Getting the Best Out of Managed Care Fact Sheet 2: Understanding Quality Measures

Executive Summary

This fact sheet provides consumer-oriented information about understanding quality measures in Medicaid managed care plans.

What can I learn from this fact sheet? 
In order to figure out whether one health plan is better than another one, you need to have a way to measure each plan. In this fact sheet, you will learn what measurements are used to look at how well a health plan works.
Why is it important to understand quality measures? 
If you understand the quality measures, the information can be more helpful to you.

For example, suppose you ask a friend to judge two soda drinks, A and B, which are in two different glasses. Your friend tries each drink and then tells you that soda B is better. What made your friend decide that B was better? Did it have more bubbles? Was it sweeter? Did your friend like B?s color better? You would probably want to ask your friend why he thought that B was better. You would be asking your friend what measures he was using to decide that B was ?better.?

Let?s suppose that your friend decided that B was better only because it was sweeter than A. If you do not like sweet drinks, then just knowing that B was ?better? wasn?t very helpful information to you. If you know what measures someone is using, then you can decide whether the results based on those measures are useful to you.

Knowing what measures are important to you applies in managed care quality information too. If you know what questions were asked and what information was looked at, you could better decide what information works best for you.

Each person wants different quality information. Do you want to know whether the doctors? offices are accessible by wheelchairs? Is it important to know whether the doctors speak other languages? Would you want to know how long patients have to wait for appointments? Each person will answer these questions differently.

Tip: Why not make a list of the things about a health plan or about doctors that are important to you? As you read the information about quality, you can see better what types of measures you will want to look for.

Keep in mind: No measure of a health plan is perfect. Each measure has its problems.

You should look at several different performance measures that are important to you. A plan may perform well on some things and badly on other things. It?s up to you to decide which measures are most important to you.

What should I know about standards of care? 
For almost every medical condition, there is a generally accepted standard of care for people who have that condition. The standard of care is the yardstick that you can use to compare the care that your health plan offers with a level of care that is generally recommended or accepted. The standard of care may be developed by a group of specialists or by advocates for people with special needs.

A standard of care may recommend how often a person sees her doctor, what types of tests should be done, and what kind of training the health care provider should have to give this type of care.


Be the Smart Consumer: Do you know the standard of care for your child?s special needs? If not, you may wish to contact the Title V agency near you or an advocacy agency for people with your child?s particular needs. At the end of this fact sheet, there is information on contacting those agencies.

What are performance measures?

Performance measures show how well or how badly a health plan is providing quality services and meeting its goals. Performance measures are used for accreditation and for putting together report cards for the plans. Health plans use performance measures on themselves to see how well they are doing. Agencies that regulate or purchase services from health plans use performance measures to
decide whether health plans are doing a good job.
What are the three main types of performance measures? 
The three main types of performance measures are:
  • Delivery system capacity;
  • Process measures; and
  • Outcome measures.
We?ll explain each of them next.
What is ?delivery system capacity?? 
This performance measure looks at how well a health plan is able to handle all the people it is supposed to serve. This measure looks at things like:
  • How many patients per doctor?
  • What kinds of doctors and specialists are in the plan?s network?
  • How well are the health care providers distributed around town?
  • Do the doctors and the health care facilities offer services in other languages?
  • Do the health care providers have proper training in what I need, including training in understanding other cultures?
  • What is the most time and longest distance that the plan expects patients to travel for care?
  • How long does a patient have to wait for an appointment?
  • How often do the doctors in the plan join or leave the plan?
  • Will my child have access to a pediatric special care center?
Why is delivery system capacity important? 
Knowing about delivery system capacity can help answer some of the questions you may have about a plan. You could use this information to compare it to the same information from another plan.

Suppose you knew that Plan A has a hospital and doctors? offices only three miles from your home. Plan B has a hospital and doctors? offices 25 miles from your home. Which plan is more convenient for your family?

If your child has a chronic health problem or condition and needs a doctor who has experience in a special area of medicine, you would look at delivery system capacity to see if a plan has the health specialists that your child will need. If your child has special needs, she will need a pediatrician with the proper training.

Compare the delivery system capacity to the standard of care for your child?s condition. If the standard of care requires that your child have access to a specialty care center, does the health plan include this option?

