Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University Tools of Managed Care and their Potential.

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Presentation transcript:

Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University Tools of Managed Care and their Potential Contribution in Controlling AIDS and Drug Abuse by Constance Horgan, Sc.D. August 16, 2004

Outline of Presentation 1.What is managed care? 2.Using performance measurement to achieve quality

Managed Care Dominates Health Care in U.S.

What is Managed Care? Characteristics Utilization Management Selective Contracting Provider Payment Quality Assurance

Health Plan Enrollment for Covered Workers, by Plan Type, Source: Employer Health Benefits, 2001 Annual Survey, The Kaiser Family Foundation and Health Research and Educational Trust, Exhibit 6.1, p.75. See

Adapted from: Hodgkin D, Horgan CM, Garnick DW. Make or buy: HMOs’ contracting arrangements for mental health care. Administration and Policy in Mental Health 1997; 7(4). 7 Adapted from: Hodgkin D, Horgan CM, Garnick DW. Make or buy: HMO’s contracting arrangements for mental health care. Administration and Policy in Mental Health 1997; 7(4).

What is Performance Measurement? Health care performance measurement is the process of using a tool based on research (performance measure) to evaluate a managed care plan, health plan or program, hospital, or health care practitioner. Performance implies that the responsible health care providing entity can be identified, held accountable, has control over the aspect of care being evaluated. (Source: Understanding Performance Measurement www/ahcpr.gov/chtoolbx)

Classic Framework for Quality Measures Structure Access Process Outcomes Patient Experience

Use of Performance Measures Accountability Quality Improvement

Performance Measure Example Problem - High Drop-Out Rate in Treatment Goal – Engage Client in Treatment Ultimate Outcome abstinance employment stay out of jail How – pay providers based on how well they do in engaging clients in treatment Continuous Quality Improvement (CQI)