Printer Friendly

Quality assurance in an IPA setting.

Quality assurance programs have been operating in hospitals and in group and staff model health plans for years. Quality measurements have been relatively easy to obrain, depending on the interests and resources of the health care entity. In the group-and staff-model plans within CIGNA, it is generally possible to evaluate the level of health care provided to the membership and the clinical quality of the care of individual providers. With the IPA model, however, most organizations have been uncertain as to how to implement a cost-effective quality assurance pgoram, especially as start-up IPAs do not break even for two or three years or more.

The CIGNA IPA network in San Diego, Calif., was activated as of July 1987. In 1989, it had 44,000 members, about 1,300 providers, a geographic area of 4,261 square miles, and a seven-person provider relations (PR) staff, including three clerical employees and a nurse manager. One clerical person was an addition to the staff for tracking our quality assurance program, and several of the staff also had responsibilities in the quality assurance area. The PR staff had quarterly meetings with a quality assurance committee formed from the San Diego provider network.

Personnel Management/Human


Most health care organizations, including HMOs, face shrinking financial resources, forcing close scrutiny of how to efficiently manage high administrative and staff and salary costs. The variety of medical care products, the increasing numbers of provider organizations, the large numbers and complexity of benefit designs, linked supplements and claims billing/patient visits information have expanded demands on providers. PR coordinators were hired at CIGNA to provide educational materials and orientation regarding health plan policies and procedures to all providers.

The number of such people needed by a health care organization will vary over time, depending on:

* Total numbers and types of providers, i.e. primary and specialty physicians and ancillary/allied providers--home health workers, mental health workers, nonphysician staff, hospitals, pharmacies, physical thereapists, ambulatory surgery and urgent care centers, etc.

* Geographic distribution, freeway access, and size of service area.

* Number and complexity of benefit packages.

* Number of competitors/health care organizations in market.

* Billing and information systems requirements.

* Stability of network arrangements--frequency of contract changes, policy and procedure changes, etc.

Provider relations departments in CIGNA have reported either to the medical director or through operations to th general managers. The functions of a provider relations staff were initially not considered to be a medical director's responsibility because they related to the business interface between the health plan and provider. However, there are advantages to integrating utilization management, quality assurance, and provider relations activities under a medical director, for example:

* A single stream of consistent information goes from the medical department to providers.

* Close cooperation is achieved between provider relations and utilization management, without territorialism.

* Intradepartmental communication is eased--each manager attends the other's staff meetings.

* Willingness to fill in when the other department is short-staffed leads to leaner staffing.

* Quality management is the responsibility of both utilization management and provider relations departments, i.e., work loads can be equalized and provider problems shared.

Such a plan would be less likely to succeed if the medical department does not have an appropriate strategy/understanding of the health plan's goals, is not service oriented with respect to the provider network, or cannot manage human resource issues.

Initial Training

When the San Diego CIGNA plan first became a countywide IPA network contracting through five IPA entiries, its three provider relations staff members reported to operations. None were experienced--once came from the consummer service department, one from memebership, and one from marketing. After several months of difficulties, the general manager requiested that the medical department assume the responsibilities. A basic training program for the staff was initiated and included review of:

* CIGNA's Group Service Agreement, our objectives, and the roles and responsibilities of a provider relations coordinator.

* Contracts with primary care and specialty care physicians.

* Credentialing requirements and their rationale and the relationship of the provider relations program to the quality management program.

* Presentation skills, with critiqued dress rehearsals.

* Recruitment of new physicians by specialty and geographic area.

* Provider handbooks and the format for newsletters.

* Department policies and procedures, with attention to geographic segmentation of responsibilities to enable travel efficiency, accountability, and provider identification with a specific person.

* Provider's office staff, billing, claims system and relationship to CIGNA orientation and education materials.

* Relative value scale and and CIGNA claims systems.

* All lines of CIGNA businesses and their effect on providers.

