Continuous Quality Improvement and Managed Care

The rapid growth and proliferation of managed care organizations (MCO) in the health care industry has caused many public health agencies, providers, employers, and consumers to question the efficiency and effectiveness of MCOs with respect to the quality and delivery of health care. This folder explores several sites and documents on the World Wide Web that are concerned with maintaining the quality of health care, in the managed care environment, through the process of continuous quality improvement (CQI).

Document

CDC - Prevention and Managed Care

In January of 1995, the Centers for Disease Control and Prevention (CDC) created the Managed Care Working Group. The purpose of this agency was to help guide the preventive efforts of the CDC and to foster partnerships between public health agencies and managed care organizations. Recently, this group published a report containing recommendations on implementing and incorporating prevention programs into managed care. This document presents a thorough description of the recent changes in health care and the necessity for prevention programs. Additionally, it highlights several barriers which hinder the union of prevention and managed care, and proceeds to offer suggestions on overcoming those barriers. One of the recommended high priority areas for the CDC includes the development of quality assurance systems (internally and externally) which guarantee a high standard of quality of preventive services to be delivered by all providers. This document is informative, easy to read and offers insightful recommendations.*****

Health Policy Institute

The Health Policy Institute is a unit of The University of Texas - Houston Health Science Center, School of Public Health. The Institute maintains several focuses, including community oriented primary care and the regulatory climate of health care. In this particular document, the Institute provides a list of upcoming activities and events pertaining to health policy and challenges in the 21st Century. In addition, the document lists several papers and videotapes that are available through the Institute, including conferences entitled "Continuous Quality Improvement for Public Health" and "Managed Care and Health Professional Education." Not only does this document identify available health-related materials for health care professionals, but it also provides a list of professors to contact, each with a very specific area of interest.***

HMOs: Quality Health Care

This document created by the Massachusetts Association of HMOs illustrates the fundamental differences between an HMO and the traditional fee-for-service approach. For instance, the document expands on continuity of care, internal quality controls (quality assurance and utilization management systems), and external accountability. The document clearly targets the concerned health care consumer who is searching for quality care.**

HRSA's Eight Priority Areas

This is a specific document formulated for the World Wide Web by the Health Resources and Services Administration, a division of the Department of Health and Human Services. This document outlines eight areas that HRSA considers to be of key importance in its pursuit to improve the "health of the Nation by assuring quality health care to underserved and vulnerable populations." This document specifically addresses the necessity to implement systems which assess the quality of health care delivery and training programs. Further, the document supports the principles of continuous quality improvement both internally and externally. The targeted audiences appear to be public health professionals and individuals/organizations interested in serving vulnerable or underserved populations.*****

IMPAQ Series

This document reviews the series of Improved Margin Performance, Appropriateness, and Quality (IMPAQ) products offered by HCIA. The page continually emphasizes that IMPAQ products are useful in analyzing the efficiency and effectiveneness of various health care delivery systems, including managed care organizations. Moreover, this page suggests that IMPAQ reports help to painlessly assess the outcomes of continuous quality improvement efforts. The intended audiences for this page appear to be hospitals, physicians, and managed care organizations in search of products which can effectively measure cost reduction initiatives, quality improvement, and utilization management practices.**

Kaiser Permanente and NCQA

Kaiser Permanente, like every other managed care organization, recognizes that today's healthcare consumer expects quality care in addition to reduced costs. This document defines for the consumer what NCQA accreditation means, and then cites specific areas examined during a review (e.g., member rights, credentialing, utilization management, and quality improvement). The document focuses on the accreditation process of a managed care organization by the NCQA and quality. This page stresses that Kaiser Permanente received the highest level of accreditation possible from the NCQA, which can be used as an effective marketing tool.***

NCQA's Executive Summary for Report Card Pilot Project

This document consists of the Executive Summary for the HEDIS (Health Plan Employer Data and Information Set) Project. The document describes the purpose of this one year pilot project, the involvement of the steering committee, and valuable lessons learned at the conclusion of the experiment. The summary is brief, yet thorough, and reinforces the need to develop one standard of quality measurement in the rapidly growing industry of managed care. This external system of measurement and improvement, set out in report card form, is an excellent way to monitor the internal process of continuous quality improvement in a managed care organization. Any health care provider, managed care representative or employer is likely to benefit from the information offered here.****

NCQA's Guide for Consumers

In an effort to inform the consumer about the levels of quality found in managed care organizations, this page is designed to provide the consumer with a step-by-step guide on how to choose an appropriate health plan. This page is extremely reader friendly, and provides a glossary of terms at the end. This page strives to educate the consumer and in the process, advances the NCQA's mission to ensure quality in health care.*****

Peer Review Organizations

This page provides an alphabetical listing (by state) of peer review organizations (PRO). PROs play an important role in the assessment and monitoring of continuous quality improvement in managed care organizations. This listing is part of a handbook developed by the Health Care Financing Administration, whose mission is "to provide its beneficiaries with access to affordable and quality health care services." The intended audience for this document might vary from a concerned consumer with questions, to a managed care organization under review.**

Site

HCIA

HCIA develops and markets clinical and financial support systems for many heath care delivery systems, including managed cared organizations. Specifically, its databases and products are designed to measure clinical outcomes, health care costs, and various aspects of health care delivery. This particular site offers a plethora of information pertaining to health care products, resource guides, conferences, and recent news. This site would be of benefit to both health care providers and delivery systems, who are interested in monitoring their performance, financially and clinically.***

Integrated Healthcare Association

The mission of the Integrated Healthcare Association (IHA) is to "promote the continuing evolution of integrated health care...as the best means to achieve positive outcomes for the patient and the general public." This site contains information about the various aspects of the IHA and also provides an in-depth look at the evolution of managed care, including IHA principles of managed health care. It comes as no surprise that these principles incorporate the concepts of continuous quality improvement and accountability. This site includes a listing of other valuable Web sites on the topic of managed care.****

Kaiser Permanente

The purpose of this site is to familiarize the consumer with Kaiser Permanente's (Georgia Region) health care system. The site provides information on individual health care, continuous quality improvement efforts, provider locations, and available plan/coverage rates. The site targets individuals who do not belong to a plan (self-employed or working part-time), but are looking for affordable yet comprehensive, quality heatlh care.***

Massachusetts Association of HMOs

The Masssachusetts Association of HMOs (MAHMO) is composed of 19 health maintenance organizations in Massachusetts. The purpose of the association and this site is to improve the public's understanding of HMOs. This site primarily focuses on the quality of HMOs, relevant research to support this claim, consumer satisfaction and recent issues. This site is user friendly, complete with a glossary of managed care terms.****

MEDIC

This particular site describes various aspects of the Medical Education Information Center (MEDIC), a part of the Department of Pathology and Laboratory Medicine at the University of Texas - Houston Medical School. Within this site, a viewer can quickly and easily access MEDIC's mission statement and various educational programs offered through the University. In addition, this site provides a wide range of forums which contain information on the art and practice of medicine. The intended audience varies in this site. For example, the "health care professional" forum is designed to be a reference guide for practicing physicians and nurses, while the "health explorer" forum is specifically designed for patients and members of the community.****

NCQA

The National Committee for Quality Assurance (NCQA) is an independent, non-profit organization devoted to assessing and reporting on the quality of managed care plans. NCQA's mission is "to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed decisions." This site identifies and explains the processes of accreditation and performance measurement, including the HEDIS report card. The site is comprehensive, informative, and lends itself to easy navigation. The audience might range from a concerned consumer to an organization involved in the measurement of quality within a managed care setting.*****