Você está na página 1de 15

Quality Assessment and Improvement

Page 1 of 15
16 Quality Assessment and Improvement
Objectives
After completing this module, you will be able to:
discuss the issue of patient safety,
define and give examples of the three main types of quality measures and state
the advantages and disadvantages of each,
identify the three main categories of data that health plans use to assess quality,
and
describe four approaches to improving health plan quality.
Utilizing healthcare resources efficiently is an important objective of healthcare
management, but equally important is ensuring that health plan members receive high-
quality care and service. In this module we describe how health plans use quality
management (QM) to establish goals for quality, measure and monitor performance,
and make improvements. In the following module we examine in more detail quality
measures, standards, and accreditation.
We begin with a brief overview of the nature and importance of quality in health plans.
We then describe the activities that make up QM. Although QM is a continuous process
that consists of a variety of interrelated activities, for the purposes of our discussion we
divide it into two broad categories:
Quality assessment includes activities designed to define and measure quality
and performance and identify any need for change.
Quality improvement involves planning and implementing changes and then
reapplying quality assessment techniques to assess the impact of those changes
on outcomes.
Quality
What Is Quality?
Although there is a consensus that quality is an essential goal in healthcare, there are
many different ideas about how to define quality, how to recognize it, and how to provide
it. In its most general sense, the term quality in the context of a health plan refers to the
plans success in providing healthcare and other services in such a way that plan
members needs and expectations are met.
Quality Assessment and Improvement
Page 2 of 15
Two Types of Health Plan Quality
There are two broad categories of quality in a health plan:
Service quality generally refers to a health plans success in meeting the needs
and expectations of plan members with regard to nonclinical (nonmedical)
customer services. It has to do with such matters as how well member services
representatives answer members questions and resolve administrative issues,
how long a member has to wait for a response to a complaint, or how friendly
and helpful provider office staff are.
Healthcare quality. According to an often quoted definition formulated by the
Institute of Medicine, healthcare quality is the degree to which health services
for individuals and populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge. In common language,
healthcare quality refers to whether health plan members receive care based on
the most up-to-date and effective medical practices and their medical conditions
are successfully cured or managed.
Why Is Quality Important?
The mission of a health plan is to provide top-quality healthcare at an affordable price.
Therefore, the most straightforward answer to the question, Why is quality so important
for health plans? is that quality is a major part of a plans reason for being. A health
plans purpose is to, as effectively as possible, maintain and restore members health
while protecting their safetyin other words, offer quality care.
There are also good business reasons for a health plan to provide quality and make
known that it does so. For many consumers, employers, and other purchasers, quality is
an important factor in choosing a health plan, and the ability to demonstrate superior
quality gives a health plan a competitive advantage.
Another issue is that, because managed care plans have been in the forefront of efforts
to hold down healthcare costs, some people have expressed concerns that they have
compromised on quality. This is not the case, as many studies show that the quality of
care provided by managed care plans equals or exceeds that of traditional fee-for-
service insurance.
1
But health plans may need to demonstrate quality to dispel such
doubts and earn the publics confidence.
Patient Safety
One of the most important reasons to promote healthcare quality is to ensure patient
safety and reduce healthcare (medical) errors. The National Patient Safety Foundation
defines patient safety as the prevention of healthcare errors and the elimination or
mitigation of patient injury caused by healthcare errors; with a healthcare (medical)
error defined as an unintended healthcare outcome caused by a defect in the delivery
of care to a patient.
2

Research has documented an alarming incidence and severity of medical errors and
adverse events (instances of patient harm) caused by them. In 1999 the Institute of
Medicine (IOM) published a landmark study that is widely cited; it estimated that nearly
Quality Assessment and Improvement
Page 3 of 15
100,000 Americans die in hospitals each year as a result of medical errors.
3
More
recently (in 2006) IOM issued a report on preventable adverse drug events, which
estimated that in one year there were 380,000-450,000 such events in hospitals,
800,000 in long-term care facilities, and 530,000 among outpatient Medicare patients.