Early Initiatives

Faced with the task of providing quality assurance functions with no initial budget, I decided to approach it from a different angle. I felt that we could obtain information on our members' health status through laboratories with which we had contracts. The idea of using a laboratory provider in the quality assurance process was conceived during may previous negotiations at the corporate level when contracting with a national laboratory provider for several of our staff model health plans. In 1986 and 1987, part of CIGNA's contract with these laboratories included the stipulation that they provide us information on a monthly basis on laboratory utilization by physician and by member. Included in our information requirement was a monthly tabulation of all
Category Percentage of I, II, III quarterly
Breakdown smears for each lab annually
Member-Pap Percentage of women ages quarterly
Rates 18 to 65, as function of annually
 total membership, receiving
Provider Percentage of appropriately quarterly
Compliance followed Class II and III annually
Level smears per physician and IPA
 (where identifiable)

CIGNA members who had abnormal paps. Each health plan could then review members' medical records, using the pap list provided, to ensure appropriate follow-up had occurred.

The objectives of this program were:

* To determine the percentage of appropriately followed Class II pap smears and above.

* To identify and notify providers not meeting standards of car (poor follow-ups or no paps on women needing them).

* To obtain appropriate follow-up for members where needed.

Guidelines of the American college of Obstetrics and Gynecology were used. The table above shows the types of reports and data that this initial CIGNA program generated.

In the San Diego health plan, we enhanced the program. The laboratories provided a list of all paps performed and the CIGNA computer system provides the number of women in the 18-65 age goup so that we can calculate how many women actually came in for routine paps. We also follow up on patients with abnormal results by doing provider record review.

The process of obtaining records from physician offices was laborious. Some members refused permission for release of the data. A copy of the California Code was sent to physicians to demonstrate that CIGNA was allowed access to the information without the member's specific permission. This solved the access problem. We also took steps to reduce our clerical work load. We required laboratories to send pap retesting reminders for members to physicians' offices. This way, we could scrutinize the monthly lists we received from the labs for the names of members who should be retested. We did not contact physicians unless the test had not been performed.

Preliminary results from the IPA plan indicate that the level of pap testing done is low. It appears that, in spite of our encouraging women to go to their doctor for paps, many still don't or won't. However, the program is a start at answering the question, "How well does CIGNA Healthplan do preventive medicine?" "Can we demonstrate that we make a difference to a population's (employer group's) health status?"

We then developed a similar program to track statistics on mammography performed by IPA radiologists. The concept mirrors the pap study in that CIGNA can track whether members accept the prevention guidelines and whether doctors do appropriately follow up on abnormal mammograms.

During 1989, we conducted two additional studies, one to assess immunization levels of children ages 6-24 months, and one to audit hospital discharges with readmissions within 30 days. Both studies require review of physicians' medical records. Reviews of patients with 30-day readmissions are triggered by a member of the utilization review staff. Medical records are obtained from primary care physician offices for peer review.

These four studies are fairly ambitious for a young IPA. However, by requiring contract providers to help with information on the first two projects, we were able to accomplish the studis using a clerical person, supervised provider reltions coordinators, and a nurse manager. The quality management program can expand and evolve, looking constantly at the cost-effectiveness of ideas to adopt. The results are reported to the plan's QA committee and to all providers or members via newsletter.

At he time this article was written, J. Sim Tan, MD, FACPE, was Senior Vice President and Medical Director, CIGNA Health-plans of California, San Diego. She is now Medical Director, Travelers Health Network, San Diego. Dr. Tan is Chair of the College's Roundtable and of its Forum on Women in Medicine and Management. She is also an Associate Member of the Societies on Federal, State, and Local Government and on Managed Health Care.
COPYRIGHT 1991 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:independent practice association-model health maintenance organization institutes effective quality assurance measures
Author:Tan, J. Sim
Publication:Physician Executive
Date:May 1, 1991
Previous Article:Meta-analysis: apples and oranges, or fruitless.
Next Article:Myths and misconceptions of the medical staff organization.

Related Articles
Physician fee-setting requires scrutiny.
What's ahead on quality: the managed care perspective.
Risk management in an IPA setting - part I.
Risk management in an IPA setting.
The appointment-keeping habits of managed care patients.
Quality assessment tools add value.
Teaching clinic lowers pharmacy costs: how to achieve more cost-effective prescribing. (Prescription Drugs).
Discover the key to HMO bad-faith cases: effective discovery will unlock the potential of your client's bad-faith claim against a managed-care health...

Terms of use | Copyright © 2017 Farlex, Inc. | Feedback | For webmasters