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10 Cards in this Set
- Front
- Back
Reasons why QM is important
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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 |
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Possible Sources of Data to use for measuring health plan performance
See General –Data Sources for a consolidation of this list with similar topics. |
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 |
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TYPES OF QUALITY ASSURANCE (QA) MEASUREMENTS
Structure criteria |
(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. |
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Process criteria
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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. |
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Outcome Criteria
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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 |
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Peer Review
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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 |
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Appropriateness Evaluation
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(Appropriateness of Utilization / Resource use)
Used for: Elective procedures very-high-cost procedures controversial procedures |
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Cost and Financial measures
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cost components
reimb methods, cost-shifting. |
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THE MODERN QM MODEL
New ideas in QM: |
Systems thinking
Identify key customers Meet the needs of consumerism Define “Quality” |
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The Steps in Modern QM
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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. |