4

These large numbers represent people whose physical wellbeing or even lives were put
at risk, and who may have undergone unnecessary suffering. It should also be noted
that medical errors add to the cost of healthcare, as they can worsen patients conditions
and lead to the need for additional treatment. The 1999 IOM study estimated the annual
cost of medical errors at between $17 and $29 billion.
5

Medical Errors
What exactly are medical errors?
An error of commission is doing the wrong thing. A wrong treatment or
procedure is performed, as when the wrong medication is administered.
An error of omission is not doing the right thing. A patient does not receive the
appropriate test or treatment, or does not receive it in a timely manner.
An error of execution is doing the right thing in the wrong way. A planned
treatment or procedure is delivered incorrectly, as when a mistake is made in a
surgical operation.
An adverse event is any harm a patient suffers that is caused by something
other than her underlying condition. The cause might be a medical error, some
other deficiency in the patients care, or something else.
A federal Quality Interagency Coordination (QuIC) Task Force, expanding on an earlier
IOM definition, defined a medical error as: "the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Errors can include
problems in practice, products, procedures, and systems. A useful, brief definition of a
medical error is that it is a preventable adverse event.
6

The Causes of Medical Errors
Medical errors have a number of causes. In some cases an individual practitioner makes
a mistake, but more often there is some breakdown in the healthcare system.
Lack of communication. Communication among healthcare providers is often
limited or faulty, and this is the cause of many errors. To give a simple but
frequent occurrence, doctors often write illegible prescriptions leading to incorrect
medications, or illegible orders resulting in inappropriate procedures. Another
example: an outpatient diagnostic center fails to call a physician about a patients
chest x-ray showing pneumonia, and as a result the patient does not receive
timely treatment for the pneumonia and has to be hospitalized. The problem of
poor communication is compounded by the large numbers of people who may
participate in a patients care.
Quality Assessment and Improvement
Page 4 of 15
Lack of reporting. Most healthcare organizations have internal systems for
reporting such incidents as adverse drug interactions and minor medical errors,
and federal law requires that adverse drug reactions be reported to the Food and
Drug Administration (FDA). But compliance with these requirements is often very
low, and incidents frequently go unreported. And without adequate reporting,
plans often cannot identify the causes of medical errors or develop effective
strategies to prevent them.
Lack of verification. Many treatment decisions are based on one individual
analysis of test results, without secondary verification, and studies have shown
that the error rates in such cases are high.
One problem that is being addressed is the lack of coordination among parties
concerned with medical errors. The National Practitioner Data Bank (NPDB) and
Healthcare Integrity and Protection Data Bank (HIPDB) were established to centralize
healthcare quality reporting in relation to practitioners. State licensing agencies, health
plans, malpractice insurance carriers, criminal courts, and others are required to report
quality of care incidences to these databases, subject to very high fines. The databases
also notify practitioners and state licensing entities whenever a report is received about a
practitioner, allowing the licensing entity to conduct a further investigation when
indicated, as in the case of a criminal conviction or malpractice claim. Health plans may
also query these databases when a practitioners applies to participate, as can hospitals
and medical groups reviewing an application for staff privileges. The national databases
have significantly reduced the ability of a poor-quality practitioner to move from one state
to another without the new states licensing board being aware of prior issues. It has
been recommended that an even more comprehensive nationwide mandatory system of
collecting, analyzing, and reporting standardized information about medical errors that
result in death or serious harm be established, but this has not yet been done.
Addressing Patient Safety
Healthcare providers, health plans, and other entities have taken a number of steps to
ensure patient safety and reduce medical errors.
Medical error reporting systems allow healthcare providers and facilities to
analyze common errors and identify aspects of the healthcare delivery process
that result in such errors.
Medical alert systems apply preprogrammed criteria to identify test results that
fall outside acceptable ranges.
Drug checking systems link physician and pharmacy order entry information
systems and automatically alert physicians and pharmacists of possible drug
interactions or allergic reactions to a prescribed drug.
