PEDIATRICS Vol. 112 No. 5 November 2003, pp. 1163-1165
Incorporating Quality Improvement Into Pediatric Practice Management
Thomas K. McInerny, MD*,
John R. Meurer, MD, MBA
and
Carole Lannon, MD, MPH
* University of Rochester School of Medicine and Dentistry, Rochester, New York
Medical College of Wisconsin, Milwaukee, Wisconsin
University of North Carolina School of Medicine, National Initiative for Children’s Healthcare Quality, Boston, Massachusetts
Abbreviations: CSHCN, children with special health care needs • AAP, American Academy of Pediatrics • NICHQ, National Initiative for Children’s Healthcare Quality • ADHD, attention-deficit/hyperactivity disorder
As health care costs continue to rise at an alarming rate, policy makers are increasingly recognizing that managing costs, managed care organizations’ primary approach to this problem, is not a long-range solution. Rather, some payers are realizing that improving the quality of care, especially preventive care, will lead to long-term reductions in health care expenditures. Therefore, payers are now monitoring the quality of primary preventive (eg, immunizations) and care of children with special health care needs (CSHCN) (eg, disease and case management) practices of managed care organizations and physicians much more closely and basing contracting decisions on evidence of the provision of high-quality care. For example, in October 2002 the Institute of Medicine in its publication "Leadership by Example"1 proposed that the federal government, which sets the quality standard for its six health care programs, including Medicare and Medicaid, establish standardized performance measures, encourage health care providers to adopt "best practices," and "reward providers who achieve higher levels of quality." Thus, rather than looking simply for the lowest-cost providers and clinicians, payers will be attending to outcomes data demonstrating the value, as defined by quality and price, of care provided. Therefore, it is critically important that providers, health care organizations, hospitals, and physicians, be able to document convincingly the quality of their services in an increasingly competitive marketplace. Fortunately, pediatricians have been providing preventive care for decades; however, we have not been as diligent in rigorously documenting the value of these services by measuring and publishing outcomes data.
The purpose of this Special Article is to raise awareness of the necessity of documenting the value of care provided by pediatricians, give some examples of published studies in this area, discuss briefly some measures of quality currently being used as well as American Academy of Pediatric (AAP) initiatives to improve quality of pediatric care, and point out the necessity for pediatricians to be proactive with patients and payers in designing and choosing health care plans.
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VALUE OF PEDIATRIC PREVENTIVE SERVICES
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To date, a small but growing number of studies have been published in peer-reviewed journals on the value of pediatric primary (well child) and CSHCN care. The most dramatic studies document the value of immunizations in preventing serious pediatric illnesses. Less robust are studies of the value of anticipatory guidance and periodic preventive care visits in improving healthy behaviors by parents, children, and adolescents.2–4 Evidence that continuity of care in a medical home reduces emergency department visits and hospitalization is mounting, but further studies are needed in this area.5–8
Similarly, reports of the evidence of secondary preventive services for children with chronic illnesses such as asthma and diabetes are starting to appear in the literature, but are not as convincing in numbers as would be desirable.9–11 Unfortunately, several studies indicate that pediatricians are not adhering to evidence-based guidelines that are likely to be effective in the management of children with asthma. In addition, the Institute of Medicine has identified gaps in preventive health care, medication errors, and long-wait times for primary care appointments. Thus, there is room for improvement in pediatricians’ delivery of care for well children and CSHCN.
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MEASURES OF QUALITY
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Employers and federal and state governments currently utilize various measures of quality to assess insurers, health care systems, and providers. The most commonly used measures are the Health Employer Data Information Set, the Consumer Assessment of Health Plans Survey, and the Child and Adolescent Health Measurement Initiative of the Foundation for Accountability. A relatively new measure, The National Committee on Quality Assurance (www.ncqa.org), has developed a "quality dividend calculator" for a limited number of health issues. This measure attempts to factor in the business case for quality equations and includes indirect costs, such as reduced employee absenteeism as well as health expenditures that result from quality care. These measures are often based on imperfect administrative data and focus primarily on adult health, but they often are the only measures readily available to payers. It is thus important for pediatricians to be aware of which measures are being used and how they are being rated. Additional information about this and other measures can be found in the Agency for Health Care Research and Quality Child Health Toolbox at www.ahrq.gov/chtoolbox.
