SYNOPSIS OF HEALTH CARE QUALITY 

MANAGEMENT SYSTEMS 

Administration for Community Living CBO Learning Collaborative Webinar 

 Presenter: Sharon R. Williams, Health Care Consultant 

 April 2, 2014 

 
QUALITY ASSURANCE: 

CONCEPTUALLY* 

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• Quality Management goals should include: 

• Excellent care, strong coordination, high consumer satisfaction and good consumer health 

outcomes 

• *Quality Assurance 

• The Institute of Medicine (IOM) defines quality as ―the degree to which health services for individuals 

and populations increase the likelihood of desired health outcomes and are consistent with current 

professional knowledge. 

• *Quality Improvement 

• The Agency for Healthcare Research and Quality (AHRQ) defines quality improvement as ―doing the 

right thing at the right time for the right individual to get the best possible results. 

*Medicare Part C Manual 

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COMPONENTS OF QUALITY

MANAGEMENT

• Adoption of medical quality management standards of care/QIP 

• Establishment of Quality Improvement Committee 

• Utilization Review 

• Quality Management Studies 

• Network Credentialing/Oversight 

• Grievance and Appeals Review 

• Member Satisfaction 

• Program Evaluation/Reporting/Process Improvement 

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IMPLICATIONS FOR QUALITY 

MANAGEMENT SYSTEMS 

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GENESES OF QUALITY 

MANAGEMENT 

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FEDERAL/STATE QUALITY DRIVERS 

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• Medicare/Medicaid Standards 

• Dual demos 

• Medicaid Waivers 

• Model of Care 

• ACO 

• ACA 

• Federal HMO Act 

• State health insurance regulations and legislative edicts 

• Dual Demos’ Memoranda of Understanding 

• Agency for Healthcare Research and Quality/Consumer Assessment of 

Healthcare Providers/Systems (CAHPS) 

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STATE REGULATORY AUTHORITY 

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• Michigan INSURANCE CODE OF 1956 (EXCERPT) Act 218 of 1956

• 500.3508 Quality assessment program; quality improvement program. 

• Sec. 3508. 

• (1) A health maintenance organization shall develop and maintain a quality assessment program to assess the quality of 

health care provided to enrollees that includes, at a minimum, systematic collection, analysis, and reporting of relevant 

data in accordance with statutory and regulatory requirements. A health maintenance organization shall make 

available its quality assessment program as prescribed by the commissioner. 

• (2) A health maintenance organization shall establish and maintain a quality improvement program to design, measure, 

assess, and improve the processes and outcomes of health care as identified in the program. A health maintenance 

organization shall make available its quality improvement program as prescribed by the commissioner. The quality 

improvement program shall be under the direction of the health maintenance organization's medical director and shall 

include: 

• (a) A written statement of the program's objectives, lines of authority and accountability, evaluation tools, including data 

collection responsibilities, and performance improvement activities. 

• (b) An annual effectiveness review of the program. 

• (c) A written quality improvement plan that, at a minimum, describes how the health maintenance organization 

analyzes both the processes and outcomes of care, identifies the targeted diagnoses and treatments to be reviewed 

each year, uses a range of appropriate methods to analyze quality, compares program findings with past performance 

and internal goals and external standards, measures the performance of affiliated providers, and conducts peer review 

activities. 

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CONTRACTUAL QUALITY DRIVERS 

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• Medicare Part C regulations 

• Model of Care (MOC) 

• State Medicaid Contracts 

• ACO contracts 

• Employer Contracts 

• Quality Report Cards 

• Contractual incentives/penalties for rate setting, enrollment priorities and 

bonuses tied to quality performance 

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ACCREDITATION 

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• ‘Accreditation is an evaluative, rigorous, transparent, and comprehensive process in 

which a health care organization undergoes an examination of its systems, 

processes, and performance by an impartial external organization (accrediting 

body) to ensure that it is conducting business in a manner that meets predetermined 

criteria and is consistent with national standards.’*

• Joint Commission on the Accreditation of Healthcare Organizations JCAHO) 

• URAC 

• National Committee for Quality Assurance (NCQA) 

*As defined by URAC 

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HEALTH ORGANIZATION MISSION 

DRIVEN QUALITY 

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Beyond external drivers, many health plans are organized for the delivery of 

quality health care as defined in their mission/vision statements. 