Electronic medical record systems allow providers and health plans to track
and analyze clinical data and provide reminders for needed services.
Quality Assessment and Improvement
Page 5 of 15

Assessing Quality in a Health Plan
Recognizing that quality is important is easy. But as we will see in this section, it is a
more complex task for a health plan to define precisely what quality is in certain contexts
and, based on that definition, determine whether the plan is delivering quality.
Performance measurement can help a health plan determine how well it is doing in
meeting members needs and can provide information the plan needs to improve its
performance and effectively allocate resources.
The Issue of Perception
Plan members perceptions of healthcare quality may differ from objective, scientific
criteria.
Example: A health plan contracts with a medical group because the groups
physicians have strong credentials and are recognized as experts in their fields. A
plan member visits one of these physicians and feels that she is unfriendly, and the
member does not understand her explanation of his illness or her plan for treatment.
But he undergoes the treatment and gets better. Objectively, based on the providers
qualifications, the treatment delivered, and the results, the member received high-
quality care. But he may not think so.
Consumer perception and medical science may even conflict.
Example: A member is dissatisfied with her doctor because he refuses to prescribe
an antibiotic for her sore throat. But in fact the antibiotic is not necessary or useful for
her ailment. Moreover, the overprescribing of antibiotics for viral infections of the
throat and respiratory tract has not only increased healthcare expenditures
unnecessarily but led to the growth of antibiotic resistant organisms.
While science and objective criteria take priority, consumer perceptions are also
important. They may reflect important aspects of care, such as a doctors communication
skills. And purchasers base their decisions about health plans in part on the perceptions
of the consumers they represent. Consequently, as we will see, while many quality
measures are based on scientific criteria, others reflect the perceptions of members.
Quality Measures
Measures of quality are generally divided into three categories.
Structure measures relate to the nature, quantity, and quality of the resources
that a health plan has available for member service and patient care. For
instance, a health plan might calculate how many dermatologists it has per 1,000
members, or what percentage of its physicians are board-certified.
Process measures relate to the methods and procedures a health plan and its
providers use to furnish service and care. A plan might calculate what
percentage of members received regular check-ups over a certain period, or how
often a certain medication was not prescribed when it should have been.
Quality Assessment and Improvement
Page 6 of 15
Outcomes measures gauge the extent to which services succeed in improving
or maintaining patient health. A plan might calculate the percentage of patients
with a certain condition who are still alive five years later.
Most of the measures currently used to evaluate health plan quality are structure and
process measures, but the trend is toward greater use of outcomes measures.
Structure, process, and outcomes are interdependent. Structure and process lead or are
believed to lead to better outcomes, and the best structure and process measures are
those that can be explicitly linked to improved outcomes. Conversely, outcomes are the
results of structure and process, and the most useful outcomes measures are those that
can be related to specific processes or structures. If health plans can link outcomes to
processes or structures, they will have a better idea of which processes or structures to
improve and how to improve them, and can thereby improve patient health outcomes.
Assessing Service Quality
As noted, the term service quality is used for nonclinical (nonmedical) services. It
involves the customer service that health plan members receive both from the plans
own staff and from its providers.
Health Plan Staff
The quality of the service delivered by health plan staff includes:
how long a member has to wait for an answer when calling the plan;
the attitude, competence, and efficiency of the member services staff;
how quickly member services representatives can resolve issues for members;
the accuracy and timeliness of claims payments;
the availability and understandability of educational materials for members; and
the clarity and accuracy of materials explaining to members benefits, limitations,
and administrative processes.
Health plans can use the three types of measures discussed above to assess service
quality.
structure measures, such as the number of customer service representatives
available;
process measures, such as the average wait time when members call or the
average claim processing time; and
outcomes measures, such as the rate of errors in claims payment or responses
to member satisfaction surveys.
Quality Assessment and Improvement
Page 7 of 15
In using these measures, a health plan can compare its performance to established
standards and/or its own previous performance.
