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Community Health Plans Among Best in Nation

Six of Top 10 Medicare Plans are ACHP Members

WASHINGTON, Oct. 26 /PRNewswire-USNewswire/ -- The Alliance of Community Health Plans (ACHP) today announced that 70 percent of its member plans have been recognized by the U.S. News and World Report and the National Committee for Quality Assurance (NCQA) as being among the top 25 health plans in the U.S. across Medicare, Medicaid, and commercial lines of business.

ACHP members are select regional health plans that provide coverage and health care services for nearly 15 million individuals throughout the U.S. Among the top 10 Medicare plans, one member plan, Fallon Community Health Plan, based in Worcester, MA, was rated as both the top Medicare and Medicaid plan. Six of the top 10 Medicare plans are ACHP members. Among the top 15 Medicaid plans, 5 are ACHP members.

The rankings clearly demonstrate that community-based health plans offer the best quality care available while providing enrollees the highest value for their health care dollar. These plans consistently achieve such high quality ratings through close coordination among all the providers involved in a patient's care. In addition, regional health plans actively work to identify patients' health needs through a variety of patient outreach efforts. Improving their patients' health is the key goal of these plans.

"I am extremely pleased that community health plans have again been recognized for their status as being among America's very best health plans," said Patricia Smith, the President and CEO of ACHP. "These plans are deeply invested in the communities they serve and provide the right care through a patient-centered approach. Community-based health plans are leaders in implementing such innovations as electronic health records, chronic care management programs, personalized web-based consumer tools, and health risk assessments, all of which combine to improve health care in the communities they serve."

"Community health plans achieve high quality care by providing coordinated, effective care for their patients," said Eric H. Schultz, the President and CEO of Fallon Community Health Plan. "Fallon Community Health Plan is involved with patient care at every step, whether it is a hospital stay or a physician visit, in a constant effort to improve the health and experience of our patients."

Unfortunately, among Medicare enrollees, meaningful quality data are not available for the approximately 35 million enrollees in traditional fee-for-service Medicare, nor are these data available for the 1.7 million individuals enrolled in Medicare private fee-for-service plans. These data are available, however, for enrollees in Medicare coordinated care plans. As a result, policymakers cannot truly evaluate the value of Medicare coordinated care against traditional Medicare or private fee-for-service plans because they are missing a large piece of the puzzle -- namely, the impact of the delivery system on quality of care. ACHP supports measuring and publicly reporting information about both the quality of clinical care as well as patient satisfaction with all sectors of the health care system.

Background on the Rankings

The rankings published on October 26, 2007 by the U.S. News and World Report are based primarily on two data sources: the Health Plan Employer Data and Information Set (HEDIS(R)) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)). HEDIS(R) captures whether or not patients receive appropriate care from their providers, while CAHPS(R) captures patients' experience with their providers and health plan. For example, one HEDIS(R) measure tracks the percentage of female patients, aged 40-69, who receive an annual mammogram; the National Cancer Institute, the American Cancer Society, and the American College of Radiology all recommend annual mammograms for women over 40. An example of a CAHPS(R) measure is how patients rank their health plan on a scale of 0 to 10. Within each line of business (Medicare, Medicaid, and commercial) performance on the many individual quality measures are combined into one aggregate score, and health plans are then ranked according to this score.

Providing appropriate care.

Unlike non-coordinated systems, integrated plans can increase the value of the health care dollar by coordinating care in such a way that proper care is provided. The top health plans as rated by the NCQA and the U.S. News and World Report excel at providing an appropriate level of care. Purchasers -- whether public or private; individual or group -- stand to gain considerably by spending their scarce resources on the health plans that can truly add value. Integrated plans, such as the ACHP member plans, are best situated to achieve this goal of added value.

Recent studies indicate that the U.S. health care system does not consistently provide high quality care to patients. In many cases, patients do not receive the appropriate level of care. Poor quality care leads to as many as 45 million avoidable sick days, according to the NCQA. According to one study, adults receive recommended care only slightly more than half the time, and receive recommended care for diabetes only one-quarter of the time. Further, a recent study published in the New England Journal of Medicine states that children receive proper outpatient care less than half the time, and receive the proper preventive care only 41 percent of the time.

Comparing quality of care in different settings.

Unfortunately, reliable quality data are not available for the approximately 100 million commercial enrollees in preferred provider organizations (PPOs) that did not reported HEDIS(R) data in 2007, according to the NCQA. According to the Kaiser Family Foundation, more than 60 percent of employees are covered by PPOs. Thus, the majority of workers in the U.S. presumably cannot choose a health plan whose quality and customer service is systematically assessed. The new NCQA standards that require PPOs to report quality data, in order to be accredited by the NCQA, could help address this deficiency. Beginning July 1, 2008, these PPOs will be required to report HEDIS(R) data to NCQA.

Changes in performance over time.

In recent years, performance on some quality measures has improved, while performance on others remains stagnant or has had declining performance. For example, the percentage of individuals receiving beta-blocker treatment after a heart attack has shown steady, significant improvement. Adolescent immunization rates are also increasing, particularly among Medicaid coordinated care plans. More and more smokers receive advice from providers about strategies to quit smoking. On the other hand, behavioral health-related measures have seen stagnant or decreasing performance for several years. For example, the percentage of individuals with depression who remained on antidepressant medication for at least six months has decreased.

2007 U.S. News and World Report/NCQA Rankings of ACHP Member Plans Among Top 15 in Each Category (Medicare, Medicaid, and Commercial):

Medicare Plans

Rank ACHP Member Plan

1 Fallon Community Health Plan

5 Kaiser Foundation Health Plan of the Northwest

6 Kaiser Foundation Health Plan of Southern California

7 Kaiser Foundation Health Plan of the Northwest (Demonstration


8 Security Health Plan of Wisconsin

10 Kaiser Foundation Health Plan of the Mid-Atlantic States

13 Kaiser Foundation Health Plan of Colorado

Medicaid Plans

Rank ACHP Member Plan

1 Fallon Community Health Plan

6 Kaiser Foundation Health Plan of Hawaii

7 Independent Health Association

13 UPMC Health Plan

Commercial Plans:

Rank ACHP Member Plan

5 ConnectiCare (HIP of New York)

8 Group Health Cooperative of South Central Wisconsin

12 Fallon Community Health Plan

13 ConnectiCare of Massachusetts (HIP of New York)

A complete list of the rankings is available at:

About ACHP

ACHP is a leadership organization that brings together select innovative health plans and provider organizations that are among America's best at delivering affordable, high-quality coverage and care to their communities. ACHP's 13 member plans provide health insurance to over 15 million individuals in the U.S. Drawing on years of experience, members collaborate, share strategies and work toward solutions to some of health care's biggest challenges. More information is available at

HEDIS(R) is a registered trademark of the National Committee for Quality Assurance. CAHPS(R) is a registered trademark of the Agency for Healthcare Research and Quality.

SOURCE Alliance of Community Health Plans
Copyright©2007 PR Newswire.
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