Health Insurance - A Quick Look at Quality Health Care

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Quality health care means doing the right thing, at the right time, in the right way, for the right person—and having the best possible results.

Although we would like to think that every health plan, doctor, hospital, and other provider gives high-quality care, this is not always so. Quality varies, for many reasons.

Fortunately, there are scientific ways to measure health care quality. These tools, called measures, have mostly been used by health professionals. They use measures to check up on and improve the quality of care they provide.

But there is some quality information you can use right now to help you compare your health care choices. And more and more is becoming available all the time. Many public and private groups are working to improve and expand health care quality measures. The goal is to make these measures more reliable, uniform, and helpful to consumers in making health care choices.

What is Measured?
There are two main types of quality measures that can help you choose quality health care: consumer ratings and clinical performance measures. Both types are based on "outcomes research."

Outcomes research measures the end results of health care practices and treatments. For example, after treatment, is the pain gone? Can the patient carry out his or her daily activities? Is he/she satisfied with his or her care?

Consumer ratings (or "consumer satisfaction" information). These look at health care from the consumer's point of view. For example, do doctors in the plan communicate well? Do members get the health services they need?

Many consumer ratings of health plans are based on a survey called the Consumer Assessment of Health Plans (CAHPS®) and on the Health Plan Employer Data and Information Set (HEDIS) member satisfaction survey, which includes CAHPS® questions.

Clinical performance measures (also sometimes called "technical quality" measures). Some widely used clinical performance measures are included in HEDIS. These measures look at how well a health care organization prevents and treats illness. For example, one HEDIS clinical performance measure looks at whether children get the immunizations (shots) they need when they need them.

More information on CAHPS® and HEDIS is provided in the Choosing a Health Plan section.

What Should I Look For?
Quality Reports. You may be able to find consumer ratings, clinical performance measures, or both in quality reports. Quality reports go by different names, including performance reports and report cards. Quality reports don't tell you which health care choices are the best. But they can help you decide which are best for you, based on the things that are most important to you.

More information about quality reports is provided in the Choosing a Health Plan and Choosing a Hospital sections.

Accreditation Reports. Another way to compare quality is to use information about accreditation. Accreditation is a "seal of approval." It is mainly used for health care organizations such as health plans, hospitals, and nursing homes.

To earn accreditation, organizations must meet national standards, often including clinical performance measures. Organizations choose whether to participate in accreditation programs. Therefore, you will not find accreditation information on every nursing home, for example.

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