Healthcare Providers
For healthcare providers, service quality includes:
how easily members can get through to a doctors office by phone;
how long members wait for an appointment;
how long members wait in the office before seeing the doctor;
the attitude, competence, and efficiency of office staff;
the doctors bedside manner. This includes how friendly and understanding the
doctor is, how well she explains clinical findings and treatment options, whether
the patient feels that she listens to his concerns, etc.).
Provider service quality can also be assessed by means of structure measures (such as
the number of primary care physicians), process measures (average wait time for an
appointment), and outcomes measures (results of member surveys).
Assessing Healthcare Quality
Healthcare quality typically refers to:
patient safety (as defined above);
practices consistent with current clinical or scientific knowledge, best practices,
and professionally recognized standards of care; and
care delivered in a timely manner to avoid harmful delays; and
care respectful of and responsive to patient needs, preferences, and values.
Structure Measures
Structure measures of healthcare quality include:
the number of primary care providers in the plans network,
the number of specialists,
the number of providers accepting new patients,
the geographic distribution of providers within the service area,
the percentage of providers who are board-certified,
physician turnover in the plan,
Quality Assessment and Improvement
Page 8 of 15
hospitals in the plans network,
the number of hospital beds,
emergency room access, and
the availability of member education programs.
The advantage of structure measures is that they are relatively easy to calculate and
report. The problem with them is that there is little research specifically supporting a link
between them and high-quality outcomes. However, it does seem highly probable that
many structure measures are related to quality. For instance, other things being equal, a
health plan with more board-certified physicians very likely provides higher quality care,
on average, than a plan with fewer board-certified physicians. Likewise, it seems clear
that if so few doctors are available that members have to wait a very long time for an
appointment, healthcare outcomes will be adversely affected.
Process Measures
Among the most popular process measures are preventive care statistics. They are
relatively easy to calculate and understand, and they fit well with the current emphasis
on prevention. Examples include:
the percentage of children receiving immunizations;
the percentage of adults (particularly the elderly) receiving regular medical
checkups;
the percentage of members receiving certain screenings, such as mammograms,
pap smears, or cholesterol screening; and
the percentage of members receiving advice on smoking cessation or other risk-
reducing programs.
Health plans also use various process measures related to how providers treat patients.
One important element is appropriateness of careappropriate care can improve health
outcomes and increase member satisfaction, while inappropriate care can lead not only
to poor outcomes but to adverse events. In general, inappropriate care can be divided
into three categories:
Overuse of care is unnecessary tests, medications, or procedures. Overuse of
care not only wastes resources and increases costs, it can reduce the
effectiveness of appropriate treatments and expose the patient to unnecessary
risks and possible adverse effects.
Underuse of care occurs when a provider fails to render a service or treatment
that would likely improve the patients health (an error of omission). For example,
despite evidence of their benefits, beta blockers are not always routinely
administered to patients following a heart attack.
Quality Assessment and Improvement
Page 9 of 15
Misuse of care occurs when the wrong treatment is provided (an error of
commission) or when the correct treatment is delivered incorrectly (an error of
execution).
In many cases appropriate care is codified as professionally recognized standards of
care. A standard of care is a diagnostic and treatment process that a provider should
follow for a certain type of patient, illness, or clinical circumstance. Standards of care are
generally published by medical organizations such as the American Medical Association
(AMA) and others.
The advantage of process measures is the same as for structure measuresthey are
relatively easy to determine and report. But while links have been established between
some process measures and positive health outcomes, for others they have not.
Outcomes Measures
Outcomes measures can be divided into three types: clinical status, functional status,
and patient perception.
Clinical status relates to biological health outcomes, either for an individual or
for a population served, such as the following:
o the change in tumor size for patients treated for cancer,
o the five-year survival rate for cancer patients (the percentage still living
five years after treatment),
o the occurrence of chest pain in patients who have received coronary
angioplasty,
o the survival rate of patients receiving coronary angioplasty,
o the number of hospital admissions for members with certain medical
conditions,
o the average length of hospital stay by type of injury or illness,
o the number of patients contracting an infection in the hospital,
o the incidence of certain conditions that commonly afflict long-term
diabetes patients (such as foot ulcers or blindness),
o the occurrence of infants with low birth weight or of premature births,
o patient safety issues (such as the outcomes of patient falls).
