Quality screening and management using claims data in a managed care setting

Abstract

Quality screening and management (QSM), developed by United HealthCare Corporation for its own health plans but applicable to other settings, analyzes health care provided to an enrolled population using claims and administrative data supplemented, when necessary, with medical record review. For selected topics/conditions, QSM compares the care received by patients to that recommended by established practice guidelines and also reports and describes quality through incidence rates, condition-specific process and outcome measures, occurrence of adverse events, and use of preventive services. Results of the analyses are linked to appropriate quality management actions and are used to identify strategies for improvement. Data permit health plans to make performance comparisons on individual indicators and longitudinal comparisons on the effectiveness of quality improvement initiatives.