Term Paper on "Health Care Quality Management"

Term Paper 10 pages (3838 words) Sources: 1+

[EXCERPT] . . . .

Lessening the number of staff in an organization concentrates on health care professionals and administrative staff and plans to advance efficiency while diminishing pay expenses. Case management strictly watches each individual patient's improvement with the aim of making sure effective use of resources in the limited period of time. (Morgan, 1996)

Thus from what we have understood, managed care is often viewed mainly as a cost cutting scheme tussle to establish to the people at large that managing quality is as essential as managing costs. (Carefoote, 1998) Due to this the assessing and guarantee of the quality of care in managed care settings has turned out to be a main concern. Government agencies, nonprofit organizations, and consumer groups have all started to concentrate on the two main features of this matter, measurement and improvement. The measurement efforts are developing tools, gathering data, determining pointers of health care quality, examining the data and reporting it. After this is done, measures must be taken to assure that the quality of care is up to par, and to make developments, wherever needed, by education plans. Information on the quality of care offered under managed care plans is helpful to customers and owners when trying to select the best plan to buy, and also to plan to find out where developments have to be made. (Quality Measurement and Improvement in Managed Care)

In a newly published article, Jan Greene raised doubt on whether managed care has lost its spirit or not. In that article Greene remarks that managed care was once occupied by non-profit organizations with a communal undertaking. Currently managed care is mainly governed by profit-oriented organizations staring at Wall Street for investment. A lot of persons dread that the objective of managing care is being substituted by the objective of managing expenses. Likewise distressing is that profit-oriented managed care organizations have a lawful and fiduciary duty to put stockholders and not payers or consumers first. Additionally, new inclination that move the financial threat to suppliers through capitation or other systems that compensate suppliers for competence concurrently offer suppliers a financial incentive to hold back required care.

These are just some of the reasons why managed care organizations have encountered a sequence of assaults with respect to the quality of care that they offer. With these quality awareness issues as a background, controllers, creditors, employers and consumers alike are introducing increasing responsibility on managed care organizations to noticeably and publicly tackle quality. (Carefoote, 1998) Are managed care organizations really appreciating the exclusive needs of the susceptible populations that depend on Medicaid? How can quality be guaranteed, particularly when consumer option is limited? These are some of the many issues states and the federal government has wrestled with particularly as the movement to managed care expands beyond mothers and children and includes Medicaid recipients who are older and have disabilities.

Nowadays, above 32% of all Medicaid beneficiaries are registered in managed care, an amazing growth from the 9.5% registered in 1991 quality Management

http://www.nursingworld.org/ojin/tpc2/tpc2_4.htm

. All but six states have produced managed care programs, with 32 states reporting programs based on risks. Fast growth in registration of Medicaid beneficiaries into a range of managed care preparations brings up a further anxiety about quality of care. Eventually, the real suppliers of care can best encourage good quality health care. Encouraged by the achievement they observe in managed care for women and children, states are bending to managed care delivery systems for older persons and persons with disabilities. States expect to have the similar understanding in supporting better access and quality while limiting costs. While it is too soon to wrap up whether managed care is an efficient delivery system for these more susceptible populations, initial understanding implies that design features of most state systems for women and children are inadequate to check the special needs of older persons and persons having disabilities. (Booth, 1997)

We are already studying that quality management system for programs helping more susceptible populations, such as elders and persons with disabilities, must use a different lens to its actions. A system must be built which is competent to assess program performance where very small complete standards of care exist and where quality of life deliberations may be as important as those connected to quality of care. These show new viewpoints for a state Medicaid agency and expect a new set of skills and know-how. Increasingly, states are studying that quality oversight cannot be a remote activity but needs that other state agencies, community organizations, advocacy groups, consumers, and suppliers become important partners in the quality management process. (Booth, 1997)

For the health insurance market, managed care schemes are a considerable and increasing share. As managed care combines financing with service delivery, supervising quality and access to health care within individual schemes is very vital. Several of this can be done by official appraisal of clinical quality using medical records, administrative systems, or similar information. But, these sources are not compatible to measuring the awareness of health plan customers. For recognizing consumer viewpoints, surveys are a helpful device, offering more methodical data to balance information from complaint systems and other sources of consumer feedback. Consumer reviews are getting increased focus as a component of Total Quality Management and Continuous Quality Improvement to improve quality of care and service.

Though some disagreement stays alive about the role of consumer information in monitoring quality, most researchers, policymakers, and managers accept that consumer satisfaction is a significant gauge of quality and, hence, of system and health plan performance. But, as many of these applications are ready, they are badly recognized in the published literature, which is a weakness. As more of the population registers in managed care, there has been an enhanced policy focus on use of consumer satisfaction surveys to offer information to purchasers and consumers to aid them in making selections among procedures. (Gold; Wooldridge, 1995) In a review carried out by the federal Agency for Health Care Policy Research and the Kaiser Family Foundation, health care consumers affirm that quality is their biggest concern in selecting among managed care procedures. But, health care consumers are not comfortable with quality information formed by independent organizations, and even when they have seen these pointers, keep on depending on personal advices. Consumers evaluate quality by the personal advices of their doctors, family and associates. (Rivera; Lee, 1999)

Even then, as per the study, Americans affirm that having quality of care information, like, how well an arrangement cares for members who have health problems, easiness of receiving needed care, and achievement at early disease detection, is very significant to them when selecting a health preparation. Those that have seen relative quality data consider that there are large dissimilarities in quality across health plans. These points to the requirement for health care consumer education to enhance consumer knowledge about and assurance in dependable quality information and data. Quality information will in no way be the only factor consumers think when they make options. Other aspects comprise cost, continuity with particular doctors or hospitals, and specific advantages. But reachable and comprehensible quality data are necessary if consumers and purchasers are to hold suppliers answerable. (Rivera; Lee, 1999)

There are various influences motivating managed care organizations to give specific attention to the quality of care and service they offer. The remarkable thing is that independently any one of the influences would have an effect on the quality of care and services offered by a managed care organization, but together, their effect has been major. Parisi and Silberman have done a superior job at delineating the activities that are pushing the quality development in managed care. Here are just a few of the pushers influencing the new alterations: The states normalize Health Maintenance Organizations -HMO and other types of managed care typically through their department of insurance. The U.S. Department of Health and Human Services also has the liability for managing particular Managed Care Organizations -MCO embracing federally qualified HMOs and those procedures registering Medicaid or Medicare enrollees. (Carefoote, 1998)

Though it is not essential for managed care organizations to acquire an orderly certification, the rivalry from other certified organizations is forcing them to do so. There are three major forces in the field of voluntary accreditation, namely The National Committee on Quality Assurance -NCQA, the Joint Commission on Accreditation of Healthcare Organizations -JCAHO, and the Utilization Review Accreditation Commission-URAC. The Health Employer Data and Information Set -HEDIS has more than 60 performance measures and is a popular marker of excellence in managed care today. At present NCQA has the accountability for HEDIS. HEDIS was intended to offer MCOs with a uniform reporting system for recognizing quality enhancement indicators. With this MCOs can trace their functioning over a period of time.

Likewise, HEDIS also offers owners and buyers of health care with significant facts for evaluating the worth of… READ MORE

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