Evaluation of the U.S. Preventive Services Task Force Recommendations
The Impact of Health Plan Structures on the Delivery and Integration of the USPSTF Recommendations
The Impact of Health Plan Structures on the Delivery and Integration of the USPSTF Recommendations
Overview. No research has examined whether the structure of health plans, and the influence this has on the relationship between the plan and provider, may impact the integration and delivery of the USPSTF recommendations for clinical preventive services.
Key findings include:
The structure of managed health care plans has changed dramatically over the last twenty years. Plans have evolved with differing structures that influence the level of plan versus provider control and member choice. In the 1980s, health maintenance organizations (HMOs) were typically either open-panel plans or closed-panel plans.1 In an open-panel plan, any qualified physician who accepts the HMO's contract rate is allowed to join as a participating provider (e.g., independent-practice model and network model); whereas, in a closed-panel plan providers are direct, exclusive employees of the health plan (e.g., staff model HMOs). In the late 1990s, the distinctions between closed and open-panel HMOs blurred substantially. Many HMOs now encompass characteristics of both open and closed-panel plans. These plans are often referred to as hybrid plans or mixed-model health plans.
Limited research has explored how the relationships between managed care organizations (MCOs) and providers may have larger implications for other health care variables, such as the integration and delivery of preventive services recommendations.2 Rigotti (2002) et al. explored tobacco-dependence treatment guidelines of 11 staff-model MCOs, concluding that staff model plans (closed-panel health plans), have more direct control over the implementation of tobacco cessation guidelines than do independent-practice models and network-models (open-panel health plans).3 Another study, Mehrotra et al (2006) examined the rates of implementation of three types of preventive services. This study revealed that integrated medical groups (for the purposes of this study these were akin to closed-panel plans) scored better than the independent practice associations (akin to open-panel plans) on preventive quality measures, while hybrid models fell between the two. Finally, studies have explored provider attitudes towards clinical preventive services recommendations, concluding that primary care providers in two staff model (closed-panel) HMOs and one mixed-model (hybrid) HMO had highly favorable attitudes towards clinical preventive services recommendation implementation to increase quality of care.4-6 In contrast, primary care providers in independent group practice (open-panel) were less likely to have favorable attitudes toward clinical preventive services recommendations.7
No research has examined whether the structure of health plans, and its influence on the relationship between the plan and provider, may impact the integration and delivery of the U.S. Preventive Services Task Force (USPSTF) recommendations for clinical preventive services.8 As part of a larger evaluation of the USPSTF recommendations, NORC at the University Chicago studied the integration and delivery of the recommendations in four different types of health plans: a closed-panel health plan, open-panel health plan, hybrid health plan having both open- and closed-governmental plans are employees of the plans, whereas providers of the open plan are independent contractors that may have relationships with multiple health plans. The hybrid plan exists in the middle of this spectrum, since approximately half of the providers are employees of the plan's affiliated health system, and the other half are contractors. Qualitative interviews were conducted with over 40 health plan staff members, including Medical Directors, Directors of Quality Improvement and Health Information Technology (IT), Quality Improvement and Health IT staff, and Clinical Advisors (clinicians who also serve in a leadership or broader prevention role). This overview explores how health plan structure impacts other variables related to the integration of the USPSTF recommendations.
Health plan system structures are largely characterized by two key factors: 1) the health plan- provider relationship (e.g., are providers employees or contractors?); and 2) the centralization of the decision-making at the plan (e.g., does the plan have local/regional autonomy to make decisions or are decisions made at a centralized headquarters?). While not a structural issue, it is clear that a plan's corporate culture, values, and mission also affect its focus on prevention activities, making it difficult to disentangle the influences on decisions related to integration of the USPSTF recommendations in some instances.
Focus on Prevention
Closed-panel plans, in theory, should have an easier time implementing prevention-focused activities than other types of health plans because the health plan has more direct control over providers (who are employees of the plan). The closed-panel plan in our study does have a strong and public focus on prevention, given plan staff are actively involved in clinical preventive services research and that the plan employs a highly aggressive public prevention campaign. However, while the closed-panel plan has a solid focus on prevention, the governmental, hybrid, and open-panel health plans also make prevention a paramount priority, suggesting that the plan-provider relationship may not be the determining factor of whether health plans have a strong focus on prevention. Since all of the health plans have a strong culture of prevention, it is possible that plan culture, values and mission may have a stronger influence on whether health plans have an underlying mission of prevention.
Health Information Technology
|Plans with more provider control like the closed-panel and governmental plans were more successful in implementing clinical reminder systems than plans with less control like the open-panel and hybrid plans.|
Our study supports the body of existing research that suggests that health plan structure/organizational type strongly predicts how well the plan implements reminder systems for delivering preventive care. We found that plans with more provider control like the closed-panel and governmental plans were more successful in implementing clinical reminder systems than plans with less control like the open-panel and hybrid plans. The open-panel and hybrid plans are not as well-positioned to integrate the USPSTF recommendations via health information technology because all providers are not employees of the health plans. In the open-panel plan, where all providers are independent contractors to the health plan, health information exchange is more tenuous. The open-panel plan does not currently have an electronic medical record, and thus relies on paper-based patient reminders. While the open-panel plan is making strides towards implementing a patient-based community health record (CHR) in the near future, there may be additional problems related to coordinating a plan-wide CHR with providers' existing EMRs.
