Fairbrother Gerry, Luciano James, Park Heidi L
Division of Health and Science Policy, New York Academy of Medicine, New York, NY 10029-5293, USA.
J Urban Health. 2002 Dec;79(4):617-27; discussion 628-37. doi: 10.1093/jurban/79.4.617.
The ability of health plans to bring about quality improvement is limited by the fact that physician networks are highly differentiated, with physician groups participating in many plans and plans contracting with many physician groups. The primary purpose of our study was to investigate the problems in the current system of quality monitoring by managed-care organizations (MCOs) at a large integrated health care delivery system (Montefiore Medical Center) and to develop ways of addressing these problems through collaboration among MCOs. The project began by mapping the current system for collecting, reporting, and using performance data to improve performance, using breast cancer screening as an example. We found that neither health plans nor providers were satisfied with the current system. From the perspective of the health plans, the current quality monitoring was costly and, more important, was not yielding appreciable increases in screening rates. From the providers' perspective, multiple health plan requests for chart pulls and other data collection activities cost them substantial amounts of time and money and generated multiple mailings of educational materials and reports, but rarely supplied meaningful information about their performance. From the perspective of the hospital, the current procedure of reporting from MCO to provider or center bypassed the institution's own quality monitoring and management structure and thus limited the institution's ability to assist in quality improvement. This study clearly showed the importance of collaboration among plans at a given provider site. Specifically, it pointed to the need for provider-oriented reporting of data, rather than plan-oriented reporting, to give physicians numbers that they believe. It also showed the need to engage the institution's own quality-management system to assist in bringing about improvements.
健康计划实现质量改进的能力受到限制，原因在于医师网络高度分化，医师团队参与多个计划，而计划也与多个医师团队签约。我们研究的主要目的是调查大型综合医疗服务提供系统（蒙特菲奥里医疗中心）中管理式医疗组织（MCO）当前的质量监测系统存在的问题，并通过MCO之间的合作来制定解决这些问题的方法。该项目首先以乳腺癌筛查为例，绘制了当前收集、报告和使用绩效数据以改进绩效的系统。我们发现，健康计划和提供者都对当前系统不满意。从健康计划的角度来看，当前的质量监测成本高昂，更重要的是，筛查率并未显著提高。从提供者的角度来看，多个健康计划要求提取病历和进行其他数据收集活动，耗费了他们大量的时间和金钱，还产生了多份教育材料和报告的邮寄，但很少提供有关他们绩效的有意义信息。从医院的角度来看，MCO向提供者或中心报告的当前程序绕过了机构自身的质量监测和管理结构，从而限制了机构协助质量改进的能力。这项研究清楚地表明了在给定提供者地点各计划之间合作的重要性。具体而言，它指出需要以提供者为导向进行数据报告，而不是以计划为导向，以便为医生提供他们认可的数据。它还表明需要让机构自身的质量管理系统参与进来以协助实现改进。
