Quality Assurance and Utilization Review in a Health Insuring Organization

Abstract

HealthPASS is a Philadelphia-based health insur ance organization (HIO), owned and operated by the Penn Health Corporation, a subsidiary of Maxicare, the large for-profit health maintenance organization (HMO) company based in California. In a contractual agreement with the Pennsylvania Department of Public Welfare (DPW), Maxicare contracts primary care physician services on a capitated basis, and other services on a fee basis, to about 96,000 Medicaid enrollees in certain zip codes in Philadelphia. Al though HealthPASS does not provide care directly, it contracts with providers for these medical services. HealthPASS serves a primarily poor, minority, and inner city population with high rates of drug abuse, alcoholism, and mental illness. Currently, the enrol lees are served by a network of providers including more than 40 participating hospitals and over 500 primary care providers (PCPs) in the community. HealthPASS is unique as previous HIOs in Kentucky and Arizona both failed.

This paper describes the quality assurance and uti lization review (QA-UR) system implemented by HealthPASS with specific examples of case discus sions and a detailed look at the structure and function of the internal review process. Before outlining the QA-UR system, a brief history is provided of the recent controversial trend toward managed care for Medicaid recipients, as there have been marked fail ures in this arena nationally. The HealthPASS system is described—what it is, how it is staffed, who it serves, and the health services it offers. Discussion of the QA-UR system follows. Lastly, some of the thorny political issues that remain, such as the effort by HealthPASS to educate physicians about managed care, to develop protocols of care, and to coordinate QA-UR for so many physicians and hospitals, are examined.