In addition, plan-provider relationships play a big role in the hybrid plan's ability to integrate the USPSTF recommendations using health IT. Given its open- and closed-panel features, the hybrid plan operates within a larger health system that integrates the USPSTF recommendations into its EMR. While the system has a sophisticated EMR, since only approximately half of plan members access services through health system providers, integration is limited and uneven. Contracted providers, who provide services to members of multiple health plans, are provided access to, but often do not use, the EMR. The end result is incomplete patient records as the EMR only captures data on patient visits to system-employed providers. As a result the hybrid plan has a reduced ability to integrate the USPSTF recommendations using health information technology.
The hybrid plan's mixed-model structure also affects its strategy for quality improvement. Given that not all of the plan providers are employees of the health plan who utilize the EMR, quality improvement can be very difficult and costly. Essentially, the mixed-model structure of the plan makes it more difficult to track and monitor members. For example, the quality improvement activities involve a large patient outreach component (e.g., phone calls, letters, and mailings) because many plan members are not recorded in the system EMR. According to one Clinical Advisor, who had been heavily involved in a quality improvement effort to increase the delivery of colorectal cancer screenings, the EMR is an important tool and potentially could be more useful if all of the plan's providers utilized it: "There's always another panel of patients you're not seeing. If you don't have an EMR—if you have paper charts—you don't even know that you have them. If you have EMR, you can find them." The hybrid plan's mixed-model structure necessitates that it employ a targeted patient outreach component for its overall quality improvement strategy.
The closed-panel, open-panel, and governmental health plans are heavily involved in quality improvement activities as well, which may be the result of their focus on prevention as a part of their organizational values and mission. One Clinical Advisor from the closed-panel plan indicated that "[quality improvement] is all we do. Every day is about trying to pick a priority and make it happen." However, their structures do not impact their strategies for quality improvement as much as is the case at the hybrid plan.
Research suggests that incentives relating to quality of care and patient satisfaction are more frequently employed in closed-panel health plans, which have more direct control over their providers.9 In our study, while the closed-panel plan did not directly incentivize individual providers to deliver clinical preventive services, high-performing medical groups receive other in-kind bonuses, such as group meals, and public recognition. The closed-panel plan works closely with its providers to improve delivery rates of clinical preventive services, and has aggressive quality improvement techniques for providers who fall below acceptable margins.
The hybrid plan also has a sophisticated pay-for-performance program which provides financial rewards to high performing health plan staff and providers. This feature has likely been facilitated by the plan's corporate interest in pay-for-performance so that structure may not be the primary factor in initiating the incentive program.
On the opposite end of the spectrum, the open-panel plan does not currently promote incentives to encourage the delivery of clinical preventive services. The governmental plan falls somewhere in between, as there has been a recent movement towards adopting some type of performance based reimbursement for providers. Given the governmental plan's top-down structure, whereby all plan changes must be approved at the national headquarters, novel strategies and techniques such as pay-for-performance become more difficult to implement at the local, site level.
Adoption of Recommendations
|The process used to integrate the USPSTF recommendations differs dramatically across health plans, though there are some notable trends related to system structure.|
The process used to adopt and integrate the USPSTF recommendations differs dramatically across health plans, though there are some notable trends related to system structure. The closed-panel plan and governmental plans are highly centralized, in that they comply with recommendations for clinical preventive services issued by their respective systems-level or national headquarters. Both plans have strong leadership teams at the systems-level that are heavily involved in the development of guidelines for clinical preventive services. In contrast, the hybrid and open-panel plans have more local control over the adoption of recommendations. Both plans incorporate review and input from providers that are plan-affiliated employees as well as those that are contractors.
Conclusions and Further Exploration
Health plan structures clearly impact variables related to the integration of the USPSTF recommendations. However, the degree to which structure versus corporate values is the mitigating factor in pursuing prevention activities is not always clear, as in the case of provider incentives for quality. Future research should further explore how the integration of the USPSTF recommendations is impacted by system structure. Specifically, studies should address the degree to which health plan corporate culture and values affect the plan's ability to integrate the recommendations as compared to structural components such as plan-provider relationships and centralization.
The issue of system structure is particularly interesting in mixed-model plans which encompass features of open- and closed-panel plans. Hybrid plans have an untapped potential to serve as "learning laboratories," enabling researchers to compare characteristics of open versus closed-panel health plans while controlling for systems-level differences. Inasmuch as hybrid plans have been understudied, future research should also explore whether the mixed-model structure underlying hybrid health plans offers any unique incentives for providers to deliver clinical preventive services.
Finally, additional research is recommended to track provider usage of clinical preventive services recommendations across different types of health plans, as well as provider perceptions of the delivery of clinical preventive services over time. As health plan structures continue to evolve, it will be important to understand the associated impacts on preventive care.
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7. Salem-Schatz et al., 1997.
8. In 1984, the U.S. Public Health Service created the USPSTF as an independent panel of experts in primary care and prevention that systematically review the evidence of effectiveness and develop recommendations for clinical preventive services. The Agency for Healthcare Research and Quality (AHRQ) began sponsoring USPSTF activities in 1998 and includes the USPSTF recommendations as part of their diverse Prevention Portfolio. The USPSTF recommendations are developed by a team of clinicians and are based on a thorough review of evidence including individual studies such as randomized controlled trials, costs, the negotiations of benefits and harms, and the evidence as a whole.
9. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems. New England Journal of Medicine 1998; 339 (21):1516-21.