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Providing High-Quality Services to Children with Special Health Care Needs (CSHCN) Under Managed Care
Measuring & Monitoring Quality of Care
Renee Schwalberg, M.P.H., Senior Associate, Health Systems Research, Inc.,
Mark Schuster, M.D., Ph.D., Senior Natural Scientist, RAND and Assistant Professor of Pediatrics, University of California, Los Angeles (UCLA), CA.
Ruth Stein, M.D., Vice Chairman and Professor, Albert Einstein Medical Center,
In any Medicaid managed care system, States are faced with the challenge of measuring and
monitoring the quality of care provided by managed care plans. For CSHCN, this challenge is
particularly complex, as the number of CSHCN enrolled in any one plan may be small, and their
expected outcomes will vary greatly.
Renee Schwalberg, Senior Associate at Health Systems Research, used her experience working
with a number of different States to lay out the framework for developing a practical quality
monitoring strategy. She discussed how quality assurance strategies for CSHCN need to be
different from those used for adults and healthy children, due to children's changing
developmental needs, their reliance on parents and teachers for their basic needs, the rarity of
their conditions, and other environmental risks that they run due to poverty.
According to Ms.
Schwalberg, quality assurance activities can be examined in structural domains (e.g., provider
networks), process domains (e.g., utilization of care), and outcome domains (e.g., physical
Mark Schuster, a Senior Natural Scientist at RAND and an Assistant Professor of
Pediatrics at UCLA, discussed the development of the Global Quality Assessment Tool, which is
a clinically-based method for evaluating the quality of care provided to children and adults
enrolled in managed care organizations. He explained that this tool was useful for CSHCN
because it provided composite scores on process measures for enrollees with specific chronic
conditions, it includes measure of the quality of preventive and acute care, and because it has the
flexibility to add indicator sets for other chronic and rare conditions.
In the future, Dr. Schuster
anticipates that more quality monitoring tools will be developed, there will be attempts at
developing uniformity in measuring quality, and evidence-based practice guidelines will play a
bigger role in quality assurance.
Ruth Stein, Vice Chairman and Professor at the Albert Einstein Medical Center, discussed
diagnosis-specific, generic, and functional approaches to quality assessment. Although there are
many advantages of considering CSHCN as a group, diagnostic checklists have limitations, such
as their inability to cover every disorder. Instead, generic definitions of the population of
CSHCN have the advantage of highlighting common aspects of various conditions.
also discussed the measurement of functional status of CSHCN. Dr. Stein emphasized that
although a number of approaches are available to measure the impact of chronic conditions or
children's health and functional status (including the FS II-R), linking these measures to the
quality of care provided by a plan is extremely challenging. Therefore, she recommended that
quality assurance strategies focus on process measures and comparisons of CSHCN to other
children on standard measures.
Schwalberg R, Gabor V, Hill I, Perrin JM. Managed Care and Children with Special Health Care Needs: Strategies for Monitoring the Quality of Care.
Health Systems Research, Inc., March 1997.
Stein REK, Westbrook LE, Bauman LJ. The Questionnaire
for Identifying Children with Chronic Conditions: A Measure Based on a Noncategorical Approach. Pediatrics April 1997;99(4):513-21.
Stein REK, Jessop, DJ. Functional Status II(R): A Measure of Child Health Status. Medical Care Nov. 1990;28(11):1041-55.
Newacheck PW, et al. Monitoring and Evaluating Managed Care for Children with Chronic Illnesses and Disabilities. Pediatrics Nov. 1996;98(5):952-8.
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