Ensuring Quality Health Care

Efforts to Ensure Quality Care

The Health Plan Perspective

Many of the sessions in this workshop have addressed the necessity of making the health plans an integral part of the quality assessment and improvement process. This session discussed the issues concerning quality from the health plan perspective.

Even before managed care became prevalent, quality of care problems existed, such as the over utilization of certain treatments and the under utilization of others. A number of important issues that health plans must address in improving quality were discussed. These issues included:

• Measurement issues and related data problems.
• The identification, assessment, and application of potentially effective interventions.
• The challenges associated with dealing with factors such as mobile populations and inconsistent regulatory requirements across jurisdictions.

A number of areas in which health plans have made progress in improving quality were described, such as:

• Preventative care (e.g., identifying children requiring immunizations).
• Acute care (e.g., treating peptic ulcer disease effectively).
• Chronic care (e.g., intensive case management for diabetes patients)
• Service (e.g., telephone help lines).

Factors were presented that would promote continued quality improvements, including:

• Improved information systems and data standards.
• Purchasers placing an emphasis on quality.
• Increased regulatory responsibility.
• The development of appropriate risk adjustment measures.

References

Siberman P. Ensuring Quality and Access in Managed Care: How Well Are We Doing? Quality Management in Health Care 1997;5(2):44-54.

Bodenheimer T. The HMO Backlash-Righteous or Reactionary? New England Journal of Medicine 1996;335(21):1601-4.

Mariner WK. State Regulation of Managed Care and the Employee Retirement Income Security Act. England Journal of Medicine 1996;335(26):1986-90.

Jewitt JH, Hibbard JH. Comprehension of Quality of Care Indicators: Differences among the Privately Insured, the Publicly Insured, and the Uninsured. Health Care Financing Review 1996;18(1):75-94.

Young G.J. Bridging Public and Public Sector Quality Assurance. Quality Management in Health Care 1997;5(2):65-72.

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