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

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

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

3. Managed Care Dominates Health Care in U.S.

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

5. 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.

6. 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). 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

7. 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)

8. Classic Framework for Quality Measures • Structure • Access • Process • Outcomes • Patient Experience

9. Use of Performance Measures • Accountability • Quality Improvement

10. 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)