Armstead, Rodney C

Armstead, Rodney C., Elstein, Paul, & Gorman, John. (1995, Summer). Toward a 21st century quality-measurement system for managed-care organizations. Health Care Financing Review, 16(4), 25-37.(13)

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Subjects: Managed care plans (Medical care): Standards

Medical care: Quality control

United States Health Care Financing Administration: Standards

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Author's Abstract: COPYRIGHT U.S. Department of Health and Human

As the Nation's largest managed-care purchaser, the Health Care Financing Administration (HCFA) is working to develop a uniform data and performance-measurement system for all enrollees in managed-care plans. This effort will ultimately hold managed-care plans accountable for continuous improvement in the quality of care they provide and will provide information to consumers and purchasers to make responsible managed-care choices. The effort entails overhauling peer review organization (PRO) conduct of health maintenance organization (HMO) quality review, pilot testing a new HMO performance-measurement system, establishing criteria for Medicaid HMO quality-assurance (QA) programs, adapting employers' HMO performance reporting systems to the needs of medicare and Medicaid, and participation in a new alliance between public and private sector managed-care purchasers to promote quali

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viders alike with the data they need to make informed, accountable choices. HCFA is engaged in a number of collaborative projects with other purchasers and the managed-care industry toward that end. As there is wide agreement that HCFA's current system of QA for MCOs is not currently meeting these goals, it is worth examining the system to understand how it must be reinvented. MEDICARE Internal QA Medicare-contracting HMOs are required to have an internal quality-assessment and improvement (QAI) program. In addition, those that receive risk-based payment are subject to additional external quality review of the care they provide. The QAI program involves the following: * An ongoing program evidenced by: a written plan describing the structure, responsibilities, types of activities, and specific quality-improvement projects for the coming year; a committee of practicing physicians and other representative practitioners with the commitment of adequate resources, including staff; and board accountability for the QAI program. * An approach that stresses health outcomes, covering the entire range of care provided, and that examines the effects of provider compensation and incentive arrangements to ensure that appropria

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