A growing number of healthcare system stakeholders and reform gurus are getting on the “prevention” bandwagon. They are recognizing that only if we reduce the incidence and prevalence of disease and injury along with the crises, complications and worsening of chronic conditions that already afflict us, can we solve the cost crisis and afford the costs of universal health insurance.

A solid illustration of the growing movement toward prevention and control of sickness, rather than simply paying for its treatment came in recent reports on the quality of healthcare in California. These reports addressed how well health plans and physician groups perform in that state, using a series of indicators that reflect both prevention and disease management, rather than sickness care. They include ratings of PPOs by NCQA, and of physician groups by county, though the one I will discuss in detail is that for HMO health plans. [“Healthcare Quality Report Card: 2007 HMO Ratings” Office of the Patient Advocate]

The HMO ratings are based on how well physicians in such organizations take care of patients over time, how well they manage risks and chronic conditions, rather than specific sickness events. They begin with ratings of the care provided for asthma, based on the percentage of adults, teenagers and children who get the “right medicine” for their condition. All HMOs rated did well on this measure, with percentages getting correct medications ranging from 87% to 98%. Ratings for cancer care were based on how many members get screened for breast, colorectal and cervical cancer, where HMOs did not nearly as well, with percentages ranging from 61% to 77% for breast, 80% to 86% for cervical, and 48% to 58% for colorectal cancer.

Diabetes care was rated on how many patients got eye exams, testing for blood sugar, cholesterol and kidney function, as well as how many had their blood sugar and cholesterol levels under control. Eye exam rates ranged from 47% to 76%; blood sugar testing from 86% to 92%; cholesterol testing from 82% to 89%, and kidney function testing from 77% to 93%. But the percentages of patients whose blood sugar was under control ranged only from 66% to 78%, and cholesterol control from 41% to 55%.

Heart care was rated on physicians’ giving heart attack patients beta blockers, and testing such patients’ as well as heart surgery patients’ cholesterol levels, along with the percentage of overall members who had their blood pressure and cholesterol under control. The right medications were given to heart attack patients from 55% to 85% of the time, while cholesterol was tested in targeted patients from 88% to 95% of the time. But cholesterol was under control in members only 57% to 66% of the time, and blood pressure from 54% to 74%. Maternity care was rated on the percentage of pregnant women who began prenatal care during the first trimester, where percentages ranged from 85% to 97%, and how many had a check-up visit within 21-56 days post delivery, where scores ranged from 79% to 89%.

Mental health care was rated on:

• the percentage of depression patients seen at least three times during initial treatment, where scores ranged from 17% to 30%
• the percentage of such patients who remained on anti-depressant medications during initial treatment, where scores ranged from 56% to 86%
• the percentage of such patients who remained on anti-depressant medications for 6months following initial treatment, where scores ranged from 40% to 67%
• the percentage of members hospitalized for a mental illness that were seen by a mental health provider within 30 days after discharge, where scores ranged from 70% to 84%

Ratings for the care of sexually transmitted disease were based solely on the percentages of patients aged 16-20, and 21-25 who were screened for Chlamydia, where scores ranged from 30% to 66% for younger patients, and 34% to 69% for older. Ratings for back pain treatment were based on the percentage of patients whose evaluation met recommendations relative to the use of high-cost x-ray services, where ratings ranged from 77% to 86%.

Treating adults was rated on how many patients prescribed long-term medications were tested for harmful side-effects, with ratings ranging from 60% to 71%; and how many rheumatoid arthritis patients got a prescription for an appropriate drug, with ratings ranging from 67% to 91%. Treating children was based on:

• how many with AHDH prescriptions had a follow-up visit within four weeks to check for side effects (20% — 36%)
• how many had, by age two, received the seven recommended vaccinations (49% — 82%)
• how many adolescents had, by age 13, received all recommended vaccinations and booster shots (38% - 74%)
• how many children ages 2-18, diagnosed with a throat infection and treated with an antibiotic were tested for strep throat (32% — 86%)
• how many ages 3 months to 18 years with a common cold had not been given an antibiotic (78% — 95%)

While included under member ratings of their HMOs, rather than based on medical records, as were all other ratings, HMOs were also rated on how helpful they had been in helping members who smoked to quit this unhealthy habit:

• whether their doctor had advised them to quit in the past year (66% to 83% across the three plans who had a large enough sample)
• had their doctor had supplied information on medications that would help in quitting (37% to 53%)
• had their doctor supplied information on how to quit (41% to 58%)

Members were also asked about their health plans’ customer service, paying claims, help in finding a doctor, getting appointments and care quickly and easily, doctor communications, and finally on their overall rating of their healthcare, where ratings ranged from 61% to 73%.

By my count, there were 25 quality ratings that solely reflected the process of care that HMO members received, whether their physicians had “done the right thing”, with widely varying percentages of their having done so. There were two ratings that reflected a combination of both physician and patient compliance, i.e. both of them doing the right thing, namely the first prescribing and the second taking the right medications. Only four of all the healthcare quality ratings related to whether the care they got worked, namely, whether diabetes and heart patients had their blood sugar, cholesterol and blood pressure under control.

Moreover, where both process and outcomes measures related to the same thing were used, namely whether physicians tested for blood sugar, pressure and cholesterol – in diabetes and heart disease patients, the outcomes scores were consistently lower than the process scores:

• blood sugar was tested in 86-92% percent of diabetes patients, but under control in only 66-78%
• cholesterol was tested in 82-89% of diabetes patients, but under control in only 40-55%
• cholesterol was tested in 88-95% of heart patients, but under control in only 57-66%
• while no rates were cited for testing it in heart patients, blood pressure was under control in only 54-74%

While there has been a long and consistent history of physicians resisting being held accountable for any kind of results, there has also been a strong demonstration of measuring such results in sickness care. Measures of patient outcomes, e.g. mortality, complications, re-admission rates for particular illnesses and treatments, are commonly used in sickness care quality report cards. Why are so few are available in health care, e.g. how many smokers quit, how many heart attack patients did not have a repeat episode, what kind of quality of life improvements were noted in patients with asthma, diabetes, mental health, heart disease, etc.?

Even how many patients were diagnosed with cancer at an early enough stage to improve their chances of survival would be a more meaningful measure than just how many were screened. How many patients have avoided sexually transmitted disease, thanks to advice and support given them regarding safe sexual practices? What are the rates of patients who don’t get diabetes or heart disease thanks to their health plan’s or physician’s preventive and proactive services? How has the quality of life among mental health patients improved thanks to the medications and support given them?

While it is good news to see health plans and physicians being rated for their preventive/proactive processes, it would be even more useful, it seems to me, if they were also rated on how well their overall efforts are working, i.e. on the outcomes they are able to achieve. True, such outcomes reflect the extent of cooperation among their members and patients as much as plans’ and physicians’ efforts. But it is how well both carry out their preventive/proactive care, not merely whether or not they did something, that makes the biggest difference, and should be of interest to plans, physicians, and certainly patients.