Quality in Health Care

Strategic Issues in Health Care Management

Manouche Tavakoli, Huw T.O. Davies

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351755603
• Edition: 1
• Topic: Medicina
• Subtopic: Sanità, amministrazione e assistenza pubblica

This title was first published in 2001. Enhancing the quality of health services remains a key challenge for all health systems, whatever their stage of development. This collection of leading-edge research from Europe and America explores both quantitative and qualitative approaches to identifying and remedying deficiencies in health care.

Section Two
Bringing About Quality Improvement

Chapter Three
Challenges on the Road to Clinical Governance: The United Kingdom’s Strategy for Health Care Quality Improvement

Andrew B. Bindman

Introduction

For more than two decades numerous studies have documented variations in health care service delivery across small areas (Folland and Stano, 1990). Although these studies have rarely controlled for underlying differences in patients’ health care needs or treatment preferences, the prevailing explanation for small area variation in health care utilisation is that this represents inappropriate variation in physician decision-making. This hypothesis is supported by studies that have found that the greatest variation in service occurs when there is a lack of consensus on the best approach (Wennberg, Bames and Zubkoťf, 1982). Even when there are clear professional practice norms, many patients do not receive appropriate care (Shuster, 1998).

While small area variation in health care utilisation has long been recognised, it is only recently that health planners and policy makers have formally sought to address it. The increased interest in this issue is related to the financial stress associated with the growth of health care costs. Policy makers and planners have promoted the concept that the elimination of variation in health care utilisation will reduce unnecessary care and thereby result in cost savings. This policy is predicated on the assumption that variation in utilisation is more of a sign of unnecessary overuse of services rather than inappropriate underuse of services.

The US and the UK have chosen somewhat different strategies for addressing physician behaviour and practice variation. Contrasting the approaches and results in the two countries could provide an important learning opportunity.

US-managed Care

In the US, much of the activity focused on changing physicians’ behaviour is being led by managed care organisations (prepaid health insurance plans with an integrated network of providers), which are developing and implementing a series of mainly top-down management strategies to control physicians’ practice patterns. Prior to the emergence of managed care plans, the majority of physicians in the US were free to practice as they saw fit with minimal interference from the patient’s health plan. In many cases, physicians benefited financially under a fee-for-service system when they utilised greater amounts of services for their patients. Managed care plans have attempted to rein in physicians’ practice patterns by:

• 1 using primary care physicians as gatekeepers;
• 2 scrutinising physicians’ decision-making with utilisation management tools;
• 3 profiling physicians’ performance on cost and quality measures; and
• 4 linking physicians’ practice patterns with financial incentives.

In managed care, much of this activity has been focused on primary care providers. Managed care organisations have expanded the primary care provider’s role beyond clinical functions to include responsibility for controlling patients’ costs. Borrowing from a practice that has been present in the UK’s National Health Service (NHS) for more than 50 years, managed care plans use primary care physicians as gatekeepers who must authorise patients’ referrals to specialists for high cost tests and procedures and for hospitalisation. Prior to the introduction of gatekeeping, many American patients with feefor-service insurance would self-refer to specialists without first consulting a primary care provider. Managed care plans opted to deploy primary care physicians as gatekeepers because research suggested that this could reduce health care costs (Martin et al., 1989).

In addition to using primary care providers as gatekeepers, most managed care plans use health care utilisation management tools to control physician practices. Utilisation review enables the managed care organisation to alter the clinical plan developed between a physician and patient. Typically, these strategies require physicians to obtain the authorisation of a nurse or other health care professional working on behalf of the plan prior to obtaining expensive diagnostic tests, therapeutic procedures, or hospitalisations. Utilisation review procedures are associated with a decrease in service use. The insertion of the health plan into clinical decisions has not been viewed favourably by patients or providers. However, utilisation review strategies do reduce health care costs. It appears that the requirement for health plan permission in and of itself has a powerful moderating effect on physicians’ practice patterns. A randomised trial of utilisation review comparing sham utilisation review procedures in which no services were actually denied versus actual utilisation review procedures found a reduction in service use in both groups over time but that there was no significant difference between the two groups (Rosenberg et al., 1995).

Managed care plans also profile the utilisation patterns of their providers. An individual provider’s actual use of services in various categories such as laboratory tests, radiology and specialist referrals, is aggregated over a time period and is compared against the average use in these categories during this same time period by other physicians in the medical group or health plan (Salem-Schatz et al., 1994). Profiling has also been extended to include measures of physicians’ quality of care and their patients’ ratings of satisfaction with their care. In most cases, these data are used internally within a managed care plan or medical group, but there has also been public reporting of these data so as to inform consumers and to create pressure on the providers to respond to the results (Epstein, 1995). Most of the public reporting is aggregated to an entire managed care plan or medical group, but there has been public reporting of individual physician performance as well.