Functional status refers to a patients ability to perform certain normal activities.
Can he go to work? Can he bathe, get dressed, and get around without help? Is
his bowel function or sex life impaired? Functional status outcomes measures
are commonly used in these areas:
Quality Assessment and Improvement
Page 10 of 15
o stroke rehabilitation (physical, occupational, and speech therapy);
o cardiac rehabilitation (following a heart attack or open heart surgery); and
o sexual function impairment following surgery or certain drug therapies.
Patient perception/satisfaction relates to whether the patient feels an
improvement or cured after treatment. (As mentioned above, it should be kept in
mind that while patient perception can be valuable and important, it is not an
objective measure.)
These three types of outcomes measures do not always coincide to indicate to providers
and patients the best treatment. For example, for a certain type of cancer, Treatment A
offer a smaller chance of remission than Treatment B, but on the other hand it impairs
the patients day-to-day functioning more than Treatment B. In this case clinical status
and functional status outcomes measures conflict.
The advantage of outcomes measures is that they directly gauge the extent to which the
ultimate goal of healthcare qualitybetter patient healthhas been achieved. But they
also have a number of limitations and problems.
Outcomes measures are useful only if they can be linked to structures or
processes that a health plan or providers can modify. If no changes can be made
that would affect an outcomes measure, it has little value in quality improvement.
In some cases data is costly or difficult to obtain. For example, it can take 10 to
20 years to track the outcome of treatment of some slow-growing tumors such as
prostate cancer. For complications from diabetes, the delay between treatment
and outcome may be as long as 20 to 30 years.
To compare outcomes from provider to provider and health plan to health plan,
data from different sources must be used, and such data may not be consistent
or reliable. There may be differences in the way data was recorded and reported,
making it unusable or requiring adjustments.
Outcomes often depend on factors that are independent of the quality of care
provided and beyond the control of the provider, such as the patients gender and
age, the severity of his condition, and other illnesses he might have. To compare
outcomes fairly among providers, statistical adjustments must be made to
account for these factors (called risk adjustment or case-mix adjustment).
Outcomes measures have the potential to create undesirable incentives for
providers. If outcomes are made public and used to evaluate providers, some
providers may be reluctant to treat the sickest patients. Providers are especially
likely to adopt this attitude if the outcomes data are not risk-adjusted, or if they
believe that the risk-adjustment methods used are inadequate or invalid.
Note: In this section we have discussed measures of quality in general terms. In the
next module we will look at specific performance measures and quality standards and
the organizations that sponsor them, including HEDIS and the National Committee for
Quality Assessment and Improvement
Page 11 of 15
Quality Assurance (NCQA) and the new star system for rating Medicare Advantage
plans.
Collecting, Analyzing, and Reporting Quality Assessment Data
Types of Data
The data health plans collect for quality assessment can be divided into three
categories:
Financial Data
Financial data describe the costs of physical, technological, and human resources
needed to provide administrative and healthcare services to plan members. Financial
data are used to analyze how efficiently health plans and providers use resources. They
typically come from the health plans claims and encounter reports, its administrative
records, and hospital records.
Clinical Data
Clinical data include data related both to certain diseases and to general health and
functional status. For disease data patient medical records and claims and encounter
forms are the primary sources. Information on members general health and functional
status is collected directly from members using such tools as the SF-36 and HSQ-39
(Health Status Questionnaire) surveys.
A significant amount of information is available from these sources, but their usefulness
is often limited. Poor documentation and multiple sources of information make collecting
data from medical records time-consuming and expensive. Information from claims is
readily available, but it is limited to diagnostic and treatment codes and costs of services.
