Performance Improvement 1995. Future Directions in Evaluation

02/01/1995

In addition to NPR and GPRA, PHS must be responsive to public health issues of the future. Public health has an opportunity to change the American health care system, shifting its focus toward protecting and improving health. This opportunity to reinvent public health is the theme of the PHS Strategic Plan for FY 1995. The plan centers on the following three goals, which PHS, working with the public health community, will pursue:

  • Help the State health agencies--and their component communities--shift from a treatment-oriented to a health-oriented health care delivery system;

  • Become partners in the managed care revolution to ensure that vulnerable populations have access to cost-effective preventive services; and

  • Take a leadership role in the National Information Infrastructure (NII) from the sides of both consumer health information and population-based or integrated national, State, local, and private health care information systems.

As the following pages detail, PHS leadership envisions these three goals as guiding future priorities of the Evaluation Program.

1. Shift from personal care to population-based services The PHS FY 1995 Strategic Plan focuses on strengthening the public health infrastructure of the Federal Government, tribal governments, States, and communities to identify and address high-priority health problems for their populations and to do so in a way that focuses on the outcomes of their activities. PHS intends to provide the States with more flexible funding by consolidating several categorical programs into Performance Partnership Grants (PPGs). Partnerships are proposed in six program areas--mental health, substance abuse, immunizations, infectious disease, chronic disease, and prevention. These grants would be based on the premise that giving the States greater flexibility to develop and manage programs in exchange for increased accountability for results will encourage more effective use of Federal funds to address national public health objectives, such as those developed for Healthy People 2000. The success of PPGs with the States depends on knowing what the grant funds can achieve (goals), whether the results over time can be known (measures), and how performance can be rewarded (incentives). Program goals, to be specified in legislation, would lay out national objectives for each grant. Performance measures would quantify national and State progress toward the goals. The measures must be results oriented, measuring success based on program outputs and health outcomes developed mutually by PHS Agencies and the States. Performance incentives would be an integral part of the individual contracts between the States and the relevant PHS Agency, including specific performance targets and timeframes for achieving them. The incentives might, for example, be to extend greater flexibility to States that meet their performance targets.

The PHS Evaluation Program will play an important role in each performance partnership, from the development of the performance measures to the collection and analysis of indicator data. PHS Agencies will work with the States to select the measures, design data collection strategies, and develop analytic models for interpreting results relative to performance targets. The States will be able to use grant funds to develop integrated information systems for managing programs and measuring performance.

2. Public health partnership with managed care The managed care revolution has the potential to establish the foundation for a full partnership between public health and the personal care system on behalf of the health of defined populations. With payments based on annual premiums, managed care creates financial incentives that reward health plans for having healthy clients. Potentially, this incentive could encourage health plans to make sure that their enrollees take advantage of cost-effective preventive services. It also encourages plans to work with and support the efforts of public health agencies and community organizations, which can prevent unnecessary disease and health care costs through communitywide interventions. Realizing the benefits of organized systems of care, however, requires a strong system of performance monitoring to ensure that health plans are living up to their commitments and taking responsibility for improving the health of enrolled populations.

In the next few years, PHS Agencies will examine the impact of managed care on public health systems. First, Medicaid Waiver (Section 1115) demonstrations in five States will be evaluated to determine the extent to which those eligible have participated and the effects of the program on the care participants receive. Particular attention will be given to access and quality issues for special populations, such as American Indians and Native Alaskans, children with special health care needs, people in underserved areas, substance abusers, and the chronically mentally ill. The effects on costs to providers, especially the extent to which cost neutrality is achieved, will also be studied.

Many academic health centers (AHCs) have been particularly affected by the managed care revolution. PHS will analyze the changes in the capacity of AHCs resulting from the fiscal impact of competitive health insurance and Medicaid managed care plans. The impact of these organizational changes on medical education, biomedical research, advances in medical technology, access to tertiary care, and the provision of services to indigent populations will be assessed.

In the future, PHS will also support health services research in the areas of quality measurement and consumer choice. These studies will provide valuable preliminary information to managed care organizations and other providers as they develop their quality measurement tools. PHS evaluations are already under way at AHCPR to examine clinical practice guidelines and assess how well they can be incorporated into managed care operations. AHCPR will also assess alternative educational methods for disseminating the guidelines and review criteria for changing the practice behavior of providers.

3. Leadership in the National Information Infrastructure The National Information Infrastructure (NII) refers to the web of electronically accessible information resources available to Americans. The NII holds potential for rapid and vastly enhanced interactive information flow. Multi-user list server technologies will allow infor-mation that is sent to a single location to go to all entities on the list. Electronic bulletin boards and multiple-recipient electronic mail (e-mail) are revolutionizing the way information is dis-seminated and the ability to have followup communication and dialogue. More and more communities or their critical components are becoming part of local and wide-area health information networks, often called community health information networks. These networks can ease transmission of and access to consumer health information.

The Federal Government has played a major role in the production and dissemination of health information to consumers, but its role in evaluating that information is limited. It monitors effective dissemination, including who receives the information, how it is used (particularly by specific population segments), and what behavior changes are associated with it. For example, research has been conducted to determine how target consumers become aware of, receive, accept, and use disseminated information. The test of effective use is the extent to which target audiences become more informed, make decisions, or change behavior patterns and attain better health as a result of using the disseminated information. The Federal Government also helps determine whether consumer health information improves patient satisfaction, care, outcome, and overall quality of life. PHS, particularly, should be measuring the effect of consumer health information on such traditional aspects of public health as maternal and child health, childhood immunization, prevention and control of communicable diseases, and environmental health problems. The issue of maintaining or validating the quality and integrity of health information is also a serious concern in a digital information marketplace. The Government's role in ensuring that the content of such health information (either publicly or privately generated) remains scientifically sound needs to be defined.

In addition to evaluating the consumer health information dimension of NII, the PHS Evaluation Program will examine the role of population-based health information systems in achieving public health objectives. A strong consensus about the features of a public health/personal health care information network is emerging among major stakeholders. At the Federal level, most legislative bills envision a public/private partnership in which the private sector owns and operates the bulk of the system and the Federal Government establishes the overall policy framework, including national uniform standards for reporting and electronic exchange of data; unique identifiers for individuals, health plans, and providers; and strong privacy and security protections. This type of NII health information system could simplify administration and enhance the usefulness of information in several ways. It could create a standardized clinical vocabulary and coding structure for health information. It could ensure a secure environment for the transmission and exchange of health information. It could allow information routinely collected in health care service delivery and payment to be used for other health-related purposes, such as promoting access and quality of care, achieving public health objectives, and advancing medical research.

As a major goal of the PHS FY 1995 Strategic Plan, the PHS Agencies will develop integrated information systems that protect privacy; reduce reporting burdens; and provide participants in both the public and personal health care systems with the information they need to define health problems, assess performance, ensure quality, support decisionmaking, and take timely action to protect and improve health. To support this goal, the PHS Evaluation Program will examine PHS programs and policies that help State and local communities develop their information systems serving both public health and medical providers. One current OASH project is developing indicators that communities can use to assess performance of the health care system and foster a closer collaboration between the public health and personal health care systems to achieve public health goals.

An assessment of national, State, and local health data systems is also essential to identify optimal processes for developing performance measures for the public and personal health care systems, in the framework of Federal-State partnerships designed to achieve public health objectives. PHS will be reviewing and evaluating past efforts, current issues, and future opportunities for partnerships with the States to conduct health surveys that collect data for planning, policy development, research, and other purposes. Evaluation information is needed on the successes and failures of past PHS data collection efforts with the States to aid discussions about strategies for future partnerships in this area.

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