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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., Washington, D.C.

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, Bronx, NY.

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 function).

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.

Dr. Stein 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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