Quality Improvement in a Primary Care Case Management Program
Walsh, Edith G., Osber, Deborah S., Nason, C. Ariel, Porell, Marjorie A., Asciutto, Anthony J., Health Care Financing Review
Quality monitoring and improvement are important activities in MCOs, intended to promote medical care consistent with clinical guidelines or address consumer satisfaction issues. While it is common for MCOs to use a variety of approaches to quality monitoring and improvement, the use of these techniques in a Medicaid primary care case management is unusual. Since 1995, the Massachusetts Medicaid Program, MassHealth (administered by the Massachusetts Division of Medical Assistance [DMA]), has implemented policies and procedures in its PCC plan that emulate MCO quality monitoring and improvement practices, including profiling individual primary care practices. Given the problems States have had attracting or retaining MCOs in the Medicaid market, it is valuable to understand what may be transferable from this program to other States, as well as the associated challenges and limitations to the Massachusetts approach. In this article we summarize issues regarding the use of physician profiling as a quality monitoring and quality improvement (QM/QI) technique, describe key aspects of the MassHealth primary care profiling activities, and report on provider perspectives. We also discuss the limitations associated with the use of claims-based data for profiling and the implications for the appropriate use of these data.
Issues in QM/QI
The literature regarding QM/QI in health care focuses on several themes including: defining aspects of quality, the relative value and availability of process and outcome measures of quality, and approaches to changing physician behavior as the crux of improving quality of care. The Institute of Medicine defines quality of care as "... the degree to which health service for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge." Deficient aspects of care are typically the reason for monitoring physicians' practice patterns. Three classes of process measures are typically reported in the medical literature: (1) patients not receiving beneficial care, (2) receipt of unnecessary treatments, and (3) poorly performed interventions (Becher and Chassin, 2001).
Quality of care can be measured either by looking at the process of care (i.e., the delivery of recommended procedures), or at health outcomes (i.e., morbidity and mortality rates). While positive health outcomes are the ultimate goals of care, outcome measures are difficult to develop and interpret, and can be affected by exogenous factors such as the short eligibility periods common in a Medicaid Program. Process measures may be more useful and attainable for several reasons. Process measures dearly indicate which processes a clinician did or did not follow, in realms in which clinicians feel accountable. The information from process measures is "actionable," i.e., the provider can do something about improving processes of care (Rubin, Pronovost, and Diette, 2001). Case-mix adjustment, which can be challenging, is not as relevant for process measures as for outcome measures. Indeed, differences in the delivery of preventive or screening services by patient characteristics (e.g., age, sex, or comorbidities) are relevant information that should not be case-mix adjusted out of process analysis. While there may be some technical challenges to defining the eligible population in process measurement, the challenges are not as great as the case-mix adjustments necessary for meaningful health outcome measurement (Mant, 2001). Furthermore, measurable processes of care occur more frequently (e.g., annual rates of immunization) than specific health outcomes that might derive from the process of care (e.g., cases of whooping cough resulting from missed immunizations), as well as being "immediate, controllable, and rarely confounded by other factors." (Eddy, 1998).
Improving quality of care boils down to changing physician behavior. …