• ‘Our mission is to help people live healthier lives by ensuring access to health care coverage for 

the underserved. We accomplish that mission through innovative strategies like our Winning 

Priorities approach, and through innovative programs such as the Personal Care Model, Healthy 

First Steps, and disease management.’ United Health Care Community Plan 

• ‘AmeriHealth Caritas is a different kind of mission-driven health care organization. We've been dedicated to helping the 

underserved for 30 years. Wherever our members live, we reach them in ways they understand - with outcomes-driven care that 

enhances their quality of life...’ Amerihealth Caritas Plan 

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COMMON CLINICAL AND NON 

CLINICAL PERFORMANCE INDICATORS 

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CONVENTIONAL HEALTH CARE 

QUALITY INDICES 

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 HEDIS 

• Preventative/Well Care 

• Flu Shots for Adults 

• Smoking Cessation 

• Older Adult Measures 

• Fall Risk Management 

• Osteoporosis Testing in Women 

• Chronic Disease Management 

• Comprehensive Diabetes Care 

• Appropriate Medications for Asthmatics 

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HEDIS 

• The Healthcare Effectiveness Data and Information Set

• NCQA owned reporting tool 

• Used by more 90 percent of America's health plans-allows cross plan comparisons 

• Measures performance on important dimensions of care and service. 

• 75 measures across 8 domains of care. 

• Required reporting for Medicare Part C plans, most state Medicaid programs and 

Dual Demonstrations 

• Based on health plan encounter/claims, medical record data, etc. 

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MODEL OF CARE 

• Required for Medicare Part C Special Needs Plans (SNPs) and participating 

Dual Demonstration health plans 

• Health plan roadmap providing high quality care to the target population 

• MOC reviewed by NCQA on behalf of CMS 

• 11 elements, including: 

• Target Population definition/needs 

• Case Management protocol 

• Interdisciplinary Care Team 

• Overview of Quality Improvement Program, including ID of Quality Improvement 

Projects/Chronic Care Improvement Programs (CCIP) 

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MOU 

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• Precursor to 3 way contract between feds, state, health plans for dual 

demonstrations—contract blue print 

• Details the principles under which CMS/state and contracted plans will implement 

and operate the dual demonstration 

• *Contains plan specific expectations, including quality performance indicators, such 

as: 

• Customer Satisfaction (CAHPS) 

• % of enrollees with initial assessments completed w/in 90 days of enrollment 

• Follow up after hospitalization for mental illness 

• Readmission rates (30 days) 

• Reducing the risk of falling 

• Nursing facility diversion 

*OH MOU 

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STAR RATING 

• Medicare specific rating system for contracted plans 

• Score--1-5, ‘5’ is highest. High scoring plans get ‘bonus’ which can be 

applied to plan premiums/co pays to reduce member costs—enrollment 

incentive. Plans rated 2 or below may be subject to termination/enrollment 

restrictions 

• Uses HEDIS, CAHPS and other data sources for evaluation 

• 9 domains/53 measures including: 

• Staying healthy-screenings/testing 

• Managing chronic conditions 

• Health plan responsiveness 

• Member complaints/appeals 

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ALIGNMENT OF QUALITY MANAGEMENT 

BETWEEN CBOS/HEALTH PLANS 

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• Utilization Review 

• Healthier Outcomes 

• Consumer Satisfaction 

• Population Based Quality Improvment (MOC) 

• Data analyses/evaluation/process improvement 

• Financial incentives 

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CRITICAL RESOURCES FOR CBOS 

• MOU/Dual Demonstration 3 Way Contract 

• Medicare Manual—Quality Management Chapter/MOC 

• NCQA/HEDIS and other accreditation entity standards 

• CAHPS 

• ACO contract 

• Medicaid Contract 

• Standard Health Organization Provider Agreement 

• Health Organization Quality Improvement Plan 

• Health Plan Report Cards 

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REFERENCES 

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• https://cahps.ahrq.gov/ -- Consumer Assessment of Healthcare Providers and 

Systems (CAHPS) 

• http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2014/

Mar/1724_Zainulbhai_care_integration_dual_eligibles_ib.pdf --Assessing Care 

Integration for Dual-Eligible Beneficiaries: A Review of Quality Measures Chosen by 

States in the Financial Alignment Initiative (Issue Brief from The Commonwealth Fund) 

• http://www.ncqa.org/HEDISQualityMeasurement.aspx -- Healthcare Effectiveness 

Data and Information Set (HEDIS) 

• http://www.cms.gov/Outreach-andEducation/Training/CMSNationalTrainingProgram/Downloads/2013-5-StarEnrollment-Period-Job-Aid.pdf -- Medicare health plan star ratings 

• http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Quality_Measures_Standards.html -- Medicare 

Shared Savings Program (Accountable Care Organization) Quality Measures and 

Performance Standards 

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THANK YOU!!!!! 

MORE ???? 

sharonr.williams@comcast.net 

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