Are you ready to work in a managed care-dominated environment?
Quality professionals face new challenges, job changes
Managed care is changing the rules in health care quality, and your role as a quality professional is changing accordingly. The organization that accredits the quality profession recognizes these changes, and is adjusting its requirements to take the new situation into account. (See article on the changing CPHQ examination, p. 174.)
A lot of what managed care plans are being graded on follow-up care, for example comes from quality professionals on the provider side. "There’s a fair amount of variation from health plan to health plan," says Sharon Ricciuti, RN, manager of quality measurement and research for Santa Ana, CA-based PacifiCare Health Systems, a group controlling 18 Medicare managed care organizations nationwide. "But the clinical care management coming out of hospitals drives the appropriateness of the performance measures we look at."
Plans rely on hospitals’ coding and submission of information. "We’re all part of this health care continuum, and we rely upon the information we get from quality professionals in hospitals," says Ricciuti. "We’re frequently capitated for hospital services, so we depend upon the facilities for claims data, including complete ICD-9 coding for diagnoses and procedures. All that information feeds our systems so we can generate and apply the HEDIS [Health Plan Employer Data and Information Set] specifications." HEDIS is a set of quality and utilization measures developed by the National Committee on Quality Assurance (NCQA) in Washington, DC.
Take, for example, the measure required by the federal Health Care Financing Administration (HCFA), based in Baltimore, regarding administration of beta-blockers to discharged patients diagnosed with acute myocardial infarction. "That information comes from hospital data," says Ricciuti. "As a health plan, we look through hospital claim information to identify individuals who meet that diagnostic criterion. They have to have appropriate ICD-9 diagnosis codes and discharge statuses."
Soon you’ll have baseline information on the Medicare managed care measures that HCFA is interested in. The agency is about to release its Medicare HMO quality report that will, for the first time, assess the performance of more than 250 HMOs nationwide.
"Hospital quality staff have to be aware of what managed care requirements are," warns Judy Homa-Lowry, RN, CPHQ, director of quality improvement for the Delta Group in Greenville, SC, and a member of the Hospital Peer Review editorial advisory board. "Relationships among all those people in the continuum are not always as good as they can be."
HCFA requires all Medicare-participating managed care plans to have utilization review (UR) programs. As of January 1997, the agency has required that data be reported using HEDIS 3.0. (See related story on MCO quality, p. 180.)
The performance indicators measured by HEDIS 3.0 include four quality of care categories and 11 utilization of services areas. The quality of care measures are the rates at which each plan provides breast cancer screening, beta-blocker treatment after heart attack, eye exams for diabetics, and follow-up after inpatient mental health treatment. The utilization categories measure the frequency with which plan members undergo surgical procedures including cardiac catheterization, angioplasty, coronary artery bypass graft, carotid endarterectomy, prostatectomy, partial excision of large intestine, hysterectomy, and total knee and hip replacements. (See related story on NCQA’s assessment of a selection of these, p. 180.)
When HCFA releases its data to the public, not only will you have valuable benchmarking information, but Medicare beneficiaries will be provided with data so they can compare plans. In addition, managed care organizations (MCOs) themselves can use the data to identify areas for quality improvement.
Quality staff: Scrutinize your contracts
Make sure your staff is up to date on details of all your hospital’s MCO contracts. How you get paid depends on your hospital’s reimbursement agreement. "Look at the current financial incentives in each of the contracts," says Patrice Spath, ART, a health care consultant in Forest Grove, OR, and Hospital Peer Review’s consulting editor.
The UR staff must understand your facility’s financial arrangement under each contract. "If your facility has signed a risk-sharing capitated contract, and you’re receiving, for example, $20 per member per month, you may need to process bills and go do UR on skilled nursing facility patients. You’re responsible for paying for that," says Spath.
Under a risk-sharing capitated contract, your goal is to provide quality patient care at the lowest cost. To accomplish this, patients should be in the hospital using hospital resources as little as possible.
If your hospital has a Medicare managed care or Medicaid contract specifying per diem payment, you are not paid until the patient is in the hospital. But your goal is to keep them there for as short a period as possible because there’s typically a cap on the per diem. Other Medicare HMO arrangements specify a DRG payment, and your responsibility is to be efficient on the hospital side.
Look proactively at your marketplace
MCO requirements must be integrated into your quality endeavors. Look carefully at your facility’s relationships with outlying clinics and physicians’ offices involved in managed care as well. "If your integration is good," Homa-Lowry notes, "contracts, reimbursements, or relationships should not be of issue. If, however, there has been trouble potential elimination from a program either because of competition among physicians or compliance problems from the medical staff quality managers have to get involved and make sure things run smoothly."
For example, if Kaiser Permanente of Oakland, CA, is one of your organization’s participating MCOs, its benchmark for C-section rates must be considered when analyzing your outcomes.
"You have to look at those report cards and make sure your figures measure up to them," says Homa-Lowry. The consequence of not measuring up can be loss of a contract, as well as exclusion from consideration for others coming down the pike. "A quality manager’s involvement with the managed care manager varies," she continues. "It depends on how the quality department is structured. Some facilities still have fragmented, decentralized models."
The degree of integration has to do with how deeply managed care has penetrated your organization. "But even some small hospitals with minimal penetration know they have to get aggressive in keeping their eyes on that environment," explains Homa-Lowry, "and are acting proactively to prepare themselves so they can stay competitive in the market."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content