans are accountable in regard to
objective, measurable standards.
QISMC adds two major changes to the quality assurance standards that exist in Medicare
First, plans will be required to meet minimum performance levels on standardized measures
(see HEDIS and CAHPS below). Such minimum performance levels are to be set by HCFA on
an annual basis and will be based on local or national observed historical experience.
- Second, plans will be required to show demonstrable and measurable improvement in
specified broad clinical areas (e.g., preventive services, acute ambulatory care, chronic care,
hospital care, etc.) based on performance improvement projects that each plan will identify.
With QISMC, we will shift from looking at whether plans have the infrastructure to improve care
to whether plans demonstrate measurable improvement. The question is not whether plans are
able to improve, but rather did they improve. QISMC will define in advance for plans what is
acceptable, demonstrable, and measurable improvement. These definitions will also serve as the
basis for HCFA reviewers to monitor plan performance and compliance based on data.
The current draft of QISMC has been sent out for comment. NASHP will then incorporate those
comments and give us a completed report by June. This will serve as the basis for HCFA to
have further discussions with the various stakeholders.
One of the sources for standardized measures under QISMC will be the Health Plan Employer
Data and Information Set (HEDIS) 3.0. This choice, in part, is an effort to move toward
standardization with other purchasers. HEDIS 3.0 reflects a joint effort of public and private
purchasers, consumers, labor unions, health plans, and measurement experts, to develop a
comprehensive set of measures for Medicare, Medicaid, and commercial populations enrolled in
managed care plans. Four measures that impact on Medicare beneficiaries were added to the
"effectiveness of care" category in HEDIS 3.0, including: mammography rates, use of retinal
examinations for diabetics, outpatient follow-up after acute psychiatric hospitalization, and
utilization of beta blocker in heart attack patients. HEDIS 3.0 will facilitate comparison of plan
performance measures. It will also permit HCFA to establish minimum performance levels for
these standardized measures, thus, holding plans accountable for the quality of the care they
Last year, HCFA directed all Medicare managed care plans to report date for 1996 on 32 HEDIS
3.0 measures to the National Committee for Quality Assurance (NCQA) by June 30, 1997.
These 32 HEDIS 3.0 measures cover: effectiveness of care, access/availability of care,
satisfaction, health plan stability, use of services, cost of care, informed health care choices, and
descriptive information. Since many of the specific measures break down by age and other
demographic characteristics, there are up to 850 data elements per plan.
HCFA, working with the HEDIS Committee on Performance Management, was instrumental in
adding functional status for enrollees over age 65 as a measure in the "effectiveness of care"
category in HEDIS 3.0. The "Health of Seniors" functional status survey will be the first
outcome measure in HEDIS that will longitudinally track and measure functional status. It
addresses both physical and mental status through a self-administered instrument which
determines whether the beneficiary perceives that his or her health status has improved, stayed
the same, or deteriorated. This measure will be administered by independent venders beginning
in May of this year.
HEDIS 3.0 data is self-reported by plans and is unaudited. Many purchasers and consumers are
making judgments and comparisons based on this data. Given the importance of the data and
HCFA's leadership role as the largest purchaser of managed care in the country, we contracted
with the Island Peer Review Organization (IPRO, which serves the state of New York) to
perform an audit of the HEDIS data. The purpose of the audit was to ensure that valid, accurate,
and comparable HEDIS summary data for services provided in 1996 were obtained. Data
validation was twofold: (1) to quantify the accuracy of the information collected, and (2) to
quantify its completeness. The audit was divided into two parts. The first was a baseline
assessment of all 284 contract markets reporting HEDIS to determine the effect of their
information management practices on their ability to report accurate data. In addition, IPRO
performed an onsite audit of 79 contract markets covering 65% of Medicare beneficiaries
enrolled in managed care.
Last December, IPRO discussed its preliminary audit findings with HCFA staff. The final IPRO
report is due to HCFA within a few weeks. We do know that there were serious problems with
data accuracy due to immature plan information systems and ambiguous measurement
specifications. HCFA is conducting its analysis of 1996 HEDIS data based on the preliminary
audit findings. We are committed to making the HEDIS data and the results of the IPRO audit
publicly available as rapidly as possible. However, such a release must be consistent with our
public responsibility and the competing interests to make data widely available, be fair and
accurate to plans, and to inform the public. We will get back to the Committee on how we plan
to proceed with the data release.
