Sutton J, Milet M; Academy for Health Services Research and Health Policy. Meeting.

Abstr Acad Health Serv Res Health Policy Meet. 2001; 18: 121.

Center for Health Affairs, Project HOPE, 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814, Phone: (301) 656-7401, Fax: (301) 654-0629, E-mail: jsutton@projhope.org

RESEARCH OBJECTIVE: The objective of this study is to gather descriptive information on the types and nature of quality-related provisions that are currently contained in HMO physician and hospital participation contracts.STUDY DESIGN: This project was designed as an exploratory study. Project staff reviewed representative primary care, specialty care, and hospital contracts from a 50 percent random sample of licensed HMOs in five states -California, Pennsylvania, Illinois, Kentucky, and North Carolina. These states were selected because of their geographic diversity, diversity in their managed care regulatory environment, and because each of these states statutorily requires licensed HMOs to submit copies of provider agreements to a state managed care regulatory agency. Using information obtained from peer reviewed and managed care trade literature, as well as a review of various health plan provider manuals, project staff developed an organizational framework of quality-provisions, to guide the contract review process. The quality-related statements contained in individual contracts were arranged logically along the dimensions of this organizational framework. Upon completion of this study a total of over 100 health plan provider contracts will have been reviewed.POPULATION STUDIED: Nearly 60 licensed HMOs in five study states were included in the sample. HMOs studied varied by model type (e.g., IPA, network, and group), profit status, accreditation status, and market share.PRINCIPAL FINDINGS: Preliminary results suggest that the types of quality provisions that are contained in HMO provider agreements may be grouped into several groups including provisions to: (1) promote structural quality, (2) promote access and availability of services, (3) promote technical quality, (4) evaluate provider and plan performance, (5) transfer quality data, (6) reward or sanction performance, and (7) protect providers engaged in the health plan's quality activities.CONCLUSIONS: Tentatively, it appears that HMO strategies to manage providers' quality of care through the contractual relationship may focus on ensuring that providers meet structural and process requirements as opposed to "outcome" standards.IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: For health plans to successfully meet designated standards of quality established by accrediting bodies and large purchasers, they must ensure that their network providers also achieve designated standards of quality. The findings of this study are expected to provide information that may be used to further examine the relationship between the quality requirements that health plans impose on providers and plan performance, as measured through various venues, including health plan "report cards".PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality

Publication Types:

• Meeting Abstracts

Keywords:

• Accreditation
• California
• Contracts
• Health Facilities, Proprietary
• Health Maintenance Organizations
• Health Services Research
• Illinois
• Kentucky
• Managed Care Programs
• North Carolina
• Pennsylvania
• Physicians
• Primary Health Care
• State Government
• economics
• hsrmtgs

Other ID:

• GWHSR0001719

UI: 102273395

From Meeting Abstracts