Restructuring quality assurance programs in HMOs and other competitive medical plans

The Health Care Financing Administration recently established a new set of regulations for health maintenance organizations (HMOs) and other competitive medical plans (CMPs). These regulations require quality assurance (QA) programs in HMOs and CMPs to include a system for collecting data on provider performance and patient outcomes, ensuring that physicians and other health professionals review the processes involved in service delivery, and taking corrective action when inappropriate care is delivered. As a result of these new requirements, QA programs in HMOs and other CMPs have come under greater scrutiny than ever before by numerous external review organizations. This article describes a model for restructuring QA plans to meet the demands of the current regulatory environment.