Quality and the medical marketplace - following elephants

Article Abstract:

It may be difficult to measure and enforce quality in the managed care industry. The quality of health care may suffer as managed care organizations (MCOs) try to cut costs. However, it is very difficult to evaluate the quality of MCO services. MCOs tend to enroll healthy people and use statistics on procedures such as immunization and mammography rates to demonstrate quality. But it is the quality of treatment for chronic illnesses that is most likely to suffer under managed care. And this is very hard to measure because chronic diseases are complex and individuals may react differently to treatments.

Evaluation, Medical care, Quality management, Medical care quality

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Risk adjustment or risk avoidance?

Article Abstract:

An attempt by the Health Care Financing Administration (HCFA) to pay managed care plans according to how sick their Medicare patients are may fail. In the past, plans were paid 95% of the costs of fee-for-service Medicare. However, most Medicare beneficiaries in managed care are healthier than those in fee-for-service. Thus, the payments were very generous. When Congress ordered HCFA to adjust the payments based on the patient's diagnosis, approximately 100 managed care plans said they would no longer accept Medicare patients. Risk-adjustment systems based on diagnosis are very difficult to implement.

Analysis, Management, Risk assessment, Finance, Capitated payment systems (Medical care)

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Evaluation and management guidelines - fatally flawed

Article Abstract:

Physicians should not accept the 1998 guidelines from the Health Care Financing Administration for reimbursing physicians for treating Medicare patients. These guidelines require physicians to learn complicated coding procedures to prevent Medicare fraud. Physicians at the June meeting of the American Medical Association loudly protested these guidelines. In response to this outburst, HCFA intends to modify the guidelines and to test them before implementing them.

Standards, Compensation and benefits, Physicians, Medical professions, Relative value scale payment systems (Medical care)

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