Getting Quality Medical Care

By Chris Woolston, M.S.

Students have report cards, Consumer Reports rates new cars, and employees -- like it or not -- get regular performance reviews. But if you're looking for a new doctor and health plan, or a hospital that offers quality care, where do you go? Are there any "report cards" for health care?

The answer is yes. To start with, you need to know how doctors, medical specialists, hospitals, and health plans are overseen and rated, because these ratings are the key to checking up on the quality and performance record of your health care provider. Perhaps the best place to start is the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ), which is responsible for researching quality of care. The agency publishes an in-depth guide for patients and families called "Improving Health Care Quality" that is available on the Internet at http://www.ahrq.gov/consumer/qntlite/

Ratings of health care quality are available from both public and private groups that are developing ways to check up on and improve the quality of doctors, hospitals, health plans, and other types of health care providers. Of course, a few cautions are in order.

Len Nichols of the New America Foundations health policy program says factors such as discomfort during recovery may be equally or more important to patients than those more likely to be covered in quality control surveys. Officials at the National Health Policy Forum also believe that various kinds of rating systems need to be linked together to be effective.

The two most common types of quality measures are consumer ratings, which are compiled from surveys filled out by patients, and clinical performance measures, which are ratings on quality conducted by outside experts. Read on to find out where you can get access to both.

How can I find a high-quality health plan?

The quality of health plans varies widely. A study published by the National Committee for Quality Assurance (NCQA) found significant differences in the ways health maintenance organizations (HMOs) provide access to care, keep people healthy, treat illness, deliver high-quality service, and satisfy patients. For example, many studies show that treating heart attack patients with beta blocker drugs saves lives. The NCQA found that in some health plans, most heart attack patients got beta blockers, while in others, fewer than one in three did. The NCQA provides a detailed, online ranking of over 600 health plans in the United States. The plans are scored and ranked by customer service, clinical performance, and accreditation. To find NCQA's reports, go to http://reportcard.ncqa.org/plan/external to see a free "report card" on any health care plan they have reviewed, or call 1-888-275-7585.

You are probably looking for a type of health plan that best fits your needs in terms of cost, benefits, and access to particular doctors. Whichever type you choose, what's most important is to understand your plan options and how they affect your choice of providers. After all, your health plan determines your choice of doctors, which types of services you will receive (for example, some plans cover more preventive care than others), where you will receive your care, how quickly you will receive it, and how much you will pay.

Ask these questions when choosing a health plan:

  • Do members rate the plan highly on things that are important to me?
  • Does the plan provide preventive services to help keep people well?
  • Does it do a good job of helping them get better when they are sick?
  • Is the plan accredited?
  • Does the plan have the doctors and hospitals I want or need?
  • Does the plan provide the benefits I need?
  • Do the doctors, pharmacies, and other services in the plan have convenient times and locations?
  • Does the plan meet my budget?

Where can I find out how a particular health plan is rated?

To find out what other consumers think of a particular health plan, look for the survey compiled by the Consumer Assessment of Healthcare Providers and Systems (CAHPS), which was developed by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) (http://www.cahps.ahrq.gov/content/cahpsOverview/OVER_Intro.asp?p=101&s=1). The questions in the CAHPS survey ask patients to evaluate the quality of care in their own health plans. Their answers can help you decide whether you want to join one of them.

Clinical performance ratings focus on how well a health plan or hospital prevents and treats illnesses. One of the best places to look is HEDIS -- the Healthcare Effectiveness Data and Information Set -- a set of performance measures that rates the quality of HMOs and other managed-care plans. For example, HEDIS evaluates quality of care based on things like whether 2-year-olds are up to date on their recommended shots, and whether health care providers in the plan advise smokers to quit. (Remember that HEDIS only measures a very few items related to health care, and may miss many things that a health plan or health provider does well or poorly.)

States, employers, health plans, and groups like the California-based Pacific Business Group on Health use HEDIS performance measures to prepare reports, often known as "report cards," for consumers. These also may include HEDIS member satisfaction ratings or other consumer ratings.