In the meantime, HCFA is working to receive more accurate HEDIS data in the future and
toward that end will be working with NCQA and the health plans. We are considering
mandating a pre-submission audit of HEDIS data by all plans for this year. We do expect that,
over time, the information systems that health plans use to provide HEDIS data will advance
from their current developmental stage. HCFA also expects that other management systems,
such as provider contracting, will be better structured for easier provision of performance data.
Finally, we believe that the HEDIS measure specifications will improve as NCQA continues to
refine them through feedback from current implementation.
Accurate HEDIS data is necessary but not sufficient for the effective use of quality information.
HCFA, like many purchasers and consumer groups, continues to struggle with how particular
measures should be used for plan comparison. Much work remains to prepare Medicare
beneficiaries to use plan comparison data, as well as quality of care and satisfaction data as these
become available. At present, we are still learning about which measures or groups of measures
and what methods of presentation for these measures Medicare beneficiaries would find most
informative and usable. Both accurate data and a meaningful framework are necessary to meet
BBA requirements for broadly disseminating information to Medicare beneficiaries to promote
active, informed selection among options.
Consumer Assessment of Health Plans Study (CAHPS)
In cooperation with HCFA, AHCPR designed the Consumer Assessment of Health Plans Study
(CAHPS) to design a Medicare beneficiary survey. This survey quantifies Medicare enrollees'
evaluation of key elements of their health plans, including how easy it is to get access to
appropriate care, how well the clinicians communicate with them about their health status and
treatment options, and the quality of care provided. Survey results, which will provide extensive
information about every Medicare managed care plan, will be available this fall and will help
beneficiaries make informed decisions about their health plans. We are pleased that OPM will
work with us to have FEHBP enrollees participate in this initiative. HCFA plans to administer
the survey through an objective single third party vendor in order to ensure comparability. The
survey was just mailed out for the first time earlier this month, and results are expected to be
available to consumers for use in their decision-making this fall.
HCFA's research office recently completed an investigation of whether encounter data can be
used to measure access to and quality of care for Medicare beneficiaries enrolled in managed
care plans. The results of this study, which used data from a large HMO and from fee-for-service,
successfully demonstrated that using encounter data in this fashion is possible. Encounter data
would obviate the need for many current HEDIS measures. However, there are many clinical
processes and outcomes that are not captured by claims-based encounter systems, thus there will
be a continued need for NCQA or FAcct - like efforts.
Accountability and Quality Improvement In Fee-for-service Medicare
The movement toward performance measurement and accountability for quality improvement is
not limited to managed care. We are currently revising our conditions of participation for
hospitals, end-stage renal disease facilities (ESRD), home health agencies, hospices and
ambulatory surgical centers in order to move away from process requirements and instead require
that providers monitor the quality of care that they provide, improve that quality and document
that improvement. The new requirements do not mandate the structure or processes that must be
used to accomplish the expected outcome, unless those requirements are predictive of quality and
patient safety (i.e. infection control, life safety code standards).
In order to evaluate and improve quality, health care organizations must have data that will
inform them about the quality of care that they provide. Our standards will require the collection
of quality indicator data in those areas where the science is available and consensus exists on the
value of the information. The state of quality indicator development varies by provider type. We
are requiring collection of OASIS data that supports outcome measures in home health,
indicators of the efficacy of dialysis for ESRD facilities, and MDS data in skilled nursing
facilities. Providers such as hospitals, hospices and ambulatory surgical centers do not yet have
quality indicators that are supported by science and industry consensus. For those providers, our
standards will require that they select a set of the many measures available to them.
HCFA's Clinical Measures group is working with other public and private partners to develop
measures in those areas that need them and to improve and converge the quality indicators
already developed. As the health care environment continues to change and the science evolves,
our standards will be modified to reflect and support our continuous efforts to improve the way
we improve quality.
