Accountability for quality in managed care

BACKGROUND: It is often difficult to understand where responsibility lies for monitoring and improving quality in managed care. From 1996 through 1998 a group of individuals convened by the Institute of Medicine's (Washington, DC) National Roundtable on Health Care Quality developed a model of accountability for the quality of care provided by managed care organizations (MCOs). Each of three overarching forms of accountability (professional, market, and regulatory) has a set of tools for imposing accountability and-because accountability relationships are not self-enforcing-sanctions for failures of accountability. PROFESSIONAL ACCOUNTABILITY: Fiduciary relationships in medicine are an essential part of any quality accountability mechanism, and it will be important to maintain the strength of the professional model in the changing health care system. Yet it is not easy to preserve the strength of the professional model in an MCO environment in which professionals are not dominant, and there is likely to be increasing pressure to weaken their autonomy. MARKET ACCOUNTABILITY: The primary assumption of market accountability is that consumers will select options based on perceived value to them and will make new choices based on their information and experience. Market accountability requires choice among competing providers and information to inform choice. In health care, however, individuals rarely have the information they need and often do not have choice. Accountability for quality generally has not been a major feature in contracts. REGULATORY ACCOUNTABILITY: There is a widespread perception of defects in a market-based health care system. Many believe there is a need for a regulatory structure to correct market failures. The use of regulation to impose accountability for quality requires that a regulatory framework, penalties for violations, and effective enforcement mechanisms are all established. PUBLIC GOODS: The model of accountability for quality in managed care does not promote public goods such as education, research, public health, or care for the uninsured. Indeed, the locus of responsibility to the community when markets fail to supply these public goods is controversial. Nevertheless, such responsibility should be considered by MCOs and policy makers. COLLABORATION TO IMPROVE QUALITY OF CARE: Given market-driven models of health care financing and delivery, it might be feasible and desirable to encourage collaboration among MCOs to improve quality, whether at the national or local market level. The health professions in general, and the medical profession in particular, are and must be accountable to society for providing leadership in the development of knowledge about effective medical care, in defining high-quality care, and in advocating for and improving the quality of care. CONCLUSION: Establishing effective accountability for quality involves multiple entities and many different kinds of accountability relationships. The three forms of accountability interact, and all operate at once.     

Protecting patient welfare in managed care: six safeguards

The public is very suspicious and fearful that managed care threatens their health because of its interest in reducing costs. Because physicians' decisions control 75 percent of all health care spending, managed care organizations are focusing their cost-cutting strategies on influencing physician decision making through financial incentives and guidelines. These two techniques have had some important contributions, especially in enhancing efficiency and standardizing care to a high level. Nevertheless, they pose a threat--and are perceived by the public to pose a threat--to patients' health and well-being. How can we mitigate the threats to patient welfare posed by financial incentives and guidelines? We propose and analyze six safeguards. These safeguards are not an attempt to revive the fee-for-service system, but an effort to make managed care ethical and to focus it on improving patient welfare. They are designed to work together to ensure that patient welfare remains the primary focus of managed care organizations; they try to create institutional structures that emphasize quality over mere cost reductions.     

Experienced anesthetists show better reaction to central gas supply dropout--an anesthesia simulator study

The reform process underway within the Italian National Health System is aimed at making decision makers responsible for appropriate and efficient resource utilisation and at ensuring quality of care, eliminating conflict between fairness, quality and cost control. The risk for the quality of the services provided entailed by resource rationalisation is avoidable and controllable. This article explains how the Italian NHS has managed the reform process assuring quality improvement, and describes the policy and the tools adopted. As well as involving all players and the system as a whole in constant improvement, the Italian NHS's policy in pursuing quality of care is based on the adoption of a wide range of measures: measurement of health care and of clinical outcomes, systematic data collection, team work and protocols. The tools adopted, currently under implementation, to support quality control are: an integrated system of indicators for measuring efficiency and quality of NHS structures (demand and accessibility indicators, resource related indicators, activity indicators and result indicators); compulsory accreditation as a prerequisite for health care providers; a system to monitor and control the effects of the new prospective payment system; clinical guidelines (each related to a specific clinical problem); a menu of services (Carta dei Servizi) released by all NHS accredited service providers with full information and warranties regarding the services provided and their quality.     

