Ensuring Quality Health Care

Quality Assurance for Special Populations

This session discussed both the importance of, and the challenges associated with, the development of measures to assess the quality of care provided by managed care organizations to special populations, such as:

• Medicaid recipients.
• Children with special health needs.
• People with chronic illnesses and the disabled.

There are several reasons why these and other special populations are likely to encounter greater obstacles in receiving appropriate care, and as a result, will require system performance measures beyond those of the general population. These reasons include the diversity and complexity of the health and social needs of these populations, as well as the difficulties of coordinating care for those dually eligible for Medicare and Medicaid.

The building blocks for a sound quality management approach that addresses the needs of these special populations were discussed. These key features included the development of:

• Appropriate performance measures. (Specifically, the presenter highlighted measures geared to chronic conditions that had been or were being developed by key quality measurement organizations.)
• Contract specifications that articulate States' expectations of health plans with respect to these special populations.
• Quality systems that, among other things, clearly identify goals, engage and empower beneficiaries, include appropriate benefits and sufficient access/network capacity, provide for adequate reimbursement, and include enrollment and educational support.

References

National Academy for State Health Policy. Quality Improvement Strategies for Risk-Based Contracting, Attachment B, January 1997.

National Academy for State Health Policy. Quality Improvement Strategies Primary Care Case Management Programs (PCCM), Attachment C, January 1997.

National Academy for State Health Policy. Federal Barriers to Managed Care for Dually Eligible Persons: Differences in Federal Risk Contracting Requirements for Medicaid and Medicare, Attachment D, Page 1, August 1997.

National Academy for State Health Policy. The Quality Improvement System for Medicaid and Medicare Managed Care (QISMC), Fact Sheet and Mission Statement, 1997.

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