Shared Flashcard Set


CSP-GH: Quality Measures
Flashcards for the quality measures learning objective for the actuarial CSP-GH exam.

Additional Insurance Flashcards





Reasons why employers should focus on the quality of health care

  1. There are numerous errors in the delivery of health care services
    1. Adds unnecessary cost to the health care system
  2. There is substantial evidence of overuse and underuse of health care services
    1. Appropriate care is rarely received
  3. Failure to exercise due diligence in evaluating quality of care may impact an employer's liability for a bad outcome of care
    1. Recent trend is for insurer to be liable
  4. Lack of attention to quality can have negative consequences in relationships with employees, providers and others in the community
  5. Poor quality of care erodes the value of health care purchases

Components of quality care

  1. Appropriateness - given the current state of the art of medicine (evidence-based guidelines)
  2. Excellence - in the execution of care
  3. Patient satisfaction

* Quality must be measurable to improve it


Structural issues in the U.S. healthcare system

  1. Decentralized nature of the system
  2. Poorly-aligned payment structures and incentives
  3. Widely varying roles of hospitals and physicians in the delivery of health care services

Considerations in assessing physician quality

  1. Assess the physician's training, experience and professional certifications (e.g. state licenses and hospital staff privileges)
  2. Review the physician's history of malpractice claims
    1. Questions remain whether malpractice experience accurately depicts physician quality
  3. For physicians performing specialty procedures, consider advanced training received; volume of procedures performed; complication, mortality and success rates; and ALOS following the procedure
  4. NCQA has developed some programs to recognize high quality physicians
  5. For physicians in managed care plans, review performance report cards provided by some MCOs
  6. Schedule an office visit to evaluate the physician's communication skills
    1. Physician-patient communication is very important

Considerations in assessing hospital quality

  1. The hospital should have the appropriate accreditations (from the state, CMS and JCAHO)
  2. Consider the results of JCAHO on-site surveys
  3. The American Hospital Association publishes information on hospital facilities, staff and services
  4. Consider government data sources on hospital performance (e.g. CMS, Medicaid)
  5. For specific procedures or conditions of interest, consider questioning the hospital directly regarding the volume of admissions; complication, mortality and success rates; ALOS; and whether it is a center of excellence
  6. Consider whether the hospital is a major teaching hospital
    1. Teaching hospitals have lower mortality rates for certain conditions
  7. Review hospital satisfaction survey results
  8. Review hospital quality ratings provided by and The Leapfrog Group

Considerations in assessing MCO quality

  1. Accreditation by the NCQA (see card 7)
  2. Accreditation by JCAHO (see card 8)
  3. Information may be available from the state department of public health or the state department of insurance
  4. Review the MCOs credentialing criteria, quality assurance plan and preventive care programs
  5. Review the MCOs reimbursement mechanisms
    1. Are there substantial financial incentives for providers to withhold care?
  6. Consider performing a site visit

MCO Accreditation by the NCQA

  1. Review of quality-related processes including medical care authorizations and review; provider network quality; and member rights and responsibilities
  2. Site survey is conducted as part of review
  3. Standardized measurement and reporting a) NCQA developed the Health Plan Employer Data and Information Set (HEDIS) to score health plans based on effectiveness of care, access and availability of care and patient satisfaction
  4. Levels of accreditation
    1. Excellent - meets or exceeds NCQA requirements with high HEDIS scores
    2. Commendable - meets or exceeds NCQA requirements
    3. Accredited - meets most NCQA requirements
    4. Provisional - meets some NCQA requirements
    5. Denied - failure to meet NCQA requirements
    6. Suspended - accreditation withdrawn to investigate and implement corrective action
    7. Under Review - health plan has requested review of accreditation
    8. Discretionary Review - accreditation status is being assessed

MCO Accreditation by JCAHO

  1. Accreditation process is very similar to the approach used by the NCQA
  2. Levels of accreditation
    1. Provisional accreditation
    2. Accreditation with recommendation
    3. Accreditation with or without recommendation
    4. Conditional accreditation
    5. Nonaccreditation

Provider approaches for improving quality (supply management)

  1. Use a hospital database to identify deficiencies in quality and monitor quality improvements
  2. Provide feedback on hospital and medical staff performance - can have a significant impact on quality
  3. Use quality care data to selectively contract with providers
  4. Use care guidelines
  5. Promote continuous quality improvement (CQI) plans

Consumer approaches for improving quality (demand management)

  1. Provide preventive services
  2. Use shared decision-making programs to get the consumer involved
  3. Disseminate information about provider quality
    1. Must be easily accessible and understood
  4. Offer telephonic nurse counseling services
    1. Improves care appropriateness
  5. Offer telephonic disease management
  6. Offer "minute clinics"
    1. Provide same services as telephonic nurse counseling services as well as routine clinical services (such as vaccines)
  7. Encourage use of reliable internet sources (such as HHS and NCQA)