What are ?process measures?? 
Process measures look at what was done to care for the patient. These measures will look at how many visits patients have and the number of tests ordered for patients. Process measures include utilization data (how many times or how much the patients use the plan?s services) and encounter data (how much service is provided to each individual member of the plan).

As an example, suppose you had diabetes. It is very important for people with diabetes to see their health care providers regularly and to have their kidneys, feet, and eyes examined each year. The health care provider should show them how to check their skin for problems. The performance measures for Plan A show that people with diabetes only see their doctors and have their eyes and kidneys tested once every two years. Patients in Plan B see their doctors and get these tests each year, and the health care providers are expected to show patients how to care for themselves at home. Which plan is going to give you better care for your diabetes?


What are ?outcome measures?? 
Outcome measures look at the results of the plan?s health care services. Do the patients? lives get better? How often do people have to go back into the hospital for the same problem? Are people with chronic illnesses able to live independently or are they most often in an

Outcomes measures look at whether the health care improves a person?s life. For people with chronic illnesses, good outcome measures mean having a satisfactory or good quality of life.

How do performance measures work together? 
Let?s take the problem of childhood asthma. Asthma can be a difficult illness for children, and if it is not properly treated, can even lead to a child?s death. We can take the three different kinds of performance measures to figure out how well a health plan deals with childhood asthma.
Does the health plan have enough pediatricians? If a health plan does not have enough doctors who specialize in children?s health, then the plan does not have delivery system capacity.

How often do children with asthma see their doctors? If the children are not seeing their doctors regularly, then the plan may not be providing enough care to keep good track of the asthma. If the children are seeing their doctors too often, this would indicate that the health plan is not providing health education so that families can keep the asthma in control. Process measures that show too high or too low use of services could be problems. If you look at the standard of care for children with asthma, it will tell you how many visits to the doctor would be considered ?normal.? Of course, each person is different. But the health plan should compare well to the standard of care for asthma.

How well do the children with asthma live? If the children must constantly seek emergency care for their asthma, then the health plan would have poor outcome measures.
What are the problems with performance measures? 
There are several things that you will want to keep in mind when you are looking at performance measures.
Most process and outcome measures only look at what happens to patients who have been in the plan at least one year. People who leave the plan in less than a year do not get included. Also, people who are only enrolled for a short time, like many people
on Medicaid, are not included.
Because the information is so complicated, it sometimes takes two or three years to put the information together. Look at the year that the
information was collected. A plan can make big improvements or get a lot worse in two or three years time.
The information may not be complete. If a person receives health care outside of the plan, this health care will not be included in the plan?s measures. If someone needs to get care from a specialist that is not in the plan?s network, this care will not show up in the measures.

Performance measures may only be collected for certain areas of service. A health plan may concentrate on making those areas look good. If a health plan knows that someone is only going to measure how well it serves people with diabetes, then the plan may work harder with those patients with diabetes. Those performance measures will not tell you how well the plan serves people with heart problems or mental health needs.

Who puts the performance measures together?

There are a couple of organizations that put this information together.

As mentioned in Fact Sheet #1, NCQA uses HEDIS to measure performance. Many health plans, state agencies, and employer groups use HEDIS standards to compare health plans. The Child and Adolescent Health Measurement Initiative (CAHMI), originally developed at the Foundation for Accountability (FACCT), is a set of consumer-centered quality measurement tools. CAHMI is now a project at the Oregon Health & Science University. Some of the CAHMI measures are included in CAHPS surveys and HEDIS. Some health plans use the CAHMI measures to look at their own services. The Agency for Healthcare Research and Quality (AHRQ) also has developed the Consumer Assessment of Health Plans (CAHPS) survey. This survey is given to members of health plans to get their opinions about their health care providers and the care that they receive. Fact sheet #5 tells more about consumer surveys like CAHPS

Where can I get the results of these measures?

The HEDIS measures are put together in NCQA?s Quality Compass and the Health Plan Report Card. The Pacific Business Group on health uses HEDIS for its HealthScope. Some state health departments and Medicaid agencies use HEDIS measures and may have report cards using the measures. CMS requires HEDIS measures for all Medicare managed care health plans. See the end of this Fact Sheet to find out how you can get this information.

You can find links on this fact sheet and the other fact sheets in this series to many Web sites where you can see the results of these measures. State Web sites provide the information for free. Some other Web sites or companies may charge you for the results. You may also want to ask your health plan for the results of their performance measures.

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