In an effort to make health information attainable more easily and less expensively, the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) encourages all
types of clinical practitioners and organizations to move toward electronic medical
records. HIPAA also addresses the challenges of aggregating claims information by
encouraging standardized claim forms and clearinghouses that convert nonstandard
forms to standardized forms for more efficient processing and reporting. It should be
noted that the U.S. is scheduled to convert to an updated diagnosis coding system (ICD-
10) in 2013, and this will undoubtedly create additional challenges in diagnostic tracking,
trending, and reporting.
Customer Satisfaction Data
Customer satisfaction data describe how a health plans members, providers, and
purchasers view the way the health plan delivers services.
Member satisfaction data address both members overall satisfaction with the
plan and their satisfaction with key factors such as access, quality of care, and
administration. Member satisfaction information is typically gathered through
telephone or mail surveys. One of the most commonly used surveys is CAHPS

,
discussed in the next module.
Quality Assessment and Improvement
Page 12 of 15
Provider satisfaction data address healthcare providers satisfaction with the
plan overall and with key factors such as availability of contracted ancillary
services (x-ray, labs, durable medical equipment, etc.), the delivery and
availability of information regarding best practices, and administration.
Customer satisfaction data also provide health plans with information about which plan
services work best and which services are most important to members, providers, and
purchasers.
Data Analysis
The analysis of financial, clinical, and customer satisfaction data provides a snapshot of
a health plans current level of performance. By comparing actual performance to
established standards, a health plan can identify areas that need improvement. By
comparing current performance against past performance, a plan can identify areas of
improvement and of decline.
Reporting
The final step in the quality assessment process is reporting results. Performance
reports serve two primary purposes, internal and external.
Internally, performance reports can be used to help a health plan improve the
quality of healthcare and services by identifying the plans strengths and
weaknesses, giving guidance on where to focus quality improvement efforts.
Externally, performance reports provide accountability to the health plans
customers and outside agencies. By comparing one plan, provider group, or
delivery system to another, analysts can use performance reports to identify
differences or problems in performance. Health plan customers can use this
comparative information to make informed healthcare decisions.
Quality Improvement
Quality improvement consists of producing better healthcare outcomes (clinical,
functional, and perception/satisfaction). Health plans can accomplish this by changing
the structures and processes that underlie their clinical and administrative services. In
other words, a health plan can improve its services by increasing or improving its
resources and by changing the ways it performs services. For example, a health plan
could improve access to care by expanding its provider network (a structure change) or
by changing its authorization procedures (a process change).
Elements of Quality Improvement
To be effective, changes to structures and processes must include the following
elements:
Planning. Before taking any action, a health plan must identify where
improvement is needed, define desired outcomes, identify causes of problems
and barriers to change, and decide what actions are most likely to achieve the
desired outcomes.
Quality Assessment and Improvement
Page 13 of 15
Implementation. Tasks are assigned to departments and individuals, target
dates set, activities monitored, and completion tracked.
Evaluation. After changes are implemented, outcomes are measured and
compared to previous performance and to the goals set. Evaluation is ongoing
repeated measurement and analysis provide a "moving picture" of the quality
improvement effort, showing whether it is having a positive effect over time.
When goals are not being met, problems or barriers can be identified and
changes made or additional actions taken.
Communication. The health plan must convey information about its quality
improvement efforts and the results through the organization and to its
customers. Effective communication helps define and support the plans mission,
satisfy members expectations, improve provider performance, and demonstrate
health plan value.
Documentation. Accrediting organizations and regulatory bodies require health
plans to provide documentation of quality improvement assessment, planning,
and evaluation. They also require documentation of the actions planned,
responsible parties, and intended completion dates. This provides a written
record of the health plans activities and their impact on its customers.
Quality Improvement Approaches
Health plans use a variety of strategies and tools to improve quality. We will describe
some of the most common.
Benchmarking
Benchmarking is one of the most effective quality improvement methods. It consists of
identifying for a process the best practices that produce the best outcomes and
reproducing those practices in an effort to equal or surpass those outcomes.
