In recent years the number of Americans receiving health care services through some sort of managed care organization has increased greatly. While managed care has been heralded as a means to reduce costs associated with the delivery of healthcare services, there has been much concern that this cost saving will be achieved by sacrificing the quality of care. Because of this, measuring and assuring the quality of care in managed care settings has become a priority. Government agencies, nonprofit organizations, and consumer groups have all begun to focus on the two major aspects of this issue, measurement and improvement. Measurement efforts include developing tools, collecting data, determining indicators of health care quality, analyzing the data and reporting it. After this is done, steps must be taken to insure that the quality of care is up to par, and to make improvements, where necessary, through education initiatives. Information on the quality of care provided under managed care plans is useful to consumers and employers when trying to chose the best plan to purchase, and also to the plans themselves to determine where improvements need to be made. The following internet sites provide a tool for those wishing to learn more about quality measurement and improvement in managed care.
SITES
National Committee for Quality Assurance
(NCQA)
This is the home page for the National Committee for Quality Assurance. The NCQA is a private, non-profit organization dedicated to measuring and reporting on the quality of managed care plans to enable consumers and employers to make informed choices of plans based on quality. Included in this site are reports on quality, descriptions of MCQA quality measures, a list of NCQA accredited managed care organizations, and separate sections with information dedicated to consumer, employer, provider, and government issues. Also included is a section dedicated to HEDIS, the Health Plan Employer Data and Information Set, which the NCQA is responsible for managing. HEDIS is the most widely used set of performance measures for analyzing the quality of managed care plans. Rating *****
Agency for Health Care Policy and Research (AHCPR)
The AHCPR was established in 1989 as part of the Department of Health and Human Services. Its function is to "support research designed to improve the quality of healthcare, reduce its costs, and broaden access to essential services". Within this site are many areas providing a great deal of useful information, including research findings, clinical information, and consumer health. There is also an entire section dedicated to quality assessments. Here the AHCPR provides an overview of the quality assessment initiatives it is involved in. These include the results of a national survey on the role of quality information in the choices of healthcare consumers, a description of CONQUEST 1.0, AHCPT's prototype data collection tool, and a list of abstracts of articles discussing outcome quality measurement for specific diseases. Also detailed is CAHPS (consumer Assessment of Health Plans), a kit of survey and report tools to help consumers and purchasers assess and choose among health plans. Rating****
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
The JCAHO is a private, non-profit organization dedicated to improving the quality of healthcare received by the American public. It does this by evaluating organizations that provide care, such as hospitals, healthcare networks, and nursing homes, and accrediting those that provide a high level of care. Accreditation by the JCAHO is used as a general mark of quality, and can be used to enhance consumer confidence, meet certain certification requirements, and provide information to organizations to help them improve their quality of care. JCAHO uses outcome and other performance measures to compile reports that are available to the public. Their site is divided into three sections. The first, targeted to the general public, provides information on the quality reports on specific healthcare organizations, as well as how to use this information to choose the best one. The second part, aimed at healthcare organizations and professionals, provides accreditation information for different types of organizations and the specifics of performance measurement. And the third section is dedicated to purchasers, employers, and unions to help them decide on a plan for their group. Rating*****
Health Care Financing Administration (HCFA) - Quality of Care Information
HCFA is the Health Care Financing Administration, the federal government agency that administers the Medicare, Medicaid, and Child Health Insurance programs. Although historically the vast majority of Medicare and Medicaid recipients were treated in a fee for service environment, in recent years there has been a large movement of these populations into managed care. Due to this fact, HCFA has a large stake in the quality of care delivered under managed care. This site is an entire section of the HCFA home page dedicated solely to information on the quality of care. It describes the various activities HCFA is involved in to measure and ensure the delivery of a high quality of care. HCFA is responsible for monitoring managed care organizations that it contracts with to ensure that they meet Medicaid and Medicare standards. They also work with other groups to study plans and provide accreditation. The site also provides a description of HCFA activities under its Health Quality Improvement Program, which, "emphasizes cooperation with providers, continuous quality improvement, development of performance measures, and improved information about beneficiaries' satisfaction with the care they receive." In all, this site provides insight into how the largest payer in the country looks at quality of healthcare. Rating- ****
IPRO is one of the largest healthcare quality evaluation organizations in the country. It is the quality of care expert for the Medicare and Medicaid programs for New York State. The organization conducts Quality Improvement Studies that are designed to improve the quality of healthcare by examining the patterns of care and facilitating change among providers. This site provides an overview of these initiatives in two different forms, one designed to be read by healthcare consumers, and the other by healthcare professionals. Other information provided by this site and aimed primarily towards consumers includes consumer protection initiatives and a section dedicated to consumer education. For the healthcare professional, there is information to alert and educate about quality initiatives and strategies for improvement. In addition, this site provides two online publications. "BENEprofiles" is a healthcare newsletter for seniors, and "Quality Initiatives" describes the current work being done by IPRO. Rating ****
