Power Point Presentation made to a major pharmaceutical manufacturer in 1998. Identifies cause of Medical Crisis and how Pharm mfgrs can use regulations to add value to their contracts with MCOs.

1. ENTERING INTO VALUE-ADDED PARTNERSHIPS WITH YOUR HMOs Roger H. Strube, M.D. Managed Care Consultant

2. The Cost and Cost Containment of Medical Care Roger H. Strube, M.D. Managed Care Consultant

3. The Cost = 18% of GNP$2.3 Trillion

4. NATIONAL HEALTH EXPENDITURES AS A PERCENT OF GROSS NATIONAL PRODUCT BY YEAR 16 15 14 13 Percent 12 11 10 9 8 National Health expenditures as a percent of gross national product. 7 6 1970 1975 1980 1985 1990 1995 2000 Calendar Year Source: Health Care Financing Administration, Office of the Actuary. Data from the Division of National Cost Estimates.

5. Cost of Medical Care The issue is not the cost of Coronary Surgery The issue is the cost of diagnosing and treating Chest Pain

6. Sample of Actual Medical Knowledge (Tested Knowledge) 100% Knowledge Test Score 100% 75% 75% B 50% C 50% 25% 25% D A 0% 0% 20 40 60 80 100 0 Age (years) Theoretical Test Scores “Changes over time in the knowledge base of practicing internists”Paul G. Ramsey et al, JAMA, August 28, 1991 - Vol 266, No8 pp 1103 C D A B B C

7. 100% Efficient Health Care* A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System TIME * Most cost efficient, medically necessary, effective and best expected result for the patient.

8. COMMUNITY HEALTH STATUS vs.UTILIZATION and EXPENDITURE RATE H ConservativeStyle ElaborativeStyle HEALTH STATUS of the POPULATION C B D A Range ofAcceptable Practice Underservice Overservice $/C SERVICES and EXPENDITURES PER CAPITA Source: Booz, Allen and Hamilton Inc.

9. EPIPHANY A spiritual event in which the essence of a truth appears to the subject as in a sudden flash of recognition

10. A New ParadigmThe Hypotheses isan Iconoclasm It is impossible for physicians to make appropriate medical decisions using the present memory-based system The information is too great and the medical knowledge too broad for the mind to manage All physicians are on Mission Impossible

11. TONS Tons of Paper Printed in Medical Journals Not Shinola Growth of Medical Publishing Growth of Medical Knowledge Shinola TIME

12. Managed Care Managed care is not the cause of the physician’s problems, it is a response to the cost and quality issues resulting from the failure of the memory based medical decision making process. Managed care is not simply another iteration of insurance or administration. It is the major catalyst and driving force behind the most significant, positive changes in the American medical delivery system in this century. It is the agent of change which will fundamentally alter how medicine is delivered.

13. 100% Efficient Health Care* B Judgment & Feedback Augmented memory based system Outcomes + Other Feedback A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System TIME * Most cost efficient, medically necessary, effective and best expected result for the patient.

14. PLATEAU OF COMPARABLE OUTCOMES O PRESSURE TO CONTROL COST B C PRESSURE TO SATISFY PATIENTS D A Q Q = QUANTITY OF MEDICAL SERVICES CONFLICTING PRESSURES ON THEHEALTH SERVICE DELIVERY SYSTEM O = CLINICAL OUTCOME

15. Malpractice The “Malpractice Crisis” is not caused by the litigious society or too many lawyers. It is the response of the patient to the errors which result from the failure of the memory based medical decision making process. Half of the medical care delivered in America ($500 Billion Dollars) is unnecessary, inappropriate, ineffective or harmful. “Defensive Medicine” is no defense as excessive testing and procedures do not result in better decision making and could do harm to the patient. The solution is through electronic decision support tools applied in real time.

16. Continuous Quality Improvement The Application of CQI to the Medical Care Delivery System Roger H. Strube, M.D.

17. Quality Assurance Model STRUCTURE PROCESS OUTCOME Are the right Are variables monitored Are the results of people in the and reports evaluated treatments monitored proper positions by the right people or recommendations with the appropriate and are appropriate followed up and authority to recommendations made? re-evaluated? evaluate care? Credentials Committees Catastrophes

19. Satisfy regulatory requirements

20. Identify errors (crisis management)

21. Influence through committee and peer pressure

22. Draconian tools (fines, cease & desist orders)

24. The management of all employee benefits (medical, workers comp, EAP, disability, etc.) will be awarded to a single full service financially sound entity

25. Purchasers are willing to pay for quality & value for the employee - if the health plan has the lowest price

26. Business awarded based on proof the MCO can deliver quality care at low cost (NCQA certification, HEDIS data, recommendations from Consultants -RFP/RFI*) * RFP/RFI = questions consultants pirate from NCQA & HEDIS

27. An Introduction to Total Quality Management( TQM )and theDeming Philosophy Roger H. Strube, M.D. Managed Care Consultant

28. The Study of Quality is the First Step in the Never Ending Journey of Continuous Quality Improvement TQM is a set of enabling components and a value system applied by the people in an organization which leads to a cycle of continuous improvement of the quality of the processes and and resulting outputs (outcomes) of the entity. A tool for organizational learning - the way an organization re-engineers their business to meet customer needs and expectations.