Foundation for Accountability
The Foundation for Accountability (FAcct) is a non-profit organization dedicated to helping
purchasers and consumers obtain the information they need to make better decisions about their
health care. As Federal Liaisons to the FAcct Board of Trustees, HCFA is joined by other public
and private sector partners, including the American Association for Retired Persons, the
AFL-CIO, the Department of Defense, the Office of Personnel Management, Ameritech, and
American Express. FAcct is uniquely situated to integrate the perspectives of purchaser and
consumers of health care in regard to quality measurement. Specifically, FAcct endorses and
promotes a common set of patient-oriented measures of health care quality.
Last August, President Clinton announced a major collaboration between FAcct, NCQA, ADA,
HCFA and several other organizations to develop a common set of performance measures for
person with diabetes. This important initiative should lead to improved quality of care. We
anticipate that HEDIS will include some of the measures coming out of this collaboration for
implementation in 1999.
From January 1994 to present, PROs have initiated 1044 cooperative improvement projects and
completed 359 of these. Of the projects initiated during the 4th PRO contract cycle (1993-1996),
eighty-seven percent resulted in improvements in care that have been documented.
- Cooperative Cardiovascular Project (CCP) is a national effort to improve the quality of
care for Medicare beneficiaries who have had heart attacks. The project began as a pilot
program in 1992 in four States using quality indicators based on guidelines published by the
American College of Cardiology and the American Heart Association. In 1995, CCP was
expanded to a national project focusing on quality indicators when a patient arrived in the
hospital and at discharge. Results in the pilot States showed: a significant improvement in
all indicators; a 10 percent drop in 30-day mortality and reduced length of stay.
- There have been over 60 recent PRO Projects on community acquired pneumonia involving
37 states focusing on improving timing of antibiotics. A HCFA-sponsored study conducted
by the Connecticut Peer Review Organization established a linkage between early
administration of antibiotics and mortality. Thirty-seven percent of completed pneumonia
projects demonstrated improvements in reducing average length of stay. Twenty-two percent of
the completed pneumonia projects demonstrated improvements in reducing mortality.
The Medicare Managed Care Quality Improvement Project (MMCQIP) is designed to enhance
HCFA's ability to assess how well the ambulatory care process in managed care is meeting the
needs of beneficiaries. At this time, we are evaluating the care received by Medicare managed
care plan enrollees diagnosed with diabetes mellitus, and the incidence of screening
mammography in a sample of enrolled beneficiaries. The PROs in five states (California,
Florida, New York, Pennsylvania and Minnesota) and 23 Medicare-contracting HMOs are
collaborating on MMCQIP. In addition, an on-going sister project, utilizing the PROs in
Maryland, Iowa and Alabama, will analyze the same measures in the fee-for-service setting.
The initial finding is that there is room for improvement in both managed care and
fee-for-service in these two areas.
QUALITY-RELATED CONSUMER PROTECTIONS
Quality improvement initiatives are an important part of our general effort to assure adequate
consumer protection for beneficiaries enrolled in managed care plans. It is worth noting that
Medicare has other structural provisions that protect beneficiaries. In fact, many of the
protections available to Medicare beneficiaries are not available to most commercial enrollees.
Last fall, the Advisory Commission on Consumer Protection and Quality in the Health Care
Industry presented the President with a Consumer Bill of Rights and Responsibilities. On
November 20, the President directed the Secretaries of Defense, Labor, Health and Human
Services, Veterans Affairs, and the Director of the Office of Personnel Management to assess the
extent of current compliance with the Bill of Rights, consistent with the missions of our agencies,
and to identify the process for resolving any impediments to further compliance.
Just last week, these agencies reported back to the President, through the Vice President, on the
degree to which they are currently in compliance, administrative steps that could be taken to
come into compliance, and statutory barriers to prevent these Federally-administered health plans
from coming into compliance. HCFA reported to the Vice President that both Medicare and
Medicaid are largely in compliance with the Consumer Bill of Rights.
With the Consumer Bill of Rights and Responsibilities in mind, let me briefly highlight some of
Medicare's quality-related consumer protections. As I noted earlier, these provisions were
strengthened as a result of the work of this Subcommittee on the BBA.
- Unrestricted Medical Communication: The Medicare statute requires that contracting
health plans must make all covered services available and accessible to each beneficiary as
determined by the individual's medical condition. In fee-for-service, Medicare beneficiaries
are made aware of the full range of treatment options by their physicians. In November of
1997, we sent a policy letter stating that managed care enrollees are entitled to the same
advise and consultation. The Medicare+Choice provisions of BBA included such a so-called
"anti-gag clause" provision.
