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The relationship between quality and utilization in managed care.

Sarah Hudson Scholle1, Russell Mardon, Sarah C Shih

  • 1National Committee for Quality Assurance, 2000 L Street, NW Suite 500, Washington, DC 20036, USA. scholle@ncqa.org

The American Journal of Managed Care
|August 13, 2005
PubMed
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Higher quality care in commercial health plans correlated with increased outpatient access and fewer inpatient days. This suggests a link between effective care delivery and resource utilization patterns.

Area of Science:

  • Health Services Research
  • Quality Improvement
  • Healthcare Management

Background:

  • Commercial health plans' performance on quality metrics is crucial for patient outcomes and cost management.
  • The Health Plan Employer Data and Information Set (HEDIS) provides standardized measures for evaluating healthcare quality.

Purpose of the Study:

  • To investigate the relationship between commercial health plan quality scores and healthcare utilization rates.
  • To use utilization rates as a proxy for cost in relation to quality performance.

Main Methods:

  • A cross-sectional study analyzed data from 254 commercial health plans using the 2003 HEDIS dataset.
  • Key utilization measures included outpatient visits, inpatient discharges, and inpatient days.
  • A composite quality score was derived from HEDIS indicators, with statistical analyses including bivariate correlations and multivariate regressions.

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Main Results:

  • Health plan quality demonstrated a positive correlation with access to outpatient care (r = 0.46, P < .001).
  • Quality was negatively associated with inpatient days (r = -0.30, P < .001), indicating fewer hospital days with higher quality.
  • No significant association was found between quality and total outpatient visits (r = 0.04).

Conclusions:

  • The study identified significant correlations between health plan quality measures and resource utilization.
  • These findings suggest potential links between effective care delivery and cost-efficiency, warranting further investigation.
  • Further research is needed to elucidate the mechanisms underlying these associations between quality and resource use.