Quality of Medical Care

Quality medical care can be described as the best medical care. The goal is to keep a person well and healthy and to manage acute and chronic illnesses to help a person maintain optimum health. According to a 1996 national survey, “Americans As Health Care Consumers: The Role of Quality Information,” the major concern in choosing a health plan was quality of care (42% of 2,006 adults). This is more important than low cost, choice of doctors, and range of benefits. Employers provide some information on the quality of health plans. Most people choose health providers and health plans based on recommendations from doctors, family,
and friends.

There are independent organizations such as the National Committee for Quality Assurance(NCQA) and the Agency for Healthcare Research and Quality (AHRQ) that monitor and provide information about the quality of healthcare. They develop and report their findings based on research. The AHRQ (www.ahrq.gov) is a government agency that supplies research and guidelines for use by health providers and patients to help determine what care is available and which should be preferred. The NCQA (www.ncqa.org) assesses, monitors, and reports on quality of care. It is a private, nonprofit organization whose diversified board of directors includes employers, health plans, and most importantly, patients, the consumers of managed
healthcare. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates hospitals, clinics, nursing homes, home health agencies, and laboratories. For community, home health, and hospice programs there is the Community Health Accreditation Program (CHAP). Outpatient healthcare settings like student health services, diagnostic radiology centers, and ambulatory surgical centers are evaluated by the Accreditation Association for Ambulatory Health Care (AAAHC).

In addition, most managed healthcare plans have their own internal quality assurance plans. Once a plan has been reviewed and evaluated by NCQA or other review agencies, the plan is assigned a “grade.” If the plan meets the required standards, it is then given accreditation. This means that the plan met the required guidelines for providing high-quality medical care. The NCQA uses this information to develop a report card on each plan it reviews. The NCQA measures quality using its own Health Plan Employer Data and Information Set (HEDIS) for performance measurement. This data is used for the report card. The report card includes data on the plan’s actual medical services, such as doctor availability, specialist referrals, preventive care, and emergency and hospital coverage. It also reviews charts focusing on the physician’s medical competence and performance. The physician’s licensing, certification, and other credentials are also checked. The physical setting of the office is evaluated to be sure that all quality standards are met.

In evaluating healthcare quality NCQA accreditation and HEDIS provide a comprehensive, standardized, and uniform method that is used for the HMOs it reviews.
About 75% of the nation’s HMOs are accredited by NCQA or are in the process of becoming accredited. The following areas are the primary focus of the health plan review, weighted according to the percentages indicated:
• Access and service (patient satisfaction and
easy, timely access to providers and
treatments), 40%
• Qualified providers (trained, licensed,
credentialed), 20%
• Staying healthy (wellness and prevention),
15%
• Living with illness (proper diagnosis and
treatment of acute and chronic medical
problems), 15%
• Getting better (quality of care), 10%
Meeting the accreditation standards in each
area accounts for 75% of the grade.

The HEDIS (Health Plan Employer Data and Information Set) results make up the remaining 25%. Overall, HEDIS results look primarily at quality in the clinic and patient satisfaction. The results from each plan review are then compared to certain target goals for each category reviewed, and the plan is graded. These grades are compiled and compared to other health plan report cards. The collected information is then reported in a comprehensible format for patient use in selecting a quality health plan.

Information like this is becoming more readily available. It will become, increasingly, one of the ways patients look for and find quality health plans. The Accreditation Status List (ASL) is available to anyone by calling (1-888-275-7585), by writing , or by going to the NCQA website, which provides a list of the accreditation status of participating health plans. Accreditation Summary Reports (ASR) are also available and contain more detailed information than the ASL.
Individual private doctors and group practices that use these managed healthcare plans are usually under contract with the health plan to allow for periodic quality assurance checkups and monitoring.

Health insurance that is not part of a managed healthcare plan and private fee-forservice healthcare are also being included in assessments of quality. Uniformity of quality assessment and reporting among all healthcare providers is a major issue being addressed by the government and other independent agencies that specialize in quality measurement. Soon all providers of all types of health services will have routine quality assessment and reviews, and even more information will be available for the patient to review.

Even with the researched, scientific-quality databases provided by independent organizations, patients usually select a health plan and providers recommended by family or friends rather than one that rates much higher based on a formal quality assessment and review. This trend is also reflected in the choice of doctors. Patients are more concerned about the way a doctor communicates with and cares about them than about whether the doctor has been given a high rating by a quality assurance organization. If the doctor has board certification in her or his specialty, this is also given a higher ranking by patients than quality accreditation from an independent organization.

Many people are beginning to see that quality is important, since one of the goals of managed care is to contain costs, sometimes at the patient’s expense. In order to see that this does not become an issue, quality monitoring, assessment, and reporting are vital to the healthcare system. Making it available to the patient is also important. Information is a powerful tool. It allows patients to learn and to make decisions that are best for them. Looking for quality healthcare in today’s healthcare maze can be a challenging experience. Reading information from the medical provider is a good place to start. Many managed health plans provide patient
manuals and patient representatives that are available to talk with you in person or by phone.

For more detailed information you can contact your state’s insurance commission. Health insurance plans are regulated by state insurance commissions. The AHRQ is a federal government agency under the Department of Health and Human Services (DHHS). It does research on the quality and costs of healthcare. Some of the specific areas it covers are patient safety, quality improvement, clinical outcomes, assessment of medical practices, preventive and primary care services, and funding for medical research.

AHRQ states, "Health services research examines how people get access to health care, how much health care costs,and what happens to patients as a result of this care". The main goals of health services research are to identify the most effective ways to organize, finance, and deliver high quality care; reduce medical errors; and improve patient safety. The AHRQ has maintained a database of medical care guidelines based on medical research. The research is “translated into practices and policies that have been proven to provide the best care, diagnosis, treatment, and follow-up for specific conditions. The guidelines are available free of
charge at The National Guideline Clearing House (www.guidelines.gov ).

More information on choosing the right health plan for your medical needs can be found in the following patient information brochures available on the Internet or by contacting the agency via phone or mail:
• “Choosing and Using a Health Plan” and “Checkup on Health Insurances” from AHRQ www.AHRQ.gov
• “Choosing Quality: Finding the Health Plan That’s Right for You” from NCQA
• “Which Plan Is Right for Me?” from NCQA www.NCQA.org
• http://www.healthchoices.org/ website by NCQA
• “It’s Your Health—How to Get the Most Out of Your HMO” from Consumer Action,
http://www.consumer-action.org/ a consumer advocacy group

Best health!