To find out if a CAHPS or HEDIS survey report is available for the plans you are considering, contact your employer, the health plan, or a Medicare or Medicaid office. You can also call your state department of health or insurance commissioner's office. For help in finding your state health insurance contact, visit http://www.naic.org/state_web_map.htm or call the National Association of Insurance Commissioners' toll-free consumer hotline: 1-866-470-NAIC (6242).

Where can I find out about health plan accreditation?

An organization called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits all types of health care organizations, particularly those most closely related to improving health outcomes. Its standards cover rights, responsibilities, and ethics; continuity of care; education and communication; health promotion and disease prevention; leadership; management of personnel and health information; and continuous quality improvement. Its Web site is http://www.jointcommission.org.

Another accrediting organization is the Utilization Review Accreditation Commission (URAC), which develops accreditation standards and programs for managed care and other health plans. For a directory of accredited organizations, visit URAC's Web site: http://www.urac.org.

How do I choose a high-quality hospital?

There are several sites on the Internet where you can research hospitals for free. A new Web site at http://www.healthgrades.com is a good place for consumers to research a local hospital. You can also search under specific types of care to compare best hospitals in your area. The AHRQ site at http://www.ahrq.gov/consumer/guidetoq/guidetoq7.htm has links to online tools that compare both hospitals (http://www.hospitalcompare.hhs.gov.) and nursing homes (http://www.medicare.gov/NHCompare/home.asp).

The organization that oversees hospitals is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Make sure JCAHO accredits the hospital you choose by calling 1-630-792-5800 or visiting its Web site: http://www.jointcommission.org. Information on accredited organizations is free of charge. The JCAHO offers a handy service called "quality check" (http://www.qualitycheck.org/consumer/searchQCR.aspx) that quickly and efficiently allows you to call up the latest report on any hospital or medical clinic. The consumer search function also allows you to search for hospitals, nursing homes, and other medical facilities within a certain radius of your home.

Outpatient surgery centers and emergency care clinics are also rated by the Accreditation Association for Ambulatory Health Care. You can consult its Web site at http://www.aaahc.org or call 1-847-853-6060.

When choosing a hospital, you also may want to make sure it's one where your doctor has privileges. To find out, call your doctor's office or ask for the hospital's directory. (Remember, not all outpatient doctors these days do inpatient work, and that may be just fine.) Many health plans only cover treatment at specified hospitals, so you also need to make sure your hospital of choice is covered by your plan. Or you can approach this the other way around; if there is a particular local hospital at which you want to be treated, select a health plan that covers that hospital.

How do I get the best treatment for a specific condition?

Before choosing a particular course of treatment, research your options. You might start with the clinical practice guidelines issued by The National Guideline Clearinghouse available at http://www.guideline.gov.

One of the most reliable places to research health conditions and treatment options is HealthFinder, a service provided by two government agencies, the Office of Disease Prevention and Health Promotion and the Department of Health and Human Services. The Health Library feature (http://www.healthfinder.gov/library/ ) offers in-depth information in the form of an alphabetized library of diseases and conditions drawing on information provided by government agencies, nonprofit organizations, and universities.

If you are looking for a provider to treat a disease or chronic health condition, make sure the hospital you choose has top quality resources in that area. For example, some hospitals have renowned cardiac units or cancer centers. Ask your specialist and primary care physicians for their thoughts on how your hospital measures up for particular areas of treatment.

If you have a choice about where to have a procedure performed, research your options and choose the facility that has the most experience with that particular condition or procedure. Research shows that hospitals that do many procedures of the same type tend to have the most success. Ask your doctor or the hospital:

  • How often is the procedure performed there?
  • How often does the doctor who would treat you perform that particular procedure?
  • What are the statistics on patient outcomes? (How well do patients fare after treatment?)

Some health departments and other agencies publish reports based on "outcomes studies" about certain procedures. These studies show, for example, how well patients do after having heart bypass surgery. Such studies can help you determine which hospitals and surgeons have had the most success with a procedure.

Be aware that these studies have certain limitations: One hospital may have poorer outcomes because, for example, it operates on a larger number of people who are older or in worse health than a facility with a higher percentage of younger, healthier patients. Ask your health department about such discrepancies, and go online to see whether reporters in your area have covered this story.

