The care accorded to patients serves as the motivation for managed care organizations (MCOs) since their objective is profit making. The managed care organizations not only seek to increase the number of their enrollees but also the long term relationship they have with them for customer satisfaction and loyalty. However, the issues of concern for managed care organizations are the quality, access and cost of care. The measurement of the quality of care and services offered provide the basis for the improvement of the health care delivery system. Generally, the quality assessment for health care organizations has been challenging due to the inconsistency of measures and application in all organizations. Despite this challenge, there are various standard measures that are used to guide the stakeholders and policy makers in health. This paper provides a summary of the quality standards and measures used, analysis of the factors that influence the quality of care in health care organizations and the organizational ratings.
Quality Standards and Measures used in Managed Care Organizations
The assessment of quality in health care organizations is based on the health and human services that are found in such organizations. Quality assurance has been defined as the actions taken for establishing, protecting, promoting and improving the overall quality of healthcare services (Donabedian & Bashshur, 2003). While aimed at enhancing the quality of health care services provided, it is categorized into the design of systems and resources, and the monitoring of performance and readjustments for improvement. The measurement of quality is mainly based on inputs to care and other process measures, and the output measures mostly based on the outcomes of patients(Shi & Singh, 2008).
The measures of quality that are used are usually formulated by the Health and Human services (HHS) through the aggregates of measurement outcomes. They include the quality indicators such as the Healthcare Effectiveness Data and Information Set (HEDIS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) databases (U.S. Department of Health & Human Services, 2010). These are usually the publicized measures. However, the HHS, which is the governing body in ensuring quality standards are maintained, considers also the unpublicized quality indicators which are made up of structural factors. Quality standards include the other factors as the formulation of criteria and standards as set by the health care organizations. This is based on issues such as the involvement in research, the quality of staff in terms of competence, integrity and commitment to serving of patients, equipment and machinery used, record and archive records as well as the reports form the outcomes. Quality assurance is the overall responsibility of the policy makers, health care providers, patients and the government all working collaboratively with information collection mainly through scorecards being emphasized for quality improvement.
Quality is faced with challenges of lack of standardization of factors, which are also inconsistent and with price variations. The outcomes of patients also do fail to fit in the overall group outcomes which makes it rather subjective. Additionally, the differences in the health care organizations affect the objectivity and reliability of quality measures (Wagner, 1998).
Factors that Impact on Care and Quality of Managed Care Organizations
The health care sector is a service industry and is affected by factors that range from individual to structural differences. The factors that determine the quality of care include: the cost of care which limits the level of service offered, equipment available and other resources that impact on health care (Shi & Singh, 2008). Other factors include structural issues such as the teaching inclusion in health care, ownership and level of management of organizations as well as the types or specialization in a condition. Geographical factors also play a key role in health care since they determine the ability of patients to access it and availability of health resources (Donabedian & Bashshur, 2003).
Organizational Ratings in Terms of Quality
The rating of organizations in terms of quality is based on the outcomes from the quality measures and indicators with the use of comparative measures. Although quality is said to be homogenous between health care organizations, it differs due to the influence of the factors that affect such quality. The rating of health care organizations based on structural factors shows that the teaching hospitals rank highly than the non-teaching hospitals, while the privately owned healthcare organizations are also ranked higher than the publicly owned health care organizations (Donabedian & Bashshur, 2003). Acute care hospitals, accredited hospitals, and those offering emergency services have higher quality ratings due to the high levels of investment required for that. The differences in standards affect the level of care offered due to the motivation of personnel in high quality hospitals and their professionalism hence their ability to offer good care unlike those in low quality hospitals. However, quality ratings are likely to influence the cost of health care with the high quality hospitals offering costly services due to their high investments compared to the low cost organizations. The reports of comparison show that the San Francisco hospital performed better than New York Down Town hospital. The likely reasons for this would be the number of patients in New York being larger than that of San Francisco thus limiting the ability of the professionals to offer individualized services to each patient as well as time constraints (U.S. Department of Health & Human Services, 2010). Further, the rating on the process care measures shows that New York was at a position of offering quality service because its geographical location endowed it with adequate resources, but it carried out unnecessary follow up.
The quality assurance in health care organizations is an overall broad sector which is very necessary for improvement of quality care offered in health care organizations. The quality, care and costs of health care are closely related. This paper has summarized the quality measures available for health care organizations, factors that influence the quality of care as well as evaluated the organizational ratings.
Donabedian, A., & Bashshur, R. (2003). An introduction to assurance in health care. New York, NY: Oxford University Press.
Shi, L., & Singh, D. (2008). Delivering health care in America: A systems approach. New Jersey, NJ: Jones & Bartlett Learning.
U.S. Department of Health & Human Services. (2010). Medicare: Hospital Compare. Web.
Wagner, E. (1998). Managed care and chronic illness: Health services and research needs. Health Services Research, 32(5), 702-714.