Beyond managing Medicaid costs: restructuring care

The apparent success of managed care plans in controlling medical costs has made the prospect of managed care for Medicaid recipients attractive for state health policy makers. However, because the principles upon which managed care was created do not apply to the most costly segments of the Medicaid population, efforts to address their needs through traditional managed care strategies are likely to be self-defeating. The Maryland Medicaid database was used to review and analyze the successes and failures of managed care Medicaid initiatives to date. This review led to the suggestion that the integration of specialized systems for specific subgroups of the Medicaid population into managed care, in conjunction with broader public policies, could lead to improved quality and lower costs.     

Managed care: rationing without justice, but not unjustly

Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The collision of economics and politics in Medicaid managed care: reflections on the course of reform in Maryland

One of the most dynamic areas of health policy is the transition of Medicaid programs to managed care and market competition. Maryland has been a leader in this trend, initiating three different systems of managed care for the Medicaid population during the 1990s as it searched for an ideal plan. The Maryland experience illustrates the complex new demands that policy makers are facing. Health plans are expected not only to deliver budgetary savings, but also to improve the quality of their services and guarantee a place for safety-net providers in their delivery systems. As a result, there is a sizable gap between the original savings projected for the new Maryland system and its actual capacity for cost containment. The apparent collision between economic assumptions and political realities, however, may point the way to a constructive synthesis--a form of managed care that balances economy with important community, professional, and personal values.     

Rapid detection and counting of viable bacteria in vegetables and environmental water using a photon-counting TV camera

A physical, cognitive, or mental disability presents significant challenges to an individual in gaining access to a coordinated program of preventive, primary, and secondary health care services. This article describes the health care needs of people with disabilities and discusses how the financial incentives in managed care may threaten access to the health care services they need to maintain their health and functional independence. We argue that despite the shortcomings of present models, managed care has the potential to improve the health care of people with disabilities. Moreover, as health plans become increasingly accountable to consumers (and begin to compete on the basis of quality), they will not be able to ignore the distinct health care needs of people with disabilities.     

Measuring organizational readiness for nursing research programs

Nursing research programs are important innovations for health services organizations (HSOs). Evidence supports the positive impact that successful programs have on both clinical practice and patient outcomes. In the current era of scarce health care resources, decision makers must be able to accurately judge HSO readiness for nursing research programs to facilitate their success. Judging innovation readiness is an important and complex process for decision makers. An Innovation Readiness Scale (IRS) was developed from research-based HSO contextual cues identified by nurse researchers as supportive of successful hospital-based nursing research programs. The IRS provides decision makers with a measure by which to judge HSO readiness for nursing research programs. Psychometric results are reported from a pilot and actual test of the IRS in two urban acute care settings involved in nursing research program innovation.     

Does dissatisfaction with health plans stem from having no choices?

Data from a 1997 nationwide telephone survey are used to assess the relationship between choice and public opinion about managed care. We found that only a minority of the working-age population effectively control what health plan they get. Persons without choice were markedly more dissatisfied with their health plan, especially when enrolled in managed care. In multivariate analysis, how respondents rated their health plan depended as much on whether they lacked choice as on whether they were enrolled in managed care. Persons without choice also had more negative opinions about managed care in general. The results suggest that the managed care "backlash" may persist so long as consumers have little control over health insurance decisions.     

Building healthier communities in a managed care environment: opportunities for advanced practice nurses

Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.     

AI in medical education--another grand challenge for medical informatics

The potential benefits of artificial intelligence in medicine (AIM) were never realized as anticipated. This paper addresses ways in which such potential can be achieved. Recent discussions of this topic have proposed a stronger integration between AIM applications and health information systems, and emphasize computer guidelines to support the new health care paradigms of evidence-based medicine and cost-effectiveness. These proposals, however, promote the initial definition of AIM applications as being AI systems that can perform or aid in diagnoses. We challenge this traditional philosophy of AIM and propose a new approach aiming at empowering health care workers to become independent self-sufficient problem solvers and decision makers. Our philosophy is based on findings from a review of empirical research that examines the relationship between the health care personnel's level of knowledge and skills, their job satisfaction, and the quality of the health care they provide. This review supports addressing the quality of health care by empowering health care workers to reach their full potential. As an aid in this empowerment process we argue for reviving a long forgotten AIM research area, namely, AI based applications for medical education and training. There is a growing body of research in artificial intelligence in education that demonstrates that the use of artificial intelligence can enhance learning in numerous domains. By examining the strengths of these educational applications and the results from previous AIM research we derive a framework for empowering medical personnel and consequently raising the quality of health care through the use of advanced AI based technology.     

