Chasing Quality: The Challenge of Delivering Quality in Managed Care

December 2017

By Faith Saporsantos

The old adage, “If it ain’t broke, don’t fix it,” popularized by T.B. Lance, Director of the Office of Management and Budget during Jimmy Carter’s 1977 administration, seems like good advice, but don’t be fooled. The path of least resistance typically leads to unfavorable outcomes. Although it’s been a common theme in today’s healthcare industry, following this motto will not only put a healthcare organization at risk, but also create a culture that is reactive, rather than proactive. Implementation of a comprehensive Quality Improvement Program woven into key functional areas is the better path.  The challenge is to establish the structures and processes that support quality improvement efforts in every aspect of the administration and delivery of healthcare, and to ensure that this improvement is ongoing.

As more and more people receive healthcare services through managed care and the healthcare industry increasingly recognizes that quality is cost effective, the central goal has become ensuring the delivery of high-quality care. And maintaining quality leaves no room for complacency.

Quality in Managed Care

Managed care was originally intended to reduce costs in healthcare delivery services, incentives for waste, and inappropriate care. Similarly, ongoing quality management and continuous improvement aligns with the Institute for Healthcare Improvement’s (IHIs) Triple Aim:

  1. Improvement in the health of populations
  2. Improvement in the individual experience of care
  3. Reduction of the per capita costs of care

While these points are focused on what and how care is delivered and the related outcomes, chasing quality can also be enhanced through collaboration and oversight of other business  areas, including utilization management, grievances and appeals, provider services and contracting, information systems, member services, claims, and finance and accounting. Early detection of quality issues and trends can improve the organization’s ability to accomplish its goal of delivering more efficient, cost effective quality care and services.

Managed care continues to expand and evolve, with payment methodologies increasingly focused on quality.  This is evidenced in the various value-based payment methods currently in place across the county.  Many managed care organizations understand the role their own organization plays in the overall delivery of care and services and the importance of establishing a quality focus throughout the organization.  These organizations will continue to set the industry standard and, through their continuous focus on quality structures and processes, will contribute significantly to value-based care delivery.

Quality: Structure, Process and Outcome

There are two key aspects to quality management: quality measurement and quality improvement. Quality measurement identifies healthcare quality indicators, and collects, analyzes and reports the data. Consumer Assessment of Healthcare Provider and Systems (CAHPS), used by Centers for Medicaid and Medicare Services (CMS), and Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA), are examples of quality measurement tools that compare experience and performance to national or regional benchmarks.

Quality improvement involves increasing quality of care and quality of service through education, policy and procedure overhauls, and the like.

It has been said that quality is characterized by three perspectives: structure, process, and outcome. Structural quality encompasses the notion that the physical circumstances of care could be controlled by optimizing healthcare services. This is reflected in the licensure and accreditation of healthcare professionals and organizations. It provides regulators subject matter that is recognizable and measurable.

Structure also includes the written description of the Quality Management Program, accountability at the highest level, oversight, and clearly defined roles and work plans.  The quality structure considers Utilization Management to be an integral part of the overall Quality Management Program, as well as policies and procedures related to timeliness of decision making.

Process as an element of quality is characterized by the collaboration and oversight of its functional areas. Quality management processes include:

  • Service elements such as accessibility, availability and continuity of care.
  • Processes in place to evaluate the effectiveness in identifying and correcting deficiencies in care or service delivery.
  • Processes in place to document that quality of care problems are being identified, effective action is taken to improve care, and follow-up is planned, where indicated.
  • Processes related to credentialing providers and practitioners.
  • Processes by which care and services are approved, modified, delayed or denied, based on medical necessity.
  • Processes to assess and evaluate compliance with utilization management requirements.
  • Processes related to grievances and appeals.
  • Processes related to provider services and contracting, including those that may impact timely access and availability of services.
  • Processes in place to ensure information systems, member services, claims, finance and accounting are operating appropriately and are consistent with regulatory and/or statutory requirements.

Outcome as an element of quality refers to the development of clinical practice guidelines accompanied by outcome measures. Although process elements are inherent to clinical practice guidelines, the different approaches to care affecting patient treatment outcomes cannot be ignored.  Outcome measures are becoming increasingly important with the growth of value-based payment methods.

The patient standpoint as it relates to quality is reflected in consumer protection law, with an emphasis on information access and the development of consumer rights. Quality defined by structure, process, outcome or patient perspective all intertwine, and as a result, have a collective impact on the delivery and evaluation of healthcare services.

Quality management in a complex healthcare delivery system is multifaceted and demands a multidisciplinary approach. It also requires an organizational culture that is committed to continuous improvement. Many of the issues we are currently experiencing in the healthcare industry do not stem from a lack of awareness of the importance of quality management. Rather, they are caused by willingness to accept the status quo, even when we know current practices are less than optimal.

The present challenge is to weave quality into every aspect of the administration and delivery of healthcare, and to ensure the quest for quality improvement is ongoing.


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