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Introduction to State Health Policy

Making Sense Out of All the Fuss Over Managed Care

Presenters:

Robert E. Hurley, Ph.D., Associate Professor, Department of Health Administration, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA.

Gregg Meyer, Director, Center for Quality Measurement and Analysis, Agency for Health Care Policy and Research, Rockville, MD.


In response to the demands to reduce health care costs, purchasers have moved a greater proportion of the population to managed care organizations. The goals of this session were to:

  • Describe the differences between various types of managed care plans.
  • Highlight important public policy questions posed by the rapidly changing health care environment.
  • Describe approaches that might be taken to ensure that quality of care is maintained and improved.

Robert Hurley, Ph.D., Associate Professor in the Department of Health Administration at the Medical College of Virginia, Virginia Commonwealth University, defined managed care as an array of techniques and structures promoted by purchasers to get more value for their health care dollar.

Dr. Hurley identified a number of different types of managed care arrangements (e.g., health maintenance organization, point-of-service plans) and examined the trends in managed care participation, enrollment, and financing over the last decade. He indicated that the future of managed care is uncertain because of the rapid evolution of the marketplace, and the role of the State in the managed care arena will continue to change as they face long-term care (LTC) issues, including but not limited to:

  • Health maintenance organization (HMO) liability.
  • Declining private coverage.
  • Occupational licensure.

Gregg Meyer, M.D., Director of the Center for Quality Measurement and Analysis for the Agency for Health Care Policy and Research, discussed the importance and challenges associated with improving and measuring health care quality. He reviewed several performance and assessment efforts that seem to develop core sets of quality measures particularly under managed care arrangements, including:

  • Health Plan Employer Data and Information Set (HEDIS) from the National Committee for Quality Assurance (NCQA)—a set of health plan performance indicators.
  • Consumer Assessment of Health Plans (CAHPS®)—a survey tool used to measure consumer satisfaction with health plans.
  • Foundation for Accountability (FACCT)—a set of focus groups that seek to develop consumer-oriented condition-specific measures.

Dr. Meyer noted that the development of measurement tools alone does not ensure improved quality. Meeting the future challenges of quality improvement requires:

  • Accessible, relevant information.
  • An increased pool of science-based evidence.
  • Backing from organizational and policymaking leadership.
  • Public and private research dollars
  • Enhanced methods of measurement.

References

Bodenheimer T, Sullivan K. How Large Employers Are Shaping the Health Care Marketplace—First of Two Parts. N Engl J Med 1998 Apr;338(14):1003-7.

Bodenheimer T, Sullivan K. How Large Employers are Shaping the Health Care Marketplace—Second of Two Parts. N Engl J Med 1998 Apr;338(15):1084-7.

Ellwood PM, Lundberg GD. Managed Care—A Work in Progress. JAMA 1996 Oct;276(13):1083-6.

Blumenthal D. Part 1: Quality of Care—What is it? N Engl J Med 1996 Sep;335(12):891-4.

Brook RH, McGlynn EA, Cleary PD. Part 2: Measuring Quality of Care. N Engl J Med 1996 Oct;335(13):966-70.

Chassin MR. Part 3: Improving the Quality of Care. N Engl J Med 1996 Oct;335(14):1060-3.

Blumenthal D. Part 4: The Origins of the Quality of Care Debate. N Engl J Med 1996 Oct;335(15):1146-9.

Berwick DM. Part 5: Payment by Capitation and the Quality of Care. N Engl J Med 1996 Oct;335(16):1227-31.

Blumenthal D, Epstein AM. Part 6: The Role of Physicians in the Future of Quality Management. N Engl J Med 1996 Oct;335(17):1328-31.

Angell M, Kassirer JP. Quality and the Medical Marketplace—Following Elephants (editorial). N Engl J Med 1996 Oct;335(12):883-5.

Iglehart JK. The National Committee for Quality Assurance. N Engl J Med 1996 Sep;335(13):995-8.


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