Quality Assurance Mechanisms

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Pay for performance programs reward providers based on the quality of care that is provided to the patients. To reduce the cost of healthcare, pay for performance programs must reward providers that focus on preventive care and reduce duplication.
Preventive care reduces the number of people who use healthcare services by preventing disease and promoting healthy behaviors. “Chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of every 10 deaths among Americans each year and account for 75% of the nation’s health spending .” Preventive care initiatives reduce the severity and number of expensive treatments for these illnesses. Providers who have high standards for preventive care through routine checkups, cancer …show more content…
Both quality assurance mechanisms have advantages and disadvantages.
The process mechanism monitors the episodes of care that are done to or with the patient. Two strengths of the process mechanism are “it relates to what providers do and it is easy to measure .” For example, aspirin dispersal time is monitored for heart attack victims.
A weakness of the process mechanism is that outcome is needed to determine the effectiveness of the process. Mortality is a possible outcome that determines whether the aspirin dispersal time was effective for a heart attack patient. Another weakness is that a “specific element of care is monitored rather than a comprehensive measure. National asthma guidelines recommend a comprehensive approach to care but a measurement on whether medication was dispensed is only …show more content…
One possible reason for this decline is the introduction of utilization reviews during the 1980s-1990s. Another possible reason is the Medicare perspective payment system (PPS) implemented in 1984.
There are three types of utilization reviews: preadmission certification, concurrent review, and retrospective review. “Preadmission certification is the process of reviewing and authorizing elective procedures or services before they are rendered .” For example, a physician requests a knee surgery for their patient. The insurance must review and authorize this procedure.
“Concurrent review is the review or authorization of procedures or services during the time the services are being rendered 1.” After surgery, a physician can request post-surgery care at an outpatient clinic. “The physician will provide information on the care received and clinical status. They will then wait for review and approval. Concurrent reviews ensure that patients get the right care in a timely and cost-effective way
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