The issues and needs associated with the process of care can be classified in three categories: (1) better knowledge of the structure of and responsibility for the process of care, (2) the determinants of the process of care, and (3) the efficiency of the process of care both generally and relatively across participants. Table 4 summarizes the key needs and data gaps in these areas as expressed by interviewees.
These issues stem, in part, from a need to understand how the delivery of care is actually structured and who is responsible for it in a system increasingly dominated by managed care and other more integrated systems in a competitive marketplace. Changes such as these are affecting the care that providers can deliver and patients can receive and how much it costs. Each type of provider wants to understand how its segment of the market is being influenced operationally, financially, and philosophically by the changes. Policymakers and consumers share these concerns. For example, who actually chooses the care that is received (the physician, physician group, health plan, or administrators), and how does this factor influence doctor-patient relationships for those participating? Thus, knowing what arrangements are in place and how they influence the process of care is of growing interest to a variety of stakeholders. Another issue is how to assess efficiency in a market in which performance has become more of a concern. These concerns extend beyond general public policy to the specific constituencies that may stand to gain or lose if they are regarded as more or less efficient or a better or worse performer. For example, are teaching hospitals really more costly when their costs are appropriately adjusted for the mix of care and then compared?
QUESTIONS HIGHLIGHTING DATA GAPS: STAKEHOLDER CONCERNS ON
THE PROCESS OF HEALTH CARE COVERAGE AND DELIVERY
A. Structure and Responsibility for Process of Care
- How do consumers actually make decisions in selecting health plans? What information on such issues as medical compensation and effects do consumers want and how do we get it?
- Is there considerable churning across health plans, especially in Medicaid?
- How does managed care really work (e.g. marketing, enrollment and other administrative functions; contracting; medical management and clinical delivery)? How does it vary in different kinds of systems?
- Are provider sponsored plans really clinically integrated and to what extent are they assuming the insurance function as well (or forming consortia with payers)?
- Who is actually delivering care, for example, what role do mid level providers play?
- What are the changing roles of providers in primary and specialty care?
- Is physician use becoming more differentiated between in hospital providers and ambulatory care providers?
- What structures are used in carve-out arrangements and what effects do they really have on the process of care delivery?
- How do we assess if there is a seamless continuum of care in existence?
B. Determinants of Process of Care
- Do physicians and other providers actually know or understand the contractual arrangements under which they function? What effect do these arrangements have on physicians and other providers and how they practice?
- What changes are occurring in how providers and patients communicate?
- How do providers decide on care, for example, what role do practice guidelines or profiling play?
- How does managed care deal specifically with aspects of care, like home health care?
- What use is being made of new technologies coming on line?
- At the enterprise level (for example, an integrated system or plan), how can we assess malpractice experience and liability?
C. Efficiency of Process of Care
- Which medical practices perform better, e.g., in terms of productivity or costeffectiveness so providers get feedback and use it to improve performance?
- What are useful benchmarks for financial, quality, and operational performance?
- Where does managed care actual performance compare against its theoretical potential to enhance coordination of care and preventive activity and to eliminate “fat” (unnecessary care and administrative costs) from the system?
- What are the effects of changes in provider roles and responsibilities in care?
- How do AMCs compare to other hospitals in financial and quality indicators? Similarly, how do other subsets of hospitals, e.g. public hospitals, rural hospitals) or types of providers (for profit versus nonprofit etc) compare?