The Patient Protection and Affordable Care Act (Affordable Care Act) places strong emphasis on quality of care as a means to improve outcomes for Americans and promote the financial sustainability of our health care system. Notably, Section 3011 of the Affordable Care Act mandates the Secretary of Health and Human Services to establish the National Quality Strategy (U.S. Department of Health and Human Services, 2012) with the aim of increasing access to high-quality, affordable health care (value) for all Americans. The National Quality Strategy is centered on the Institute of Medicine’s (IOM’s) so-called “Triple Aim” of better care, better health,...

As health plans can differ along multiple dimensions, we started by developing a conceptual framework that organizes those dimensions to give employers a structure with which they can compare plan options. One part of the framework captures the structural characteristics that can distinguish plans, another captures the processes of care that plans’ contracted providers deliver, and the final part captures the outcomes that are accomplished for plan participants and beneficiaries. The components of the framework informed a subsequent environmental scan.

The goals for the environmental scan were (1) to understand how health plans differ along the structural characteristics set forth...

We created a simplified framework that allows employers to understand differences between health plans and the results that they achieve (Figure 3.1). We based our framework on Donabedian’s structure, process, and outcomes categorization scheme, which has emerged as a standard approach in health care performance measurement (Donabedian, 1966). In short, the framework reflects the fact that the structural characteristics can be thought of as the “context” established by the health plan, under which health care providers deliver care (or which processes they use) and how those care processes, combined with health and health care–related decisions and choices of plan...

Network management captures how well a plan matches providers to the needs of plan participants and their dependents, with respect to the extent of the network (i.e., number and specialty mix of physicians and hospitals) and the capacity of the network to accept new patients. The quality of network management is commonly measured by metrics for network adequacy.

The Affordable Care Act has brought significant attention to the issue of network adequacy and requires the Secretar of Health and Human Services to establish certification criteria for qualified health plans participating in state’s Health Insurance Marketplace (National Association of Insurance Commissioners,...

Customer service is the part of a health plan that is most directly member-facing, and is therefore of critical importance to member experience. It includes communication with members about benefits and quality of care, handling of claims, appeals processes for denied claims or denied authorization of services, and other services. Our experts mentioned that some health plans try to improve customer experience by providing hospital quality reports and health plan comparison tools online, while others post factsheets explaining the appeals process to educate consumers about their rights. Others have well-organized information hotlines to educate consumers about the various products and...

According to our technical expert panel, early efforts to measure quality were driven by providers largely for the purpose of quality improvement projects, as opposed to payment or driving patients’ selection of providers. Providers sought tools to identify and address gaps in care and developed measures that reflect how well actual care processes align with recommended processes. Gaps in care were then used to target and monitor quality improvement projects. Given the complexity of medical care, a great number of individual measures are required to comprehensively capture process quality for distinct conditions. For example, the Assessing Care of Vulnerable Elders...

Outcome measures reflect the actual results that a health plan achieves in the following three areas:

Medical outcomes, reflecting safety, timeliness, and effectiveness, can be captured at two levels

-Intermediate (or proxy) outcomes, such as control of hypertension

-Health outcomes, such as rates of surgical complications

Patient experience, a measure used to capture a health plan’s patient-centeredness

Efficiency measures to reflect resource use per relevant outcomes (or value) as opposed to cost measures that do not consider medical or patient-centered outcomes.

Outcome measures are more intuitive and easier to understand for a non-technical audience, like employers, than process measures that...

The previous four chapters have shown that our understanding of the structural characteristics of health plans has greatly improved, along with the measurement science to evaluate plan performance. This chapter discusses how employers areactuallymaking decisions about health plans today, and is based on expert interviews, a review of the trade literature, and an assessment of existing decision tools. First, we discuss the key sources of information used by employers to make health plan choices. Second, we discuss employers’ key considerations in health plan selection.

Employers discussed several information sources that they use most commonly to inform health plan...

We used an environmental scan, which consisted of a review of scientific and trade literature and health insurance companies’ websites; expert panels; and case studies to evaluate the current availability of quality measures and decision tools that can inform employers’ choices of health plans and today’s actual practice of plan selection. We find that our understanding of what differentiates health plans structurally and how we measure their performance has improved and that tools and resources to help employers use such information are emerging. In theory, this evolution put employers into a position to select health plans based on quality, but...