1. Health care quality for millions of Americans enrolled in health plans that report and measure quality has improved substantially.¹ Advances in medical technology and greater adherence to evidence-based medicine contribute to this positive trend.

2. Improving quality of health care remains an ongoing challenge. Widespread variation in the way health care is delivered, from failure to deliver needed care to unnecessary procedures, endangers the health of patients and creates quality gaps throughout the U.S. health care system.²

3. Consumers need access to objective and detailed information to make informed and financially sound decisions about their care. They need to know how to find providers that measure and publicly report quality measures.

Background

There is growing interest among government, employers and insurers to demonstrate quality. Providing good quality in health care requires finding the right balance of tests, procedures and therapeutic drugs – without over-using, under-using or misusing them.³

The U.S. health care system has a quality problem with severe health and financial implications. Preventable medical errors and deaths, inconsistent use of evidence-based treatment protocols, and racial, ethnic and geographical disparities in health care are well-documented.

Huge gaps exist between the levels of care delivered by health care organizations in different regions and settings. These quality gaps result in 39,000 - 83,000 avoidable deaths each year and between $2.8 billion and $4.2 billion in avoidable medical costs.⁴ A 2003 Rand Study found that 45 percent of the time patients do not receive care in accordance with clinical best practices. Even when physicians are aware of best-practice guidelines, they often do not adhere to them.

Increased Transparency - Organizations such as the National Committee for Quality Assurance (NCQA) require health plans to measure and publicly report results to reduce quality gaps and promote better quality. Quality is reflected in the increase in life expectancy in the U.S. from 75 years in 1990 to 77 years in 2003.⁵ Quality is also reflected in the number of heart disease deaths, which have decreased 60 percent since 1950.⁶

Rewards for Exemplary Performance – Stakeholders in health care (government, employers, providers and insurers) believe that reporting quality is only half the equation. They’re working together to develop new payment systems that reward providers for quality performance. This pay-for-performance approach changes how providers are compensated, moving from a system that has traditionally paid for services based on volume to one that pays for quality outcomes and care, based on sound medical evidence.

Aetna Difference

1. In 2005, Aetna was recognized for becoming the first and only national carrier to voluntarily participate in NCQA’s consumer-focused set of quality standards aimed at promoting wellness and prevention.

2. Aetna provides access to specialists who meet clinical performance measures and demonstrate effective use of health care resources. Aetna’s national pay-for-performance framework incorporates recognized measures for quality and efficiency from leading nonprofit medical organizations and business groups.

3. Aetna is committed to giving physicians the tools and information necessary for quality improvement. Aetna continues to make its business processes, such as payment policies, as transparent as possible. It was also the first insurer to give physicians Web-based tools to understand how claims are adjudicated.

4. Aetna health plan members have access to an online health and wellness program, a hospital and quality comparison tool and clinical information on 5,000 health topics.

AVOIDABLE DEATH AND MEDICAL COSTS DUE TO UNEXPLAINED VARIATIONS IN CARE:
SELECTED MEASURES AND CONDITIONS IN U.S. POPULATION

Questions & Answers

What is quality health care?
Most consumers measure their quality of care by the way they were treated by their doctor or his/her office staff, yet may not be able to judge whether they have received the right care at the right time, just whether their results are what they expected.⁷

The Institute of Medicine (IOM) describes quality health care as safe, timely, effective, equitable, patient-centered and efficient.⁸ Many believe good quality in health care means doing the right thing at the right time in the right setting for the right person yielding the best results possible.⁹

Is quality care more expensive?
No. In fact, improving quality can result in cost savings on both an individual and system-wide basis. The Midwest Business Group on Health estimated that as much as 30 percent of all direct health care outlays are the result of poor-quality care, translating into $420 billion each year in direct costs and as much as $210 billion in indirect costs, such as lost productivity due to absenteeism.

Some research estimates that Medicare alone could save up to 30 percent by reducing or eliminating disparities in treatment – savings that would result from more efficient care without compromising health outcomes.¹⁰ Interestingly, research indicates that states with higher Medicare spending actually have lower-quality care.

Why wasn’t quality rewarded before?
The traditional payment system doesn’t emphasize quality. Pay-for-performance programs challenge a longstanding provider payment system that focused primarily on volume rather than on quality or value.

Programs that reward quality performance are on the rise. Most physicians agree that measuring quality is a good idea, although the process remains fragmented and the industry has yet to determine one uniform approach. Performance measures should be based on scientific evidence, include fair incentives and ensure that providers are involved in program design and implementation.

Are consumers interested in becoming more educated about quality?
Yes. As a greater percentage of costs are being paid by consumers, individuals are seeking objective information from websites and their health plans before making important medical decisions. They want and need better health care information to select doctors and hospitals based on success rates for clinical procedures, positive outcomes, and cost.