The feasibility of an outcome approach to quality assurance--a report from one HMO

Recent federal legislation has contained the stipulation that participating health maintenance organizations (HMOs) include a quality assurance program which stresses health outcomes. This provision was ostensibly directed at correcting alleged abuses in HMOs serving the urban poor. One version of the outcome method was employed for an 18-month period at an urban HMO caring for 2,000 Medicaid subscribers. The program involved comparing diagnostic accuracy and therapeutic outcomes for clinical conditions relevant to the study population with ideal standards established by the HMO. Three conditions were selected: contraception, depression, and hypertension. The results revealed widespread underdiagnosis (44-74%) in each condition and unacceptable therapeutic outcomes in two. Data collection was hampered by shifts in geography and financial eligibility among the denominator population and low response rates (38-63%) to telephone and mail surveys. Applying the general project guidelines to specific conditions proved considerably more difficult than anticipated. Further refinement of this approach to quality assessment must occur before its widespread use is feasible. Its effectiveness in improving quality remains to be seen. This experience raises doubts regarding the wisdom of legislating a specific outcome approach to quality assessment before feasibility and effectiveness have been demonstrated in organized health settings.