The next president of the U.S. is faced with abundant challenges, from economic instability to multiple foreign policy risks. Where will healthcare reform rank on the ensuing priority list of things to fix? Time will tell, but a new report by the National Committee for Quality Assurance (NCQA; Washington) reveals massive inconsistencies in the delivery and outcomes of healthcare in the U.S., further highlighting the need for a cure for the ailing system.

On the one hand, the quality of healthcare for millions of Americans — only those in private insurance plans — improved somewhat in 2007.

On the other, there are significant variations in performance which continue to leave many people receiving substandard care.

All of this in the shadow of ever-rising healthcare costs, insurance restrictions and millions of Americans without any coverage or care at all.

"There's a lot that we know right now about what constitutes basic quality care," NCQA spokesman Jeff Van Ness told Medical Device Daily. "I'm not talking about the latest and greatest medical technology, just basic blocking and tackling. This report shows these basic tenants of high quality care are being inconsistently delivered. The consistency can vary by where you live, by who pays for your care and even by what sort of plan you're in. The macro message: Our greatest challenge isn't making the next best medical technology. It's to more consistently apply the knowledge we have to provide better healthcare for all Americans."

The NCQA minces no words in reporting that, "Since 2000, the cost of coverage has more than doubled, yet the quality of care patients receive is often spotty and sometimes dangerous." But it also points out that transparency in reporting healthcare quality is improving. Without the performance measures, change will never occur.

"Today one in three Americans are enrolled in a health plan that is transparent regarding the measurement of the quality of its care and services," NCQA president Margaret O'Kane wrote in the report. "This increase in accountability was driven, in large part, by the addition of nearly 100 preferred provider organizations [PPOs] that reported quality data for the first time in 2008."

One reason for the increased transparency is that the NCQA updated its accreditation standards to require all plans to report audited Healthcare Effectiveness Data and Information Set (HEDIS) data as a condition of becoming accredited. HEDIS is the most widely adopted set of healthcare performance measures in the nation.

"It's about delivering the right care to the right patients at the right time," Van Ness said. "Many of our measures look directly at things that could be defined as patient satisfaction, some look at outcomes like whether blood pressure was controlled to an adequate measure or if you received a flu shot."

One area of notable improvement was the rate at which Medicare beneficiaries were kept on life-saving beta-blocker drugs six months after suffering a heart attack. The NCQA estimates that up to 30,000 lives have been saved since 1996 as a result. Similar gains have been seen in cholesterol management, blood pressure control and diabetes - HbA1c control.

The most significant declines are related to mental healthcare.

"Mental health measures stalled as they have for years," Van Ness said. "Follow up visits with a doctor after being hospitalized with mental illness is poor and there is insufficient follow-up for patients on antidepressants; there's no difference than five to seven years ago due to the fact that mental healthcare benefits are carved out and administered separately from the rest of benefits."

While commercial health plans showed improvements on 44 of 54 measures of healthcare quality, with 16 significant gains in areas such as blood pressure control, health plans serving Medicare beneficiaries posted gains on only 24 of 45 measures of care, and many of those improvements were quite small.

Additionally, there was little improvement in the quality of care provided to Medicaid beneficiaries. Among the 52 measures collected from Medicaid plans, only 26 showed any increase and most of those were very small. There was one exception: the delivery of childhood immunizations improved.

Geography also plays a major role in the quality of healthcare. Comparison of performance among plans in eight U.S. census regions shows people in accountable health plans in New England and the Mid-Atlantic states tend, on average, to receive better care than people in other parts of the country.

The performance of commercial health plans in New England, which includes Maine, New Hampshire, Vermont, Massachusetts, Connecticut and Rhode Island, exceeded the national HEDIS average by 4.7%. In contrast, plans in the South Central region (Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Tennessee and Kentucky) reported scores that averaged 4% below the national HEDIS rate.

"The real power of these measurement programs is that it shows health plans where they can direct their improvements," Van Ness said. "It also has powerful implications for benefits managers, to know what sort of performance your health plan can deliver to make a difference on the bottom line, resulting in a healthier, happier work force, reduced absences and presenteeism [when sick employees show up for work]."

For the report, 240 PPOs reported on the quality of their performance, including 99 plans that reported for the first time. A comparison of the performance of different types of plans showed HMOs averaging three percentage points higher than PPOs on the same measures.

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