sanctions or consequences, such as loss of accreditation, loss of participation in Medicare or Medicaid, and/or loss of market share. With respect to HIV prenatal testing, few, if any, health care plans currently hold their providers accountable for a high rate of HIV prenatal testing. To implement this recommendation, groups that develop performance measures, such as the National Committee for Quality Assurance (NCQA), should develop and adopt specific performance indicators for prenatal testing.

The Group Health Cooperative has decided to measure "the proportion of pregnant women with chart documentation of informed consent or refusal for HIV antibody testing within three months of the initiation of pregnancy." The long-term goal, or "optimal performance," has been set at 95%. This is compared to approximately 50% in mid-1997, before the program described above was put into place. The Jefferson County (Alabama) health department has a reporting system that could be used to measure HIV testing rates in its prenatal clinics, but it does not link performance to specific rewards or sanctions (Appendix F).

Health plans can be held accountable for offering prenatal HIV tests or actually performing them. Estimating the proportion of women who are offered tests can be cumbersome because it relies on chart review, but some have suggested that this approach is preferable where testing is not mandatory, so that voluntary testing does not de facto become mandatory. It is usually easier to calculate the proportion of women who are actually tested because laboratory data frequently are computerized (Appendix D). Given the committee's emphasis on universal routine testing, the proportion of women in prenatal care actually tested would be an appropriate performance measure. Health care plans must, however, ensure patient confidentiality and guard against coercive testing when patients refuse to be tested.

Another approach to integrating public health goals and clinical practice is the development of contract language for managed care plans. In particular,

The committee recommends that health care purchasers adopt contract language supporting a policy of universal HIV testing, with patient notification, as a routine component of prenatal care.

If universal HIV testing with patient notification is to become a routine component of prenatal care, contracts should not allow health insurers to deny benefits under "pre-existing conditions" or similar clauses based on the client's HIV status.

In 1997, as documented in Chapter 5, most women, and more than one-half of all Medicaid recipients were enrolled in some sort of managed care plan. The essence of managed care is that some entity is responsible for maintaining the health of every individual. This can be a major advantage when it comes to incentives to provide preventive services, such as prenatal care. Under fee-for-service systems, no one can be held responsible for pregnant women getting

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