June 22, 2004

Comments from Dr. Charles Cutler

Thank you for the opportunity to comment on the recommendations for measuring health care quality. At Aetna we feel it is important to have robust, reliable quality measures available in an efficient and cost effective manner to allow more informed decision making by consumers and to support health plan activities such as network design and pay for performance programs. We appreciate the leadership the NCVHS has shown in taking the lead to expand the quality data available to health plans, plan sponsors and consumers. I have attached my comments on the first eight recommendations and welcome the opportunity to comment on the other recommendations in the future.

Sincerely,

/s/

Charles M. Cutler, M.D., M.S.
National Medical Director
Aetna National Quality Management
980 Jolly Road
Mail Stop U11E
Blue Bell, PA 19422
215-775-3610
cutlerc@aetna.com

Comments on Proposed Recommendations for Measuring Quality

Health plans have taken an active role in measuring and reporting the quality of care delivered to its members. At Aetna, we publicly report HEDIS measures, provide information about hospital quality to our member through tools available on our website; have developed networks based on efficiency and quality; and reward provider for performance on quality measures. These activities are based on data we obtain largely through claims, although some come from chart review or data from vendors such as laboratories

We are in the process of looking for sources of reliable data to complement and expand the information about health care quality and outcomes we use. We will use this information to have more robust measures for pay for performance programs, develop networks based on quality, and make more specific and relevant information available to our members and health plan sponsors (employers, unions, government, etc.) for informed decision making. The major current barrier to doing so is the lack of data available in an efficient and cost effective way.

The information most lacking are those that measure outcomes. Some of these, such as blood pressure, are currently measured by physicians and can be obtained through actions listed in the current recommendations. Others, such as level of function are not currently measured by physicians in a consistent manner.

Some of the recommendations would be very helpful in expanding the data we would find useful. Many of the first 8 recommendations would provide value considered separately, but the more data that is available, the more robust and reliable programs and activities based on data will be.

Many of the recommendations not being considered this week address issues of importance and value to Aetna, such as information on disparities in care. While we understand that you only want comments on the first eight recommendations at this time, we would value the opportunity to comment on the recommendations as well. Please let us know how we can best do so.

Specific comments

Laboratory data

Laboratory data is critical to measuring the outcomes of a number of diseases and is currently a prominent part of the HEDIS data set. These measures are already being used in pay for performance programs based on HEDIS or qualification for the NCQA Diabetes Performance Recognition Program. They also are useful in risk adjusting populations. Laboratory data can be collected from providers directly or from laboratories. In either case, a standard data methodology would be very useful. Our experience using data supplied by the vendors is that it is highly accurate. It would be very valuable to have common coding for lab data.

Vital Signs

While laboratory data may be available from some lab vendors, there is currently no efficient data source for vital signs. Vital signs are important measures of outcomes of treatment, such as high blood pressure, risk, such as high body mass index (BMI), and can provide information that is very useful for risk stratification and adjustment. These measures would be used in pay for performance programs, identifying candidates for disease management programs, and targeting individuals for specific educational and other support programs. We do not have experience with the reliability of the data, but there is no reason to think that it would be less reliable than other data captured on claims.

Secondary diagnoses

While we may be able to identify diagnoses given prior to hospital admissions from prior claim history this is not always the case. Having secondary diagnoses would be very helpful for case mix adjustment, risk stratification and completeness of the clinical condition. It could be used by health plans in the manners described above for vital signs.

Operating physician

Since health plans receive claims from hospitals and physician separately, we can usually determine the operating physician from the physician claim. This measure would not be very useful to us.

Date/ Time requirements

The ability to measure time between procedures during a hospital stay could be very useful. A number of organizations have suggested quality measures such as time from admission to time of anticoagulation or other intervention. It would be ideal to have measures such as these, but they would require significant change not only in the capture of data on admission, but data captured during the hospital stay. The reliability of this data would be questionable in the current environment where the data would need to recorded and tracked manually.

Start and End Dates for Global Billing

We support the idea of capturing data that allows the identification of the first prenatal visit and post partum visits as well as length of care for surgical procedures but have concerns that proposed method will not be practical or accurate for collecting this information.

Functional Status

The goal of care is to maintain, improve or restore function. Health plan members, purchasers, physicians and plans would benefit from knowing how well specific provider interventions restore function and how successful individual providers are in doing so. This information would be used by plans in network design, pay for performance programs and in helping individuals make informed decisions about provider interventions as well as choice of providers. Functional status is not currently collected by most physicians so it is not available even on medical record review. In order to collect this information in a reliable and efficient manner, we will need to identify new tools and methods to do so. We support the recommendation to do research in the collection of functional status.