Most state Medicaid agencies monitor utilization, outcomes, consumer satisfaction, and disenrollment, through either chart review or client survey. Some have engaged in collaborative quality improvement initiatives with health plans, providers, public health agencies, and community organizations in areas such as pediatric immunization and prenatal care. Medicaid agencies are also beginning to incorporate quality-based performance indicators and specifications into their contracting strategies. Some use quality information to assess potential contractors, whereas others (e.g., Massachusetts) hold contractors accountable for measurable service improvements that are spelled out in a set of contractual terms and purchasing specifications (e.g., provision of member satisfaction data, clinical indicator data from HEDIS, and voluntary disenrollment rates) (Darby, 1998).

Public Health Monitoring

Another set of important quality assurance activities involves public health monitoring. Here, cancer registries, surveillance systems, and national survey data are used to monitor the epidemiology of cancer, the prevalence of risk factors, and the use of preventive health services. The adequacy of the nation's public health programs and services is, in part, judged by whether or not public health goals are met—for example, those established as part of the Centers for Disease Control and Prevention's (CDC's) Healthy People 2000 initiative, which highlights cancer as a priority area. The cancer objectives call for decreases in site-specific death rates (e.g., breast, colorectal); improved primary preventive health practices (e.g., reducing cigarette smoking, reducing dietary fat intake); improved early cancer detection (e.g., increased use of breast, colorectal, and cervical cancer screening); and ensuring that cancer screening and diagnostic tests meet quality standards (i.e., Pap tests, mammograms). As of 1997, progress had been made for 12 of the 17 cancer objectives, but in many cases the improvements have been slight (NCHS, 1997).

State public health agencies are building links with local health plans and providers to monitor public health goals. Plans for the Missouri Health Indicator Set, for example, include integrating public health records on births, deaths, hospital discharges, and cancer (Darby, 1998). Some States (e.g., New York, Pennsylvania) track hospital admissions and outcomes associated with certain procedures in an effort to monitor quality. New York, for example, has since the late 1980s collected standardized clinical data for coronary artery bypass surgery (CABS) patients, producing and publishing risk-adjusted mortality rates for hospitals and surgeons, and using these data to facilitate quality improvement efforts. The program has led to declines in statewide mortality (Chassin et al., 1996, 1998; Hannan et al., 1994).

Agency for Health Care Policy and Research

The Agency for Health Care Policy and Research (AHCPR) is the lead agency within the federal Department of Health and Human Services (DHHS) charged with supporting research on health care quality, cost, financing, and access (see Chapter 7). AHCPR has developed a number of practice guidelines (e.g., a 1994 practice guideline on cancer pain, which will be updated in 1999). Although no longer developing new practice guidelines, AHCPR in collaboration with the American Medical Association and the American Association of Health Plans has developed a national



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