Example (improving service quality): A health plan wants to improve member
satisfaction with claim resolution. The plans managers identify another plan with
extremely high customer satisfaction in this area, analyze its practices, and
implement them.
Examples (improving healthcare quality): A health plan identifies a hospital with
extremely high survival rates for patients undergoing coronary artery bypass surgery.
It uses that hospitals practices to develop clinical practice guidelines for treating
such patients.
Medical best practices are widely accepted in healthcare professions, so their use by a
health plan is generally supported by the plans providers.
Clinical Practice Guidelines
As noted in our discussion of utilization management, clinical practice guidelines are
based on approaches that have been proven to be successful. They are used to help
Quality Assessment and Improvement
Page 14 of 15
providers consistently deliver services that will improve their patients health and reduce
unnecessary variations in patient care.
Clinical practice guidelines can be developed in-house by joint health plan-provider
committees. Or they can be obtained from outside sources such as the National
Guideline Clearinghouse (NGC), a joint venture of the AMA, the federal Agency for
Healthcare Research and Quality (AHRQ), and America's Health Insurance Plans
(AHIP). Other sources are professional associations such as the AMA, the American
Academy of Pediatrics (AAP), and the many associations of medical specialists. Like
best practices, clinical practice guidelines are generally accepted and supported by
providers.
Provider Profiling
Provider profiling involves collecting and analyzing information about the practice
patterns of individual providers. It is used during credentialing and recredentialing to
determine how well a provider meets a health plans standards. Profiling also identifies
providers whose practices vary significantly from the normthey may use substantially
more or fewer resources than other providers, or they may use them differently. By
analyzing providers practice patterns, the health plan can sometimes determine whether
an individuals patterns produce better or worse outcomes and whether they are cost-
effective.
Provider profiling can be useful, but it can also be controversial. It is commonly used to
educate providersfor instance, a plan might inform a pediatrician that his immunization
rates for children are much lower than his peers, and this should encourage him to
assess his practices. But some health plans have acted punitively toward providers
based solely on utilization rates or have posted such information publicly, and they have
found themselves involved in class action lawsuits. As discussed above under
outcomes, comparing providers statistically can be complex and difficult, requiring
adequate risk adjustment, and consequently it may be difficult to demonstrate that
comparisons are valid and fair and defend a punitive or public action.
Peer Review
In peer review a panel of medical professionals evaluates the care delivered by a
provider. Unlike profiling, peer review is not based primarily on statistics. Peer review
can focus on a single episode of care or take a broader look at a providers practices.
The appropriateness and timeliness of the services delivered are reviewed, as well as
outcomes and in some cases patient perceptions (as when a member complaint or
negative responses to satisfaction surveys have been received). Results can be used to
educate a provider and identify opportunities for improvement or to provide a measure of
quality.
One advantage of peer review is that a physician is likely to more receptive to education
and recommendations offered by other physicians than by health plan administrators.
And should a health plan have to take disciplinary action against a provider (such as
termination of his contract), that action will be easier to defend if it is based on the
recommendation of a committee of his peers.
Quality Assessment and Improvement
Page 15 of 15
Notes

1
Landon, Bruce E.; Zaslavsky, Alan M.; Bernard, Shulamit L.; Cioffi, Matthew J.; and Cleary, Paul
D. 2004. Comparison of Performance of Traditional Medicare vs. Medicare Managed Care,
Journal of the American Medical Association (JAMA), 2004, 291(14):1744-1752.
2
National Patient Safety Foundation. www.npsf.org
3
Kohn, Linda T.; Corrigan, Janet M.; and Donaldson, Molla S., editors. 1999. To Err Is Human:
Building a Safer Health System. Institute of Medicine. www.iom.edu/reports.
4
Institute of Medicine. 2006. Preventing Medication Errors (Quality Chasm Series).
www.iom.edu/reports.
5
Kohn, Corrigan, and Donaldson. 1999.
6
Quoted in the Encyclopedia of Surgery, Medical Errors www.surgeryencyclopedia.com/La-
Pa/Medical-Errors.html

Você também pode gostar