Plan Features to Evaluate (continued)

3. Evaluating Quality Management

Every health plan has its own unique approach to quality management, although increasingly plans are adopting some or all of the National Committee on Quality Assurance's Health Plan Employer Data and Information System (HEDIS) measures. For families whose children have chronic conditions, however, many service authorization and quality performance issues arise that may not be addressed through existing standards. The following is a list of questions that can be used to evaluate a plan's quality management system for children:

A. Does the primary care clinician have the authority to approve most or all medically necessary pediatric specialty services? Yes____No____
B. Does the plan allow for simplified and flexible service authorization policies for children with chronic conditions? Yes____No____
C. Does the plan apply a medical necessity standard based on the needs of children? Yes____No____
D. Does the plan's quality management for children include peer review by pediatricians? Yes____No____
E. Does the plan regularly monitor effectiveness of treatment for chronic childhood conditions in addition to asthma? Yes____No____
F. Does the plan monitor appointment waiting times and distance to specialty pediatric health professionals? Yes____No____
G. Does the plan offer any training for clinicians related to the care of children with chronic conditions? Yes____No____
H. Does the plan conduct regular satisfaction surveys focused on the experiences of families whose children have chronic conditions? Yes____No____
I. Does the plan assure family access to medical records? Yes____No____
J. Are families whose children have chronic conditions involved in planning, service coordination, policy development and quality assurance? Yes____No____
K. Does the plan offer formal health education or disease management programs for children and families with chronic conditions (e.g., diabetes, sickle cell disease, asthma, oncology)? Yes____No____
L. Does the plan offer family support programs for families who have children with chronic conditions? Yes____No____
M. Does the plan require accommodations for handicap accessibility in all primary and specialty care offices? Yes____No____
N. Does the plan offer case management or care coordination services for children requiring multiple services? Yes____No____
O. Does the plan allow for second opinions as an in-plan benefit? Yes____No____
P. Does the plan have coordination arrangements with:  
  • early intervention programs
Yes____No____
  • schools
Yes____No____
  • public health agencies
Yes____No____
  • social service organizations
Yes____No____
   
Q. Does the plan make available to families a listing of state and community-based programs for children with chronic conditions? Yes____No____
R. Does the plan adjust the capitation payments of primary care clinicians who serve children with chronic conditions? Yes____No____
S. Does the plan reimburse for special or prolonged service CPT codes? Yes____No____
T. Does the plan offer primary care providers who serve children with chronic conditions an enhanced case management fee? Yes____No____
U. Does the plan offer any performance or financial incentives to promote early identification, shared management, and state-of-the-art treatment of chronic childhood conditions? Yes____No____

Index | Introduction