Monitoring and Evaluating the Delivery of Services under Managed Care

By Hadley, James P.; Wolf, Linda F. | Health Care Financing Review, Summer 1996 | Go to article overview

Monitoring and Evaluating the Delivery of Services under Managed Care


Hadley, James P., Wolf, Linda F., Health Care Financing Review


The Spring 1996 issue of the Health Care Financing Review focused on articles dealing with challenges and recent developments in paying managed care organizations. This issue, "Service Delivery in an Evolving Managed Care Environment," extends the discussion to monitoring and evaluating the services delivered by MCOs. As reflected in the range of this issue's articles, monitoring and evaluating service delivery is extremely important for a variety of reasons. It allows managed care's impacts on costs and utilization to be assessed and allows for an examination of the adequacy and accuracy of payment mechanisms. Perhaps the most important reason, however, is to assure the adequacy of the quality of care and access to care provided by the plans.

As the number of beneficiaries enrolled in managed care plans has increased, the Federal Government has worked closely with States, insurers, health care professionals, and consumers to assure access to care and the quality of the care provided in MCOs serving Medicare and Medicaid beneficiaries. Some current examples of these initiatives are:

* Medicaid Health Plan Employer Data Information Set (HEDIS) was developed in partnership with the National Committee for Quality Assurance to provide States, managed care plans, health care professionals, and consumers with the information and tools they need to assure high quality in managed care plans serving Medicaid beneficiaries, Medicaid HEDIS adapts the commercial sector's health maintenance organization (HMO) performance measurement system to use with the Medicaid population. Medicaid HEDIS was released to the States in February 1996.

* Medicare HEDIS is a parallel effort developed by HCFA in partnership with the Kaiser Family Foundation and in consultation with the managed care industry. It establishes a performance-measurement system designed to provide important monitoring information while minimizing reporting burdens on managed care plans. Medicare HEDIS is expected to be implemented in early 1997.

* The Foundation for Accountability (FAcct) is a collaboration of private and public health care purchasers (including HCFA) and consumer groups working to develop outcomes measures that will allow comparison of the quality of care delivered in managed care settings to that provided in fee-for-service (FFS) settings. Information will be released later in 1996.

* Quality Assurance Reform Initiative (QARI) is a collaborative effort by HCFA, States, the managed care industry, consumer advocates, and others to design and test practical and credible approaches to monitoring and improving the quality of Medicaid managed care services.

* The Medicare Managed Care Quality Improvement Project is being conducted through a contract with the Delmarva Foundation for Medical Care. The purpose of this project is the development of performance measures to be used in overhauling the external peer review of HMO contractors and promoting quality improvement in Medicare managed care. These measures are currently being tested in five States. Results of this test are expected in Spring 1997.

* The HHS Interagency Managed Care Forum is chaired by HCFA Administrator Bruce C. Vladeck and Assistant Secretary for Health Philip R. Lee, M.D., and is made up of representatives from operating and staff divisions of the Department of Health and Human Services. The forum meets regularly to share information concerning ongoing managed care activities and to coordinate managed care policy on cross-cutting issues before the Department. Managed care quality is a top priority for this group.

These initiatives focus primarily on monitoring quality. Quality monitoring is stressed here because it is perhaps one of the most important activities to pursue as the number of beneficiaries in managed care systems increases. Managed care has the potential to provide excellent quality care because of its ability to coordinate care provided to patients, reduce unnecessary hospitalizations and treatments (with a potential for a corresponding decrease in iatrogenic illness), and provide primary and secondary preventive services. …

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