Primary sources of data for measuring health plan performance

  1. Claims and utilization data
    1. Least costly and readily available
    2. Data quality depends on examiners and providers
  2. Medical records
    1. Accurate
    2. Costly and only includes information on care provided by that provider
  3. Patient-reported data
    1. Information on services from all sources
    2. Responses influenced by the form of survey, question wording and responses available
  4. Population exposure data
    1. Unreliable and incomplete
Factors that affect the credibility of health plan performance measurement reports
1. Data quality
2. Selection of the population
a) Consider how data will be used and results will be
3. Sample size
a) Should be based on the smallest grouping at
which results are to be interpreted
b) n = (Za / 2) ^2 x var / p^2
var = population variance
Z = standard normal variable
1 - a = probability the actual mean is within p
of the sample mean
p = desired half width of confidence interval
4. Sample selection
a) Random or stratified
b) The sample is used to make inferences about the
plan population as a whole
5. Year-to-year consistency of health plan results
a) High turnover in providers and members reduces
the predictability of future results
Categories for health plan performance evaluation
1. Access
a) Measured as the actual treatment received, the
opportunity to receive health care treatment
(patient within x miles of provider), or the ratio of
providers to members
2. Cost and financial measures
a) Annual cost per member, regional vs. national
costs, reserves
a) Dependent on demographics, health plan benefits,
reimbursement method and reserve method
3. Member satisfaction
a) Direct - standardized survey
b) Indirect - enrollment/disenrollment rates,
grievances, voluntary out-of-network usage
4. Medical effectiveness
a) Multiple measures are needed (see card 14)
Common measures of medical effectiveness
1. Preventive care measures
a) U.S. Preventive Services Task Force publishes
guidelines that set the standard in preventive care
2. Practice guidelines
a) Measure if the doctor's care is conservative and
efficient based on published guidelines
3. Proxy indicators
a) Events that correlate with poor treatment (such as
rates of low birth weight babies, heart attack rates
for males over 40, readmission rates, relapse
4. Cost and utilization measures
a) Measure appropriate use of resources (such as
admission rates and average length of stay)
5. Health status outcome measures
a) Goal is to determine whether the original objective
was achieved
b) Assessed by clinicians, patients or mortality/
morbidity rates
6. Provider selection criteria
a) Credentialing
b) Utilization management programs
Definition and uses of health indicators
Definition: standardized summary measures that represent health status

1. Monitor changes over time and variations across health
a) Identify best practices
b) Help focus efforts and set priorities
2. Provide evidence to inform health programs, policies
and funding decisions
3. Identify levels of health and well being of a population
4. Help address patient safety issues by encouraging
those with poor scores to improve
a) Hospital Standardized Mortality Ratio (HSMR) -
ratio of actual to expected deaths based on the
condition of the patients

* Health indicators can identify disparities, but it cannot
explain them
Definition and uses of comparative effectiveness research
Definition: a rigorous evaluation of the impact of different options that are available for treating a specific condition (transparent and unbiased information)

1. Help in the physician/patient interaction to reduce errors
2. Help make decisions more consistent
3. Clarify disputes over practice and policy
4. Persuade providers to move from one therapy to

* Agency for Healthcare Research Quality (AHRQ)
performs comparative effectiveness research for
Reasons for comparative effectiveness research
1. Level of health care spending
2. Large variations in clinical care
3. Uncertainty regarding best practices for treatments,
procedures and technologies
4. Quality of care issues
Definition and uses of evidence-based medicine
Definition: integration of best research evidence with physician and patient decisions regarding appropriate care

1. A solution to defining quality health care
2. Determine clinical quality of care, cost of care and
comparative effectiveness
3. Addresses relevancy and timeliness of a treatment
Options for payers and policy makers based on the results of comparative effectiveness research
1. Do not provide coverage for least effective or least cost
effective technology
2. Provide higher reimbursement for more effective
3. Require more cost sharing for less effective technology
4. Reimburse providers based on an episode of care
(bundle payments)
5. Reimburse providers at the cost effective price
Different approaches to quality and efficiency measurement
1. Providers - follow evidence-based medicine approaches
to arrive at quality care (clinical focus)
2. Buyers and payers - rely on measures of cost,
efficiency, utilization and resource use to determine
quality (financial focus)
3. Different stakeholders have competing goals
Uses of quality and efficiency measurements
1. Professional standards
2. Government oversight
3. Professional accreditation
4. Quality improvement
5. Network development
6. Pay-for-performance programs
7. Public reporting
8. Consumer health education
9. Purchaser decision making
Institute of Medicine definition of quality care
1. Safe - avoiding injuries to patients
2. Effective - providing services based on scientific
knowledge to all who could benefit and refraining from
providing services to those not likely to benefit
3. Patient-centered - providing care that is respectful of
and responsive to individual patient preferences, needs
and values
4. Timely - reducing waits and sometimes harmful delays
5. Efficient - avoiding waste of equipment, supplies, ideas
and energy
6. Equitable - providing care that does not vary in quality
because of personal characteristics
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