Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Other Quality Initiatives


everal other quality improvement initiatives are a part of the "quality tool kit," although there is even more diversity in approaches for these various initiatives. Some of these are defined by NCQA accreditation requirements, which have been adopted by many states. For example, to establish a basic standard of provider quality, NCQA requires that all health providers be credentialed. For physicians, the credentialing process involves verifying licensure and hospital privileges, review of provider sanctions and malpractice history, and conducting a structured review of the provider’s office, among other things.

Another critical aspect of NCQA accreditation is that complaints and grievances should be addressed quickly with a standardized approach, and that the data from this process should be analyzed to identify patterns. Our respondents did not provide concrete information on how this is done, or how frequently, but it was mentioned by several states as an important quality monitoring tool (e.g., in California, Florida, and Texas).

If we’ve got items that escalated to complaints and you start seeing a trend to the complaints, same HMO, same providers, or same class or grouping of people [we are concerned]. (State Official)

Another important quality improvement tool is intensive care coordination for high risk groups, in order to assure appropriate health services. This can take a variety of forms. For example, one health plan hired pharmacists to identify those members that were taking more than six drugs, and to identify possible contraindications of particular groups of medications. They contacted the enrollee and his or her doctor to determine whether all of the medications were necessary. In addition, some plans offer social services in addition to health services to high-cost users. The medical home model is a special case of this increased emphasis on care coordination. For example, Arizona is considering whether to provide financial incentives for plans that establish medical homes.

Another quality improvement approach is to use advice lines to assure ready access to physician advice after hours, along with electronic medical records that provide the consulting physician or nurse with ready access to information.

We created a service for 24-hour physician calls… and we have technology to make sure they have access to the medical records. The doctor can really talk to you and the doctor knows something about your child and knows what medicines/ diagnoses [he has]. (Plan Representative)

A final example of a quality improvement tool mentioned by study states is the "report card" or "dashboard" approach. While the formats and methods vary widely, at a minimum states may post the HEDIS/CAHPS scores on their web site. Some states, such as Maryland, have taken a more proactive approach. Maryland’s EQRO creates an easy-to-read chart which ranks health plans according to their scores for access to care, doctor communication, service, preventive health care, and diabetes care. This chart is then sent with enrollment materials to help new enrollees choose their health plans.

Similarly, health plans may choose to compare their contracted physicians in a similar manner, and to share the results with all providers.

We have quality reports to share with providers that indicate usage of medicines and proper protocols and who is practicing outside the norm of their peers. (Plan Representative)

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