The Quest for Quality: Does Network Participation Matter?
Herminia Palacio
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Harris County Public Health and Environmental Services
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Houston, TX 77027, USA
Corresponding Author: Herminia Palacio, MD, MPH; Harris County Public Health and Environmental Services, 2223 West Loop South, Houston, TX 77027, USA (e-mail: ).
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T heeded by many and has led to a body of research aimed
he clarion call to focus on quality of health care has been
at identifying factors associated with improved quality of
care.16 In this issue, Friedberg et al.7 explore the association
between quality of careas measured by Health Plan
Employer Data and Information Set (HEDIS) indicatorsand two
characteristics of physician group practices. Specifically,
Friedberg et al.7 examined whether HEDIS measures varied
by the size of the physician group and by whether or not the
physician group was a member of a physician network. They
reviewed data from five managed care organizations that
encompassed contracts with more than 4,300 primary care
physicians in group practices in Massachusetts. Friedberg
et al.7 found that in multivariate models, physician group size
was associated with only 3 of 12 HEDIS measures. Of note,
whereas for two diabetes-related HEDIS measures
mediumsized groups had more favorable performance scores, for
another diabetes-related HEDIS measure, small physician
groups had the more favorable performance scores.
The data regarding an association between network affiliation
and HEDIS performance yielded more consistent results.
Specifically, Freidberg et al. found that in multivariate analyses,
network affiliation was associated with higher HEDIS
performance scores in 8 (of 12) measures. These findings were fairly
robust, overall holding up well under various conditions such as
excluding the two highest performing networks from one analysis
and excluding the two largest networks from another analysis.
How does the examination of these organizational
constructs (group size and network affiliation) contribute to our
understanding of quality care and what are the policy
implications of the data presented by the findings by Friedberg et al.?7
From a policy perspective, it is particularly important to
consider interventions that are not just effective but are also
feasible, efficient, relatively generalizable to a variety of
healthcare settings. Furthermore, interventions that can be applied
at the system level are attractive, as they do not rely solely on
the vagaries of individual physician behavior.
The analyses on group size failed to reveal a pattern that
could be used to develop and test an intervention that has high
potential for meeting even the fundamental policy criteria of
being effective. Why? Because in their analysis, there was no
preponderance of evidence that any one group size had a
distinct advantage over another vis--vis the selected HEDIS
performance measures. This is not necessarily a disappointing
result. Indeed, as the ability of primary care physicians to
organize themselves into medium or large group practices is
likely constrained by a number of factors (geographic location,
population density, etc.), the data by Friedberg et al.7 offer some
comforting assurance that there are not huge missed
opportunities to improve quality of care imposed by the constraints on
altering group practice size.
The analyses on network affiliation yielded more promising
policy implications. Network affiliation was associated with
improved HEDIS performance scores across a majority of measures.
The policy implications are intriguing because if network affiliation
is truly an important player in the causal pathway toward quality,
then developing broad-based strategies to enhance physician
group enrollment into networks would be feasible relatively
efficiently and potentially generalizable to a variety of practice
settings. Indeed, during the 1990s, there was rapid expansion of
the number of physicians affiliated with networks.8 At the end of
the day, however, the findings presented by Friedberg et al.7 are
intriguing and provocative, but insufficient in and of themselves to
be the sole impetus for sound policy development. Their findings,
however, when taken into account with studies looking at the
impact of other additional organizational strategies such as pay for
performance9 should provide healthcare markets with sufficient
information to begin to implement and test the impact of specific
interventions on quality measures in a prospective manner.
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