Quality assuring managed care

Citation

Hurst, K. (2006), "Quality assuring managed care", International Journal of Health Care Quality Assurance, Vol. 19 No. 4. https://doi.org/10.1108/ijhcqa.2006.06219daa.001

Quality assuring managed care

Quality assuring managed care

We take an unusual approach in this issue in which Professor Towill publishes not only a constructively critical review of managed care, notably Kaiser Permanente’s patient flow characteristics, but also its theoretical underpinnings. Towill partly responds to a flurry of British Medical Journal publications and letters over the past few years (Feachem et al., 2002) that denigrated or supported Kaiser Permanente’s managed care system, which attempts to coordinate and control service quality and cost. These issues, understandably, attracted the attention of UK policy makers, managers and practitioners. Placing Kaiser Permanente’s ideological, political and vested interest arguments to one side, Towill’s supply-chain model, an area in which he and his colleagues are actively researching empirically and theoretically, considers health and social care as a series of well structured pipelines with key junctions and stations into which patients enter and flow – a more orderly look at seamless, managed care. There are standardised treatments that work and patients should be at least informed if not actually get to choose an evidence-based care plan, and there’s nothing wrong in describing these as a linear set of events in the form of a smooth journey along a pipeline that flows freely, doesn’t clog or leak vital materials.

Owing to the topic’s importance, we asked Professor Keen and his colleagues to examine managed care from an alternative model – in their case a conceptual framework built from a network of services that are more chaotic and uncertain because integrated health and social care systems involve state, private and voluntary services. They were able to do this following completion of a large, empirical study of intermediate care in which elderly patients (a particularly vulnerable group) with different needs were tracked.

Both authors look at managed care from different theoretical perspectives of health service design and performance. Towill’s arguments are not only clear and logical but also well supported by evidence-based care pathways, which he addresses using the supply chain model. One advantage of care pathways, as Keen et al. also point out, are that they easily married to a quality assurance strategy. In the UK, for example (but not exclusively), care pathways are married to variance analyses – a record of why care deviates from evidence-based practice. Variance analyses often speak volumes when care pathways from the same family (e.g. major orthopaedic surgery) are audited. The reasons why services fall down may be blindingly obvious but it’s interesting to see the frequency and context in which they stumble.

Towill’s notion of value-added services (when productive time is boosted in some way) and non value-added (e.g. waiting times) are diminished add considerably to our understanding of re-engineering. Even the harshest critics should be able to see how the logistician’s lens and supply chain model can be used to understand and possibly ease, for example, waiting lists and waiting times. Indeed, readers may be aware of a recent, concerted efforts to understand and improve health and social care productive time (NWP, 2005), so Professor Towill is clearly on to something and likely to be ahead of the game.

Keen et al.’s views, on the other hand, that patients are cared for in complex, overlapping health and social care service networks, which are guided rather than directed. Faults and hiccoughs in the care pathway (unplanned events in the production line), owing to service mishaps (e.g. nosocomial infection) and patient non-compliance (e.g. medication isn’t taken), what they less critically call pathway navigation, mean that care deviates so that pathways are uncertain. Another problem with the pipeline model, one about which the patient can’t be blamed, the dual (or more) diagnoses situation, which mean practitioners must simultaneously follow at least two care pathways – the so-called “dual knitting pattern phenomenon”. If care indeed is systematised by care pathways then it’s the practitioners’ knowledge and skills that achieve it. Moreover, resources are limited; there are waiting lists and certain treatments, although well understood by patients, are not approved for use (see, for example, the Herceptin metastatic breast cancer treatment debacle in the UK). This doesn’t mean that Keen et al. reject a care pathway quality-linked service – they simply underline why and how structures processes, outputs and outcomes naturally deviate from an evidence-based care pathway or pipeline. One consequence is that care fragments even under managed care (and other) conditions.

Even though this editorial précis only scratches the surface of two, detailed and exceptionally well-argued articles, the implications for patient care are clear. To what extent is managed care user centred – a point addressed in considerable detail earlier in the IJHCQA by Simonet (2005) who specifically looked at managed care quality compared to traditional fee-for-service systems – notably patient satisfaction in the context of service efficiency and effectiveness (although Simonet shows the topic to be more complex than this simple paragraph). Professor Keen and his colleagues ask if a patient can choose a diagnosis, treatment and care pipeline or shift from one to another midway in his or her journey through the service during an episode of care? Simonet (2005) explains how poor choice causes major patient dissatisfaction and consequently the concerted efforts by managed care service staff to widen the options. How desirable, therefore, is a medical, reductionist, disease-centred model, which are possibly a consequence of Towill’s supply chain approach? In contrast, Keen et al. present holistic views of patients who are complex beings influenced by biological, psychological and socio-economic factors. Moreover, even if an evidence-based care pathway moves from primary to secondary and back to primary care (and few in my experience do), owing to specialisation, patients will be passed on to different providers – essentially these are stances that Keen et al. take. These are fair comments because, despite the early 1990s Patient Focused Care movement in the UK (Hurst, 1999), we never evolved Kaiser’s specialist-practitioner supported one-stop shop, generic worker service that Towill succinctly describes.

Nevertheless, one advantage of two themed, constructively critical articles is this issues is that they compliment each other and generate new insights into healthcare policy and practice. Both linked articles in this issue (along with Simonet and other others) explore new ground and without doubt, in combination, offer new insights into wider health and social care structures, processes and outcomes. Moreover, they reintroduce readers to theoretical and practical models not only for understanding services – some of which are clearly pipelines while others are better understood as networks, but also redesigning them.

Keith HurstHealth Sciences and Public Health Research Institute, Leeds University, Leeds, UK