Table 8 categorizes the impetus for and the information needs that were the focus of each of the 11 efforts we studied in depth. Also presented are perceived barriers to carrying out the efforts. The 11 efforts can be viewed as spanning the continuum of structure, process, and outcomes of care. More specifically, the impetus for these efforts emphasizes collection of information based on perceived needs (1) to better understand the linkages between players in the health system and what these connections mean for constituencies or public policy; (2) to expand information on insurance and operational arrangements with managed care that would be useful to strategic planning and public policymaking; and (3) to develop performance measures or benchmarks on process or outcomes that would support the operations of providers, plans, purchasers, consumers, and policymakers. For example, both the AHA and AMA felt limited by having data only on hospitals or physicians, respectively. The AHA wanted to understand how hospitals were consolidating into larger entities and what their contractual arrangements were with physicians and managed care plans. The AMA similarly was concerned that a focus on capturing data at the individual physician level would not provide insight on financial incentives viewed as of critical interest yet negotiated at the level of the physician group. The impetus for these efforts mirror those we identified in phase one interviews and a review of the literature.
Many of the 11 efforts are viewed by their initiators as being limited in different ways, though focused on core concerns. The following major constraints were cited:
- Data gaps and quality problems associated with lack of standardization or audit
- The burden of data collection on providers and plans and a weakening of their willingness to provide data in an increasingly competitive environment
- Lags in data availability, which limit the timeliness of information
- Resource constraints, both in general and in given marketplace activity
It is striking that both the AHA and the AMA have had to cut back on their data collection work in response to budgetary or other constraints, particularly since these national organizations are a major source of information on the health system. It is also striking that the AHA and AAHP have eliminated major data collection activities related to financial information. In an increasingly competitive marketplace, policymakers may want to further consider how much they should or can depend on private organizations to carry out data collection activities, especially when these activities rely on informal agreements and good will.
In addition to these generic kinds of constraints, the 11 entities we interviewed also had some specific insight into substantive limitations, which might suggest important federal activity. Several groups said their efforts to understand the structure and process through which care is delivered naturally was limited by the limits of the organization’s scope. The AAHP focus on health plans limits its ability to obtain information on other key players like hospitals and physicians that are part of those structures. The AMA focus on physicians makes it difficult to obtain information on processes that are increasingly occurring at the group practice level. The focus of the AHA and AAMC on institutional providers limits their ability to generate information about other important changes in the marketplace that affect those institutions (e.g., changes in primary care practice, links between entities other than the hospital).
Groups also expressed concern over their limited ability to influence the availability of basic transaction data used to create performance measures. The AMA, for example, views the erosion of the encounter database coincident with the growth of managed care as a major problem, since it limits the association’s ability to describe health care use for the growing population under managed care. NCQA perceives underlying data as such an important issue that it developed a project specifically to help plans anticipate the systems that would be needed in the future. However, the ability of plans to develop these systems requires actions that extend far beyond NCQA’s scope and may ultimately require federal intervention, as noted in the NCQA Roadmap (1997). NIHCM’s efforts involved steps to compile existing data and thus it illustrates how limited current information is for the end user. UCSF staff found broad-based key gaps, including gaps in purchaser information and health plan performance, in the availability, consistency and comparability of state and local estimates, and in the adequacy of documentation and the public availability of some information maintained for proprietary purposes.
OVERVIEW OF FOCUS AND PERCEIVED LIMITATIONS OF 11 INITIATIVES
Source: MPR Analysis
a The absence of a check does not mean this was not a problem since responses were obtained in an open discussion and some features may not have been mentioned.