Community health centers and quality of care: a goal to provide effective health care to the community

The uniqueness of community health centers provides for a sound environment for total quality management (TQM). Structure, process, and outcome are valued equally under TQM. With strong management leadership and a framework for quality of care, community health care specialists (e.g., advanced practice nurses) can easily incorporate the TQM measurement criteria in their daily practice routines. By applying the principles of TQM, the community health center will advance toward its goal of enhancing the effectiveness of health care delivery to a community and its members in partnership with the community.     

Immature chemodifferentiation of Purkinje cell synapses revealed by 5''-nucleotidase ecto-enzyme activity in the cerebellum of the reeler mouse

Data from child and adolescent emergency mental health screening episodes prior and subsequent to privatized Medicaid managed care in Massachusetts are used to investigate the relationship between payer source and disposition and to compare the match between clinical need and disposition level of care. Having Medicaid as the payer in the post-Medicaid managed care period decreased the odds of hospitalization by nearly 60%. None of the clinical need variables that contributed to hospitalization for Medicaid episodes in the pre-Medicaid managed care period were significant in the post-Medicaid managed care period. Multiple forces shaping professional standards, decision making, and quality of care are described. Public sector agencies must lay the groundwork for comprehensive evaluation prior to the implementation of privatized Medicaid managed care initiatives.     

The quest for value in health care

Purchasers and consumers of health care will increasingly refine their definitions of "quality" and the "cost" associated with treatment. The beneficial relationship of these concepts is "value." In the new era of managed care, those providers who offer the best value will succeed. Low-value producers will fail. Understanding buyer perceptions and expectations of value will become increasingly important as markets mature and integrated systems vie for dominance.     

Tracking consumers' reactions to the changing health care system: early indicators

A survey in fifteen communities and nationwide of consumers' opinions about changes in their local health care system reveals that Americans are surprisingly positive about recent changes in their personal access to and quality of care and consistently negative about changes in the cost of care. Although many consumers think that changes in the system are making things worse, they are optimistic about the trend toward managed care. Subgroup analysis shows that uninsured persons and persons with health problems reported high rates of concern about many of the health system issues we explored, while Medicaid recipients, Hispanics, and African Americans reported positive changes in their access to and quality of care.     

Leading Psychology Forward: Staying the Course in Uncertain Times.

Like everyone in the country, those in organized psychology have functioned recently in a climate marked by threats of terrorism, uncertainty, and a declining economy. In such challenging times, it might seem logical for the profession to wonder how it needs to change to respond to current circumstances. Yet at such times, staying the course already charted is likely a far more effective strategy. For psychology, this means continuing to press for mental health parity, educating decision makers about the important role of psychological services in preventive care, helping to integrate psychological and physical health services, continuing to hold managed care companies accountable, and increasing the profession's political giving. Psychologists must also be prepared to ensure that psychological services are treated as an integral part of any health reform plan that emerges. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Future directions for the Agency for Health Care Policy and Research

The Agency for Health Care Policy and Research (AHCPR) plays a leading role in health services research. Research efforts to develop practice guidelines, outcomes research, and computer applications have led to improvements in the delivery of care and reduced health care costs. These efforts aid consumers, providers, purchasers, and policy makers in health care decision making. This article cites numerous examples of AHCPR's efforts to increase quality of care and reduce costs.     

Managed care strategy for mental health services

In the UK, managed care is beginning to be recognized as a cost effective, quality-driven system which can be used to structure patient care. This article examines the potential use of managed care pathways in mental health services, focusing on clients with schizophrenia. The strengths of managed care include the effective coordination of healthcare resources, the clear accountable audit of mental health practice and the re-engineering of mental health practice to improve patient outcomes. Problems in designing representative care pathways and encouraging healthcare providers to implement care pathways are some of the disadvantages of this system.