When paid a fixed amount per capita, even if adjusted by demographic risk factors, health plans have financial incentives to avoid providing expensive services, especially those needed on a chronic basis. Since routine measurement of quality of care is limited primarily to preventive service utilization, the potential for patients with serious chronic disease to receive poor quality care is significant. We argue that both adjustment of payments to health plans based on the illness burden among their enrollees and measurement of quality of care will be necessary to ensure health plans provide high quality care. for some costly chronic diseases, condition-specific risk adjustment and quality measurement using data already collected for clinical management purposes may be necessary. We provide two examples (HIV and CF) and discuss the implications for information systems.
BarryM.J.FowlerF.J. Jr., et al. 1995. “Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia.” Medical Care.33(8) pp. 771–782.
2.
BozzetteS. A.BerryS.H. et al. 1998. “The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium.” New England Journal of Medicine.339(26) pp. 1897–1904.
3.
CoffeyR. M.BallJ. K. et al. 1997. “The case for national health data standards.” Health Affairs.16(5) pp. 58–72.
4.
ConviserR.GamlielS. et al. 1998. “Health-based payment for HIV/AIDS in Medicaid managed care.” Health Care Financing Review.19(3) pp. 63–82.
5.
EllisR. P.PopeG. D. et al. 1996. “Diagnosis-based risk adjustment for Medicare capitation payments.” Health Care Financing Review.17(3) pp. 101–128.
6.
GalvinR. S. 1999. “An employer's view of the U.S. health care market.” Health Affairs.18(6) pp. 166–170.
7.
GanK. H.VeezeH. J. et al. 1995. “A cystic fibrosis mutation associated with mild lung disease.” New England Journal of Medicine.333(2) pp. 95–99.
8.
HibbardJ. H.Harris-KojetinL. et al. 2000. “Increasing the impact of health plan report cards by addressing consumers’ concerns.” Health Affairs.19(5) pp. 138–143.
9.
HibbardJ. H.SofaerS. et al. 1996. “Condition-specific performance information: assessing salience, comprehension, and approaches for communicating quality.” Health Care Financing Review.18(1) pp. 95–109.
10.
HornbrookM. C. and GoodmanJ. J.1995. “Assessing relative health plan risk with the RAND-36 health survey.” Inquiry.32(1) pp. 56–74.
11.
JencksS. F. 1995. “Measuring quality of care under Medicare and Medicaid.” Health Care Financing Review.16(4) pp. 39–54
12.
JewettJ. J. and HibbardJ.H.1996. “Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured.” Health Care Financing Review.18(1) pp. 75–94.
13.
KahnJ. G.LuftH. et al. 1995. “HIV risk adjustment: issues and proposed approaches.” Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 8 suppl 1: pp. S 53–66.
14.
KnutsonD.1998. “Case study: the Minneapolis Buyers Health Care Action Group.” Inquiry.35(2) pp. 171–177.
15.
KronickR.DreyfusT. et al. 1996. “Diagnostic risk adjustment for Medicaid: the disability payment system.” Health Care Financing Review.17(3) pp. 7–33.
16.
LamersL. M. 1999. “Pharmacy costs groups: a risk-adjuster for capitation payments based on the use of prescribed drugs.” Medical Care.37(8) pp. 824–830.
17.
MatoukE.GhezzoR. H. et al. 1997. “Internal consistency reliability and predictive validity of a modified N. Huang clinical scoring system in adult cystic fibrosis patients.” European Respiratory Journal.10(9) pp. 2004–2013.
18.
McDonaldC. J. 1998. “Need for standards in health information.” Health Affairs.17(6) pp. 44–60.
19.
MeenanR. T.O'Keeffe-RosettiC. et al. 1999. “The sensitivity and specificity of forecasting high-cost users of medical care.” Medical Care.37(8) pp. 815–823.
20.
MilsteinA.GalvinR. S. et al. 2000. “Improving the safety of health care: the Leapfrog initiative.” Effective Clinical Practice.3(6) pp. 313–316.
21.
MorganR. O.VirnigB. A. et al. 1997. “The Medicare-HMO revolving door—the healthy go in and the sick go out.” New England Journal of Medicine.337(3) pp. 169–175.
22.
RetchinS. M. and BrownB.1990. “The quality of ambulatory care in Medicare health maintenance organizations.” American Journal of Public Health.80(4) pp. 411–415.
23.
ScanlonD. P. and ChernewM.1999. “HEDIS measures and managed care enrollment.” Medical Care Research and Review. 56(suppl 2): pp. 60–84.
24.
SpuntB. S.DeyoR. A. et al. 1996. “An interactive videodisk program for low back pain patients.” Inquiry.11(4) pp. 535–541.
25.
TollenL. and RothmanM.1998. “Case Study: Colorado Medicaid HMO risk adjustment.” Inquiry.35(2) pp. 154–170.
26.
WeinerJ. P.DobsonA. et al. 1996. “Risk-adjusted Medicare capitation rates using ambulatory and in-patient diagnoses.” Health Care Financing Review.17(3) pp. 77–99.
27.
WellsK. B.KatonW. et al. 1994. “Use of minor tranquilizers and antidepressant medications by depressed out-patients: results from the medical outcomes study.” American Journal of Psychiatry.151(5) pp. 694–700.
28.
WilsonV. M.SmithC. A. et al. 1998. “Case study: the Washington State Health Care Authority.” Inquiry.35(2) pp. 178–192.
