MCPR 2004 - Measuring the Quality of Pennsylvania's Commercial HMOs - How To Use This Information

Helping to Keep Members Healthy

Keeping patients healthy is a goal of all HMOs. Successful measures in this category include high rates of members receiving screening procedures, appropriate medication usage and disease monitoring. 

Questions to ask an HMO representative:

Preventing Hospitalization through Primary Care

One goal of an HMO network, and especially primary care, is to decrease preventable or avoidable hospitalizations. Reporting hospitalization rates for health problems that should not require hospitalization serves as one way to analyze the effectiveness of primary care and HMOs. The statewide average scores for all HMOs in the report provide a point of comparison for each HMO. For these measures, a higher hospitalization rate is a poorer outcome of care and suggests a less effective HMO network of health providers.

Questions to ask an HMO representative:

Managing Ongoing Illnesses

HMO members with chronic obstructive pulmonary disease (COPD), asthma, diabetes and mental health conditions are at higher risk for hospitalization if appropriate and ongoing treatment is not received. A higher hospitalization rate suggests poorer management of a chronic disease. Generally, shorter lengths of stay suggest that patients recuperated in less time - a positive outcome. Longer stays in the hospital may indicate adverse or unexpected outcomes, lack of discharge planning, or over-utilization of resources. On the other hand, shorter stays may indicate under-utilization of health care resources or too-soon discharges that cause additional admissions in the future.

Questions to ask an HMO representative:

Follow-up to an Emergency Situation

HMO members being treated for a heart attack need quick, appropriate treatment and follow-up by a medical professional.

Questions to ask an HMO representative:

Surgical Procedures

Procedures are performed either in an inpatient or an ambulatory surgery setting. Location frequently provides insight into differing treatment standards among HMOs and may help identify treatment patterns by physicians or hospitals in the HMO provider networks. Practice patterns often vary across providers and geographic location. Procedure rates provide one way to study differences across HMOs associated with network management. Differences among procedure locales may suggest a divergence of network standards and protocols, or the HMO's referral to less expensive ambulatory care settings. Complications may lead to potential patient injury, increased insurance premiums, and increased costs due to rehospitalizations and higher levels of post-procedure utilization.

Questions to ask an HMO representative:

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