Despite limitations, current performance measures can be used to negotiate improved financial arrangements with payers. For example, some pediatric groups have negotiated higher reimbursement levels, decreased withholds, or other financial incentives with insurers based on high scores in the above-mentioned process and outcome measures. Similarly, Medicaid administrators in some states are willing to increase reimbursement to pediatricians who provide high-quality care as evidenced by data collected by the state.12 Documenting quality of care may provide pediatricians with an improved bargaining position with payers.
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INITIATIVES TO SUPPORT QUALITY
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The AAP has partnered with the National Initiative for Children’s Healthcare Quality (NICHQ) to develop practical programs to assist pediatricians in improving practice patterns in providing care for well children and CSHCN. For example, as part of NICHQ programs, the Academy’s Pediatric Research in Office Settings network pilot tested tools and strategies for improving the office evaluation and management of children with asthma and attention-deficit/hyperactivity disorder (ADHD). These programs are based on the Plan-Do-Study-Act small cycles of improvement techniques, which have proven to be quite effective in providing systems improvements that lead to better immunization rates, higher use of inhaled corticosteroids for patients with asthma, and reduced waiting time for appointments. In addition, NICHQ has developed toolkits, available on the NICHQ website (www.NICHQ.org), that are helpful in understanding and following guidelines for the diagnosis and treatment of ADHD. The AAP has made these tools available through an innovative online learning program called Education in Quality Improvement for Pediatric Practice. The first module on asthma was introduced in April of 2002; the second module on ADHD was introduced in April of 2003. These modules have been patterned based on demonstrated techniques developed by NICHQ in learning collaboratives that have involved hundreds of pediatric practices from around the country. Education in Quality Improvement for Pediatric Practice is a unique education initiative that has the potential to enhance implementation of clinical practice guidelines. Several insurers have already provided financial incentives to groups of pediatricians who successfully complete these online courses.
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NEW EMPLOYER AND HEALTH PLAN APPROACHES TO COST CONTAINMENT: A THREAT TO QUALITY PREVENTIVE CARE?
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Recently, more employers have started to realize that increasing copays and deductibles involve their employees in decision-making about health care expenditures and leads to reduced costs as increasing employee "out-of-pocket" expenses reduces utilization. Under these circumstances, employees may not always be aware of the long-term quality implications of their decisions, and they may forego some preventive services as a short-term savings if they are subject to copays or deductibles. In general, these new products fall under the following categories: consumer-driven health plans, medical savings accounts, defined contributions, and self-funded or self-insured plans. Because these newer products do not always provide a defined set of benefits, there is a danger that many preventive care benefits for children that are part of current insurance and managed care plans will not be offered or will require significant copayments. This, of course, could lead to significant reductions in preventive health visits, immunization rates, and follow-up visits for children with special health care needs.
As many of these new approaches fall under the Employee Retirement Income Security Act exemption, it is critically important for pediatricians to monitor changes in health care plans offered by employers, lest we lose the hard-fought gains made through enactment of child health insurance reform in many states. We must convince parents, employers, health benefits managers, insurers, and third party agencies of the value of high-quality preventive care provided in a medical home, so they will not create barriers to preventive care visits. It will be easier to maintain existing benefits than to reinstitute them after employers have discontinued or altered them. A window of opportunity exists for pediatricians to be proactive and avoid serious consequences. Advocating for essential pediatric benefits coverage is critically important for improving the health of children.
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CONCLUSIONS
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The AAP President, Steve Edwards, MD, has announced that the AAP will be focusing on the access-quality-reimbursement triad during his term of office. The timing is most appropriate as we face new challenges to demonstrate the long-term value of high-quality pediatric care in preventing illness and the complications of chronic conditions.
To meet the current health care challenges pediatricians must:
- Increase efforts that document the value of well-child and CSHCN pediatric services;
- Become more involved in implementing quality-improvement methods into their practices;
- Develop better measures of clinical performance and outcomes of care;
- Promote the demonstrated value of pediatric services to payers, employers, insurers, and state and federal government agencies.
Families, employers, insurers, and governmental agencies are all demanding, measuring, and rewarding high-quality care. Now is the time for pediatricians to respond to this initiative through quality-improvement programs and compelling demonstrations of the effectiveness of our care of "our nations most precious resources"—its children.
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ACKNOWLEDGMENTS
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We thank the following reviewers for their very helpful contributions: Steven Berman, MD, Glenn Flores, MD, and Charles Homer, MD, MPH.
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FOOTNOTES
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Received for publication Mar 24, 2003; Accepted Mar 24, 2003.
Address correspondence to Thomas K. McInerny, MD, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 777, Rochester, NY 14642. E-mail: thomas_mcinerny{at}urmc.rochester.edu
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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