QUALITY ASSURANCE: CAPITATED PHYSICIAN GROUP PROGRAMS

      As HMOs increasingly turn to group medical practices and
 independent practice associations to provide medical services,
 these capitated physician groups are becoming responsible for
 quality assurance (QA).  A study in this week's JOURNAL OF THE
 AMERICAN MEDICAL ASSOCIATION (JAMA) finds that physician groups
 vary "considerably in the focus and magnitude of their QA
 programs."  The study of 94 physician groups in California caring
 for 2.9 million patients under capitated contracts with the same
 HMO measured their "relative emphasis on monitoring of overuse
 compared with underuse and monitoring and improving preventive
 services compared with chronic disease care."  The authors note
 that "capitation places a large share of responsibility for QA in
 the hands of physician groups, but not all aspects of QA are
 being equally addressed."
      RESULTS:  All capitated physician groups in the study
 conducted some form of QA, but the emphasis on monitoring
 underuse and overuse of services varied by group.  More than 50%
 of the groups reported monitoring services associated with
 overuse -- such as cesarean delivery rates, emergency room
 visits, prescription drug use and angioplasty.  Twenty-six
 percent said they monitored "readmissions for major affective
 disorders."  In the area of underuse, physician groups were more
 likely to monitor underuse of preventive services (54%) than
 follow-up services for patients with chronic diseases (30%). 
 Approximately one-third of the groups used reminders for
 preventive services such as childhood immunizations and
 mammography, while "less than 20% used reminders for cholesterol
 screening, sigmoidoscopy screening, retinal examinations for
 diabetic patients, and follow-up visits for asthma patients."
      CONTINUOUS QUALITY:  In the area of continuous quality
 improvement, "72% of the groups reported use of special task
 forces or quality teams to investigate specific problems." 
 According to the study, 65% of the groups "systematically
 collected and analyzed data requested by quality teams," 42% used
 flowcharts and other tools to "document existing problems and
 identify areas where problems originated, and 16% used
 specialized industrial engineering techniques."  
      CONCLUSIONS:  The authors conclude that most quality
 monitoring in physician groups "assesses overuse rather than
 underuse."  Among the explanations they offer is that to remain
 financially viable, capitated groups must decrease overuse of
 services, making monitoring for overuse essential.  They also
 suggest that monitoring for overuse of services already performed
 is easier than monitoring for underuse of "services which were
 not performed but should have been."  The "emphasis on prevention
 over disease" may be due to QA tools to measure chronic disease
 services, according to the authors.  Finally, they determined
 that more profitable and well-established physician groups were
 "associated with higher levels of QA activity."  They write that
 these findings "suggest that groups with solid foundations and a
 large stake in prepaid care are more likely to monitor and
 improve quality and that less well-established groups might need
 assistance in developing QA systems (Kerr et al, 10/16 issue.)