Documents
1994 Managed Care Quality Assurance Reporting Requirements Report
This report, release by the New York State Department of Health, represents an effort to measure the quality of managed care plans in New York. It was created through a collaboration of 41 New York State managed care plans, physicians and other providers, and the New York State Department of Health. The QARR is a set of measures, based on HEDIS, that was designed as a tool to measure the quality of care delivered by managed care organizations. Because managed care is a relatively new delivery system for health care in New York, a method was needed to measure the quality of care at the present time and to track the improvement of quality over time as changes are made. This report is significant because it represents a collaborative effort between government organizations and health plans, it audits the data to insure the accuracy of the results, and is the first to specifically measure quality in Medicaid Managed Care plans and their enrollees. In this site, the report is well- organized into sections which provide information on the background of the study, its methods, limitations, results, and future steps to be taken. Rating *****
Protecting Quality under Medicaid Managed Care
In recent years, the percentage of the Medicaid population enrolled in managed care has greatly increased. Since this population is considered very vulnerable, it is of great importance to measure and analyze the care that this group is receiving. This article, from the Online Journal of Issues in Nursing, was written to analyze the mechanisms in place to try to measure and improve quality in Medicaid Managed Care. Beginning with a brief history of Medicaid Managed Care, the article then goes into more detailed description of those actions taken by state and Federal government to measure and insure quality care in these arrangements. This includes a comprehensive description of QARI (Quality Assurance Reform Initiative), developed by HCFA to measure the quality of care provided under capitated managed care arrangements. QARI is based on four major components: internal quality management programs, practice guidelines and clinical indicators, state monitoring, and annual audits of service quality. Each of these components is described in detail with the important aspect of each highlighted. The article closes with a consideration of future trends in Medicaid Managed Care, and the continuing need for quality measurement. Rating***
Medical Management - Managed Care and Quality Management
This article, written by Roberta Carefoote, an RN with twenty years
of Quality Management experience, takes a look at the important factors
for individual managed care organizations to consider while looking at
quality. There are many reasons why an MCO should be concerned with quality;
there is often state and federal oversight of a plan, especially if it
treats Medicaid and Medicare populations. A plan must meet certain qualifications
to receive accreditation, which is not mandatory but increases competitive
advantage. In addition, plans are judged by the HEDIS performance measures,
which can be used to benchmark on plan against the other. Finally, employers
are starting to demand higher quality of care for their employees, which
provides great incentives for managed care plans to accurately track and
seek to improve quality measures. The article also provides a strong analysis
of the factors that contribute to a successful quality management program.
Among these factors are a clear mission and goals, strong leadership, and
effective planning. The importance of each step is described in detail
to allow the reader to understand the components of a successful quality
management program.
Rating ****
Managed Care and The Quest for Quality Measures
This article, which appears in The Journal of Managed Care Pharmacy, addresses the current state of quality assessment initiatives in managed care. The most dominant player in this arena has been HEDIS, the Health Plan Employer Data and Information Set. This tool, developed in the early 1980's and maintained and updated by the NCQA, is used by about 90 percent of the health plans in the country. But it is generally agreed that it is very difficult, or even impossible, to create a perfect quality measurement tool for managed care. As a result of this, other tools have been developed in recent years to address the same problems. The Foundation for Accountability (FACCT), established in 1995, has developed its own system for measuring quality. While HEDIS and FACCT were both developed to measure quality of care in managed care organizations, they have taken different approaches. HEDIS takes a more population-based view of quality, including the effectiveness, access to, and satisfaction with care, and patient use of services. On the other hand, FACCT has focused on the use of patient-centered outcome measures that look at specific conditions in more detail. While it is likely that these two systems will compete in the future, neither represents the ideal barometer of managed care quality. It may be that each system of measurement may provide data that is more useful to some groups than others, and that in the future, tools will continue to be specialized to those who demand the information. Rating***
This is a very comprehensive study compiled by the SPRY Foundation (Setting Priorities for Retirement Years). It provides a strong background and introduction explaining the importance of quality measures in managed care, especially for the elderly, who will be transitioning from fee-for-service to managed care in great numbers in the upcoming years. The report itself is based on a literature review conducted by the staff of SPRY, as well as a series of interviews with individuals representing the six key players in this arena: purchasers/payers, consumer groups, HMO's, professional/trade organizations, think tanks, and private foundations. From the information gathered, SPRY provides a detailed analysis of many of the tools now in existence to measure quality in managed care. It then analyzes the concerns that exist in this area and that must be addressed in future programs. The study concludes that there is still much work to be done, especially regarding quality measures as they apply to seniors, but it also admits that the process is a massive undertaking that is extremely complex. There remains hope that future improvements will help improve the existing system. Rating *****
| Note: The information below may contain additional relevant materials and documents. Some of the information may be duplicative. The evaluations depend on the both the student doing the review and the information contained at the time of the review. Sites are subject to change! |