1. Vessey, Judith A. PhD, RN

Article Content

A large Japanese electronics firm, recognizing that research and development are key to the company's long-term success, recently announced the implementation of a 100-year strategic plan. Corporate executives stated that such foresight is needed if they are to retain their competitive edge. Compare this view with our current health care industry.


Competition among managed care organizations (MCOs) to capture and retain large market shares is shortsighted and fierce. Executives recognize that to remain competitive their MCO must reduce health care inefficiencies, decrease costs, and deliver better health outcomes. However, competition among plans continues to center on the short-term objectives of cost reduction (the primary concern of payers) and improved access and amenities (the primary focus of consumers) rather than on quality, an elusive concept that is difficult to measure. Competition based on quality requires purchaser demand, uniform and valid outcomes measures, and agreement among parties as to what constitutes quality care.


As differences among MCOs on cost and access issues are lessened, greater attention is being given to quality. Savvy payers, consumers, and policymakers are scrutinizing the MCOs' ability to provide better health outcomes, recognizing that these will be intrinsically linked to cost reduction. In response, more sophisticated MCOs are seeking to improve their market share by embracing clinical research as a method for demonstrating quality.


MCOs need clinical research that addresses their pressing needs, interests that are substantially different from those of traditional academic medicine. Clinical trials that determine medical efficacy of innovative treatment protocols for relatively rare diseases are of little interest. MCOs require studies that address prevention and treatment effectiveness of common conditions. Nurses, with their longstanding interest in health promotion, patient education, and therapeutic adherence, are ideally situated to form strategic alliances with MCOs to advance these agendas. Research methods that address cost benefit and/or cost-effectiveness analyses will be of significant value in these areas.


Nurse researchers must balance their research interests against the competing realities MCOs face in today's economic climate. MCOs are not in a position to underwrite studies that do not have a direct payoff. Although payers want better health outcomes to reduce the costs associated with health, disability, and life insurance benefits and consumers want access to experimental treatments, neither group is willing to subsidize the needed investigations through health insurance expenditures. A thorough understanding of today's insurance market helps researchers design and position their studies to mesh with corporate goals without compromising research integrity.


For example, those who use qualitative methodologies have much to offer MCOs, despite the fact that most corporate management has yet to recognize the contribution of such data to determining quality. MCOs are finding that HEDIS (Health Plan Employer Data and Information Set) and other automated data are insufficient measures of clinical quality for predicting better outcomes within population groups. Although such data sets provide precise measurements of large population data, they are limited in clinical detail. In addition, applying aggregate data to specific clinical populations underscores the need for valid and reliable measures for specific subgroups. As MCOs become more interested in maintaining their client base over time, quality measures must go beyond calculating the cost-effectiveness of a single event to examining long-term behavior change. This requires an understanding of the interpersonal dimensions, as well as the technical dimensions, of care. Qualitative data provides such illumination.


Nurses are needed to translate current nursing research into meaningful practice standards, ensure that such standards are evaluated as quality measures, and monitor documentation strategies to ensure that data are available for analysis. Widespread adoption of care standards, such as the Agency for Health Care Policy and Research guidelines, needs to be periodically reevaluated for relevance to contemporary practice.


Additionally, nursing has the responsibility to assist payers and consumers to define and determine quality in more sophisticated and meaningful ways. Patient satisfaction does not necessarily equate to quality care. Payers and consumers must look beyond the cost, choice, and amenities-the perception of quality-and learn how to evaluate the technical and interpersonal quality of the care they receive.


Patient outcomes, the ultimate measure of quality, are the most important indicator of an MCO's performance. Unlike costs, quality is not negotiable. MCOs will need to compete on quality, and nurse researchers are well situated to influence this competition.


Judith A. Vessey, PhD, RN


Associate Editor



Donna Bliss; School of Nursing; University of Minnesota; Minneapolis, MN


Marion E. Broome; Children's Hospital of Wisconsin; University of Wisconsin-Milwaukee; Milwaukee, WI


Virginia L. Carrieri-Kohlman; School of Nursing; University of California, San Francisco; San Francisco, CA


Marie J. Cowan; School of Nursing; University of California, Los Angeles; Los Angeles, CA


Colleen Dilorio; School of Nursing; Emory University; Atlanta, GA


Sara Fry; School of Nursing; Boston College; Chestnut Hill, MA


Susan Gennaro; School of Nursing; University of Pennsylvania; Philadelphia, PA


Mary R. Lynn; School of Nursing; University of North Carolina, Chapel Hill; Chapel Hill, NC


Janet Meininger; School of Nursing; University of Texas, Houston; Houston, TX


Carolyn Murdaugh; College of Nursing; University of South Carolina; Columbia, SC


Joan Shaver; College of Nursing; University of Illinois at Chicago; Chicago, IL


Virginia Tilden; School of Nursing; Oregon Health Sciences University; Portland, OR


Toni Tripp-Reimer; School of Nursing; University of Iowa; Iowa City, IA


Holly Skodol Wilson; School of Nursing; University of California, San Francisco; San Francisco, CA