Mc-Chpt 30 Quality Mgmt (Qm) In Managed Care

Front 1

Reasons why QM is important

Back 1

 Managed care is under scrutiny
 Patients' rights laws
 Rise of consumerism
 To make sure cost cuts don’t cause quality cuts
 To make up for patients’ restricted choices in an HMO
 Reimb methods may tempt providers to deny care
 to prevent Lawsuits

Front 2

Possible Sources of Data to use for measuring health plan performance
See General –Data Sources for a consolidation of this list with similar topics.

Back 2

 Claims and Utilization data
Adv:
 electronic
 cheap
 100% sample
Disadv:
 poor accuracy/completeness of coding

 Medical Records
Adv:
 Accurate & complete
Disadv:
 Paper  costly to transcribe
 a doctor’s chart only has info from one doctor at a time.
whereas a claim form could combine multiple providers

 Patient-reported data
Adv:
 Most “cognitive” measure
 patients can report on various sources of care
Disadv:
 Influenced by form of survey
 Recall is limited

 Population Exposure data from Employers
Adv:
 Shows which employees did not have a claim
Disadv:
 poor recordkeeping

Front 3

TYPES OF QUALITY ASSURANCE (QA) MEASUREMENTS
Structure criteria

Back 3

(MCO's ability to provide the services it intends to)
 Credentials
 Licensing
 Safety standards
 Recordkeeping

Advantages of Structure Criteria:
 Ease of documentation and checking
 Credentials can be purchased from the State databases.

Disadv:
 Only shows minimum standards; does not differentiate beyond that.

Front 4

Process criteria

Back 4

 Number of referrals
 Number of health screenings
 follow-up calls
 Clinical algorithms used
 access (driving time; provider-to-member ratio)
 Turnover rates
 compare to national benchmarks

Disadv:
 must link Process to Outcome
 Timing of screenings is not recorded.

Front 5

Outcome Criteria

Back 5

Indicators of Poor Quality of care:
 Unscheduled surgery
 Complications
 Deaths, Morbidity, Infection
 Poor discharge planning
 Readmission


Disadv:
 Don't reflect the cause of the poor performance
 Info systems might not [want to] screen for these events

Front 6

Peer Review

Back 6

Compare a provider's practice with:
 The peers' practice
 A standard benchmark

Disadv:
 Conformance with standards does not mean that care was good
 lack of consistency of peer group's decisions

Front 7

Appropriateness Evaluation

Back 7

(Appropriateness of Utilization / Resource use)

Used for:
 Elective procedures
 very-high-cost procedures
 controversial procedures

Front 8

Cost and Financial measures

Back 8

 cost components
 reimb methods, cost-shifting.

Front 9

THE MODERN QM MODEL

New ideas in QM:

Back 9

 Systems thinking
 Identify key customers
 Meet the needs of consumerism
 Define “Quality”

Front 10

The Steps in Modern QM

Back 10

 Understand Customer Need
 External customers, Internal customers, Suppliers
 Be proactive
 use Customer Satisfaction Surveys
 use Focus groups

Signs of Member Dissatisfaction:
 poor Enrollment rates
 out-of-network utilz

 Identify processes that would meet customer need
 Prevention/wellness
 Service Quality
 Implement Improvements
 Practice Guidelines
 Consumer Education
 Assess and Monitor performance; compare with professional or best-in-class standards
 Provide feedback to providers and customers

Done.