Sometimes the only way to pursue a cutting-edge or experimental treatment is to participate in a clinical trial. The National Cancer Institute offers a booklet on how to access clinical trials called "Taking Part in Clinical Trials: What Cancer Patients Need to Know." It's available at http://www.cancer.gov/clinicaltrials/resources/taking-part-prevention-trials or by calling the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). There is also a Web site, http://www.cancer.gov/clinicaltrials run by the National Institutes of Health (NIH) that lists clinical trials for cancer treatments.

How can I research my doctor's qualifications?

Begin with an online visit to the American Medical Association (AMA), the national organization to which most doctors belong. Its Web site, http://www.ama-assn.org/, offers many helpful services for patients researching a doctor's qualifications. Start with the DoctorFinder feature, which provides basic professional information on virtually every licensed physician in the United States: Its database includes more than 690,000 doctors of medicine (MDs) and doctors of osteopathy or osteopathic medicine (DOs) and is continuously updated. Doctors do not pay to be included in the service, so it is complete and unbiased.

The AMA's listings also list each doctor's practice areas and board certification, which organization issued the certification, and the specialties in which he or she is certified. (A doctor is certified in a specialty or line of medicine after completing a training program and passing an exam to assess his or her knowledge, skills, and experience in that specialty.) Some primary care doctors may also be certified as specialists.

Depending on which state you live in, extensive information on local doctors is available at http://www.docboard.org, which is run by Administrators In Medicine, a group of state medical board directors. Its DocFinder service, which is free, takes its data directly from state government licensing boards. It contains licensing background and disciplinary information on physicians and other health care practitioners, including detailed information on medical malpractice, hospital discipline, and criminal convictions.

For a further check into whether the doctor you choose is board certified in the specialties he or she claims, call the American Board of Medical Specialties at 1-847-491-9091 or visit its Web site: http://www.abms.org/.

The NCQA also keeps a list of physician organizations and monitors whether doctors' certifications and credentials are up to date. To access the NCQA's Physician Organization Certification list, visit http://hprc.ncqa.org/pocresult.asp.

Many organizations exist to support patients with particular diseases and disabilities. Some of these organizations certify and recommend specialists in their area of medicine. For example, in partnership with the NCQA, the American Diabetes Association (ADA) maintains a specialized listing called the Diabetes Physician Recognition Program (http://www.ncqa.org/tabid/139/Default.aspx), which recognizes and provides information on doctors with notable expertise in the disease.

References

Nichols, Len. "Health Care Quality: At What Cost?" The Urban Institute.

"Health Care Quality: From Data to Accountability." National Health Policy Forum. February 1998.

"Improving Health Care Quality." Agency for Healthcare Research and Quality (AHRQ).

Clearinghouse for Consumer-Centered Healthcare. FACCT Foundation for Accountability.

National Committee for Quality Assurance (NCQA).

Consumer Assessment of Health Plans (CAHPS), developed by the Agency for Healthcare Research and Quality.

Health Plan Employer Data and Information Set (HEDIS).

Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

American Accreditation HealthCare Commission/Utilization Review Accreditation Commission (URAC).

Accreditation Association for Ambulatory Healthcare.

The National Guideline Clearinghouse, a joint effort of the AHCPR, the American Medical Association, and the American Association of Health Plans.

HealthFinder, a service provided by two government agencies, the Office of Disease Prevention and Control and the Department of Health and Human Services.

"Taking Part in Clinical Trials: What Cancer Patients Need to Know." National Cancer Institute. 1-800-4-CANCER (1-800-422-6237).

Cancer Trials. National Institute of Health.

American Medical Association (AMA).

DocFinder. Administrators in Medicine.

American Board of Medical Specialties. 800-776-2378.

NCQA's Physician Organization Certification list.

Diabetes Physician Recognition Program, American Diabetes Association and National Committee for Quality Assurance.

New America Foundation. Staff.

Utilization Review Accreditation Commission. About URAC.

National Committee for Quality Assurance. Choosing Quality Health Care.

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