Final report : evaluation of tools and metrics to support employer selection of health plans

The Patient Protection and Affordable Care Act (ACA) places strong emphasis on quality of care as a means to improve outcomes for Americans and promote the financial sustainability of our health care system. Included in the ACA are new disclosure requirements that require health plans to provide a summary of benefits and coverage that accurately describes the benefits under the plan or coverage. These requirements are intended to support employers{u2019} procurement of high-value health coverage for their employees. This report attempts to help employers understand the structural differences between health plans and the performance dimensions along which plans can differ, as well as to educate employers about available tools that can be used to evaluate plan options. The report also discusses the extent to which these and other tools or resources are used by employers to inform choices between health plans. Read more... Introduction -- Technical Approach -- Conceptual Framework -- Provider-Facing Structural Characteristics of Health Plans -- Member-Facing Structural Characteristics of Health Plans -- Process Measures -- Outcomes Measures -- State of Practice in Employer Decisionmaking About Health Plans -- Conclusions -- Appendix A: Description of Summary of Benefits and Coverage and Glossary of Terms -- Appendix B: Description of Search Strategies and Tools -- Appendix C: Descriptions of Quality Measurement and Reporting Organizations -- Appendix D: Descriptions of Quality Measurement and Reporting Organizations. Cover 1 Title page 2 Copyright 3 Preface 4 Contents 5 Figures 7 Tables 8 Summary 9 Acknowledgments 19 Abbreviations 20 1. Introduction 21 1.1 Background: The Role of Employers Under the National Quality Strategy 21 1.2 Purpose of the Report 22 2. Technical Approach 24 2.1 Development of Conceptual Framework 24 2.2 Environmental Scan 24 2.3 Expert Panel Meeting 25 2.4 Interviews with Employers and Business Coalition Representatives 25 3. Conceptual Framework 27 3.1 Understanding the Anatomy of a Health Plan 27 3.2 Defining Care Processes for Measurement Purposes 28 3.3 Defining Outcomes for Measurement Purposes 29 3.4 Measuring Quality of Health Care 29 4. Provider-Facing Structural Characteristics of Health Plans 31 4.1 Network Management 31 4.2 Payment Arrangements 32 5. Member-Facing Structural Characteristics of Health Plans 38 5.1 Customer Service 38 5.2 Cost-Sharing Provisions 38 5.3 Care Management 39 Products and Services for Chronic Condition Management 40 Products and Services for Curative Care 41 Products and Services for Health Promotion 43 5.4 Evaluation of Member-Facing Characteristics of Health Plans 44 6. Process Measures 47 6.1 Safe Practices 48 Definition 48 State of Measurement Science 49 6.2 Adherence to Evidence-Based Care Guidelines 49 Definition 49 State of Measurement Science 50 6.3 Overuse of Medical Services 51 Definition 51 State of Measurement Science 52 6.4 Evaluation of Current State of Process Quality Measurement 53 7. Outcomes Measures 55 7.1 Medical Outcomes 56 Definition 56 State of Measurement Science 56 7.2 Patient-Centeredness 57 Definition 57 State of Measurement Science 58 7.3 Efficiency 58 Definition 58 State of Measurement Science 59 7.4 Evaluation of Current State of Outcomes Measurement 59 8. State of Practice in Employer Decisionmaking About Health Plans 62 8.1 Information Sources 62 Decision Tools 62 Employer Coalitions 63 Benefits Consultants 64 Evaluation of Tools and Resources to Support Employer Decisionmaking 65 8.2 Decision Criteria for Health Plan Selection 65 Cost Is the Primary Driver 65 Employers Aim to Ensure Network Adequacy 66 General Reputation of Plans Influences Purchasing Decisions 66 Quality of a Health Plan Is Rarely Factored Explicitly into Decisions 67 Quality-Enhancing Products and Services Are Considered Low Priority 67 9. Conclusions 68 9.1 Current State of Measurement Science 68 9.2 Current State of Employer Decision Tools Regarding Quality of Care 68 9.3 Current State of Employer Decision Process for Quality of Care 69 9.4 Implications for Research Agenda 70 Appendix A: Description of Summary of Benefits and Coverage and Glossary of Terms 72 Appendix B: Description of Search Strategies and Tools 75 Appendix C: Descriptions of Quality Measurement and Reporting Organizations 78 Appendix D: Descriptions of Quality Measurement and Reporting Organizations 83 References 87