Managed care plans have also used financial incentives as a means to increase physicians’ awareness of their practice patterns and performance. Physician incentives have been linked to a variety of measures including overall use of services, use of specific services such as laboratory tests and radiology, referral rates, patient volume (productivity), rates of performing recommended preventive care and patients’ ratings of satisfaction. These bonuses are based on an individual provider’s practice or performance, the practice or performance of a provider’s medical group, or a combination of the two.

The decline in the growth rate of health care costs and the increased focus on quality with the expansion of managed care in the 1990s has suggested that these various strategies are working. While managed care has been associated with decreased health care utilisation, it remains to be shown whether the decline in service use is related to the attempts to change physician behaviour and whether this decreased activity reflects fewer necessary or unnecessary activities, or both. Managed care advocates point to literature reviews that suggest that managed care organisations do as well if not better than fee-for-service plans for many patients (Miller and Luft, 1994). However, the literature rarely addresses how well these systems do in managing sicker patient populations and there is even less information on which managed care strategies in isolation or together are most effective in changing physician practice.

A growing public backlash against managed care and the perceived wedge it drives between physicians and patients may limit or alter the kinds of strategies that can be used in the US to change physician behaviour in the future. Patients are distrustful of providers who are financially rewarded for limiting their access to services (Grumbach et al., 1999) and many physicians believe that these incentives undermine quality of care (Grumbach et al., 1998). Recognising that dissatisfaction with access to specialists is among the most important reasons patients cite for leaving a health plan (Kerr et al., 1998), several managed care organisations have responded by eliminating the primary care gatekeeping functions and returning patients’ ability to self-refer to many specialists.

The public has not responded as negatively to publicly reported physician performance measures. However, developing valid measures of an individual provider’s practice and performance has proven to be challenging. Many physicians do not perform enough of any one activity to enable reliable estimates of performance. Furthermore, it is difficult to account for differences in the underlying characteristics of patients when forming judgments about providers. Even if the methodological challenges can be resolved, a recent review of the US experience with public reporting of provider performance suggests that this strategy has had relatively little impact on changing physicians’ practice (Marshall et al., 2000).

United Kingdom’s Clinical Governance

In the UK, the NHS has long been regarded as a highly centralised top down health care delivery system. Thus, it is striking that recent reforms in the NHS emphasise physician networking and increased professional accountability rather than top down strategies as a means to changing physicians’ behaviour. These changes are most apparent in primary care where the formation of Primary Care Groups (PCGs) has created a networking structure for all primary care physicians in a geographic area to communicate about and to become accountable for the clinical and financial issues associated with their area’s population. Each PCG has clinical governance responsibilities which make physicians responsible for participating with one another in the establishment and compliance with group norms for practice (Allen, 2000).

Clinical governance is just getting underway in most PCGs but some common strategies are emerging. In many PCGs, clinical governance is reshaping continuing (postgraduate) medical education from an individual physician-centred activity to a PCG-centred one. Prior to PCGs, many primary care physicians would attend postgraduate conferences on a topic of their choosing as a means to maintain and update their knowledge. There was no expectation that this educational experience would be used by the primary care physician who attended the meeting to educate other practitioners more broadly in their work environment. Because a physician would typically obtain this education in isolation from practice colleagues, there was little opportunity to reflect on the new material with clinical colleagues. Recognising some of the shortcomings of the traditional continuing educational experience, some PCGs have attempted to extend the learning potential of these lectures by providing an incentive for primary care physicians within a PCG to attend training sessions together which are focused on PCG-specific quality improvement. Much of the clinical content is drawn from newly-established evidence-based NHS framework guidelines that are being supplied by the Department of Health. In addition, some of the more ambitious PCGs have succeeded in taking the additional step of creating audit and feedback (profiling) tools linked to the educational experience that highlight variation in practice across general practices within a PCG. Differences in practice patterns among general practices were discussed among the primary care physicians with the goal of aiding outlier practices to move over time toward the group average.

While there is a growing willingness for UK providers to share their clinical experiences, for many PCGs there are only a limited number of areas in which there are data in common across their general practice sites. The most commonly available data are on pharmaceutical prescribing. For example, many PCGs use these data to profile practices’ use of generic drugs and antibiotics. These data have the potential to become even more useful when PCGs are able to move beyond global use at the practice level and to link the information back to individual patients so that quality of care judgments can be made about the use of pharmaceuticals in association with specific clinical conditions. In addition to pharmaceutical profiling, many PCGs are actively developing chronic disease...

Table of contents

• Cover
• Half Title
• Dedication
• Title
• Copyright
• Contents
• List of Figures
• List of Tables and Boxes
• Acknowledgements
• Editors’ Preface
• SECTION ONE: SYSTEM ISSUES
• SECTION TWO: BRINGING ABOUT QUALITY IMPROVEMENT
• SECTION THREE: VARIATIONS IN HEALTH CARE
• SECTION FOUR: INCORPORATING USER VIEWS
• SECTION FIVE: CHOICE
• List of Contributors