Tools%20of%20Managed%20Care%20and%20their%20Potential%20Contribution%20in%20Controlling%20AIDS%20and%20Drug%20Abuse

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Tools of Managed Care and their Potential
Contribution in Controlling AIDS and Drug Abuse
by Constance Horgan, Sc.D.
August 16, 2004
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Outline of Presentation

• What is managed care?
• Using performance measurement to achieve quality

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Managed Care Dominates Health Care in U.S.
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What is Managed Care?

• Characteristics
• Utilization Management
• Selective Contracting
• Provider Payment
• Quality Assurance

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Health Plan Enrollment for Covered Workers, by
Plan Type, 1988-2001
Source Employer Health Benefits, 2001 Annual
Survey, The Kaiser Family Foundation and Health
Research and Educational Trust, Exhibit 6.1,
p.75. See www.kff.org.
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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).
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).
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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)
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Classic Framework for Quality Measures

• Structure
• Access
• Process
• Outcomes
• Patient Experience

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Use of Performance Measures

• Accountability
• Quality Improvement

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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)