- Beneficiary Appeals: In this area, Medicare's protections are significantly beyond those
generally available to managed care enrollees in the private sector.
Under the BBA, Medicare+Choice plans must have a procedure for making determinations
regarding whether an enrollee is entitled to receive services and the amount the individual
is required to pay for such services. The explanation of a plan's determination must be in
writing, and must give the reasons for the denial in understandable language and must
describe the appeals processes. Determinations must be made on a timely basis; i.e., within
60 days after the request by the enrollee. Reconsiderations of the denial coverage based on
lack of medical necessity must be made by a physician with expertise in the relevant field
Plans are also required to have an expedited review process in cases for which the normal
time frame for making a determination or reconsideration could seriously jeopardize the life
or health of the enrollee or the enrollee's ability to regain maximum function. Either the
beneficiary or the physician may request an expedited review. Requests for expedited
reviews made by physicians (even those not affiliated with the organization) must be granted
by the plan. Expedited determinations and reconsiderations must be made within time
periods specified by the Secretary, but not later than 72 hours after the request for expedited
review, or such longer period as the Secretary may permit in specified cases.
An independent entity with which HCFA contracts is responsible for reviewing and
resolving plan reconsiderations not favorable to the beneficiary. If the independent review is
unfavorable to the beneficiary, the beneficiary has the right to the ALJ and judicial review.
- Physician Incentive Plans: Effective January 1, 1997, the Physician Incentive Plan Final
Rule required managed care plans with Medicare or Medicaid contracts to disclose
information about their physician incentive plans to HCFA or the State Medicaid agencies,
before a new or renewed contract receives final approval. Plans whose compensation
arrangements place physicians or physician groups at substantial financial risk must provide
adequate stop-loss protection and conduct beneficiary surveys. Current law requirements for
physician incentive plans are maintained in the BBA.
- Emergency Services: The BBA clarified the obligation of Medicare and Medicaid managed
care plans to pay for emergency services rendered to their enrollees. "Emergency services"
are defined from a "prudent layperson" perspective. Medicare+Choice plans and Medicaid
managed care organizations are required to pay for emergency services without regard to
prior authorization or whether the provider has a contractual relationship with the plan.
These provisions will be implemented for Medicare when the BBA regulations are issued
this summer. However, HCFA is sending a letter to State Medicaid directors to clarify this
There are, however, a few rights for which HCFA has determined that additional appropriate
administrative actions could be taken to bring the program into compliance with all of the major
elements of the Consumer Bill of Rights. Last week, the President directed the Department to
bring Medicare and Medicaid into compliance in these few areas. These include ensuring that
Medicare and Medicaid beneficiaries with complex and serious medical needs have access to
specialists and to some of the rights regarding participation in treatment decisions, as contained
in the Commission's recommendations.
- The Department's implementation of the BBA, combined with our commitment to
implementing the Consumer Bill of Rights and Responsibilities, will ensure that Medicare
will be in substantial compliance with the Commission recommendations by next year.
Additional authority is needed to bring the program into full compliance with regard to
confidentiality, transitional care, and choice of provider for women for their routine and
preventive women's health services. The Department has already released a report that
outlined new privacy protections that are needed to ensure appropriate confidentiality of
- As a result of recent guidance to states and new consumer protections enacted in the BBA,
the Medicaid program is quickly moving into compliance with much of the Consumer Bill
of Rights, and will soon be in substantial compliance. As with Medicare, additional
authority is needed to bring the program into compliance with regard to confidentiality,
transitional care, and choice of provider for women for their routine and preventive women's
We are well aware that there is still much work to be done to ensure that Medicare and Medicaid
beneficiaries receive high quality care. With advancements in quality measurement, our strategy
will change from monitoring processes to assuring minimum quality performance and
measurable quality improvement. Our work with managed care will assist us in addressing the
question of quality in original fee-for-service Medicare. We thank Chairman Thomas, Mr. Stark,
and other members of the Committee for working to enact the quality-related provisions that
were included by the Congress in the Balanced Budget Act of 1997. We look forward to
continuing to work with this Subcommittee on this vital issue.