30. Suppliers

31. Managers

32. Workers

33. Investors

34. Materials

36. Corporate Plan Management Plan Supervisors Workers Customers

37. - NEXT -- TOPIC -

38. W. Edwards DemingContinuous Quality ImprovementManagement Theoryfor theTRANSFORMATION OF BUSINESS THROUGHAPPLICATION OF THE FOURTEEN POINTS Roger H. Strube, M.D. Managed Care Consultant

40. invited back in 1950 by JUSE to consult on improving the quality of Japanese exports

41. Dr. Deming provided the quality improvement roadmap an promised, if followed, they would dominate world trade

42. Emperor Herohito awarded him the Second Order Medal of the Sacred Treasure for his efforts

44. Look at the long term view for the organization

46. Your goal should be to provide your “customers” with the best possible care in the most appropriate setting

47. Use industry standards and guidelines (“emenarem”*) to fulfill your customers’ reasonable expectations and constantly improve the services you provide* “emenarem” derived from the Milliman & Robertson criteria sets, as in “The director of cost containment told the UR nurse to ‘emenarem’ out of the hospital.”

49. Quality comes not from inspection but from improvement of the process.”- W. Edwards Deming

50. POINT FOUREnd the practice of awarding business on the basis of price tag. Instead, minimize total medical cost (eliminate unnecessary procedures.) Reduce the number of suppliers for any one service (limited provider network) on the basis of a long-term relationship of loyalty and trust.

52. PLAN - DO - STUDY - ACT

53. PLAN: Collect data to determine a plan of action

54. DO: Take those actions that further the plan

56. Practice Guidelines Measurement and Feedback You cannot manage what you don’t measure CLOSE THE LOOP

57. SEVEN QUALITY CONTROL TOOLS Cause and Effect Diagrams (Fish Bone diagram) Flow Chart ( How work gets done ) Pareto Chart ( y = # , x = type ) Run Chart ( y = measure, x = time ) Histogram ( y = #, x = measurement ) Control Chart ( y = #, x = time + SD limit lines ) Scatter Diagram ( v1 vs v2, plot the dots - trend? )

58. POINT SIX Institute training on the job

61. Fear of making mistakes 2 Performance appraisal

62. Fear of punishment 3 Ignorance of company

63. Fear of being powerless goals to control the aspects of 4 Poor supervision your professional life 5 Lack of operational because of the following: definitions 6 Not knowing the job 7 Being blamed for system problems

64. POINT NINE Break down barriers between departments.People in research, design, sales, enrollment, claims processing, information systems, medical management, and delivery of care (providers) must work as a team, to foresee problems of production and in use that may be encountered with the product or service.

66. Ignorance of the organization’s mission and goals

67. Competition between departments, shifts, or areas

68. Decisions or policies lacking specificity

69. Too many levels of management that filter information

70. Fear of performance appraisals

71. Quotas and numerical work standards

72. Decisions and resource allocation without regard to memory

73. Jealousies over status and salary

75. POINT ELEVEN 11a. Eliminate work standards (quotas -- days/K, claims/hour, etc.) on the factory floor (insurance company or HMO production areas). Substitute leadership. 11b. Eliminate management by objective, Eliminate management by numbers, numerical goals. Substitute leadership.

77. 12b. Remove barriers that rob people in management and delivery of care of their right to pride of workmanship. This means complete abolishment of the annual or merit rating and of management by objective, management by numbers

78. Deming believed that performance appraisals destroy teamwork and focus on the short term

79. People must be viewed as the most valuable resource a company possesses

82. Management should drive out fear and eliminate other inhibitors and barriers to quality improvement

83. Quality improvement must be proceeded first by education of employees on what quality means and the needs of the customers

84. Quality is not a department function

85. Quality improvement is a never-ending process

86. Inspection by the government or any other agency does not mean quality control

89. Achieve desirable clinical outcome

90. Care based on professional judgment

91. Care plan managed by command

93. Quality Management Viewpoint Analysis Grid CQI QA Medical Focus Customer Standards of Patient needs expectations practice Goals Standards and Identification and Diagnosis and process improvement elimination of errors treatment of illness MethodsStatistical analysis Disaster Analysis Memory based decision making Management Participative line Staff Activity Hierarchical line Style Activity activity Data Analysis Statistical analysis Individual case Outcome analysis of process review

95. Delight the customer (member)

96. Minimize Variation (critical paths)

97. Improve the process

98. Manage through participation(the Doctor as Quarterback of the Team)

100. Analyze and fix the process, not the people

101. Invest in your people -- training and education

102. Do it right the first time

103. Work as a team

105. The data will define potential (acceptable) outcomes

106. The knowledge based computer programs will present alternatives (cook book)

107. The physician must negotiate the ambiguities with the patient (informed consent)

108. The patient and the physician will agree on the most acceptable treatment (disease state management)

109. The outcome of the interaction will become part of the disease state data base (determine best practices)

113. Quality comes not from inspection but from improvement of the process.”

115. NCQA AccreditationThe Plan’s PerspectiveA Walter Mitty* StoryFantasy vs RealityRoger H. Strube, M.D. * “The Secret Life of Walter Mitty” -- James Thurber

118. Purchasers

119. Health plans

120. Union representative

121. Consumer advocate

122. Health lawyer

123. AMA

124. Quality expert

126. Kansas

127. Maryland

128. Massachusetts

129. Michigan

130. Minnesota

131. Oklahoma

132. Pennsylvania

135. State Licensure

136. Federal Qualifications

137. Medicare Certification (HCFA)

138. PRO Review - Medicare

139. Medicaid (AHCA)

141. Measures performance of individual health plans, and eventually compares them

142. HEDIS 3.0

143. Report card

144. Annual Member Health Care Survey

145. Special Medicare & Medicaid Requirements

146. NCQA Accreditation Program

147. Evaluates plans’ quality management activities

148. The majority of the Nations’ 550 plans have been reviewed by NCQA

149. Reports accreditation decisions

151. Utilization Management

152. Credentialing

153. Members’ Rights and Responsibilities

154. Preventive Health Services

156. Require integration of clinical and service issues

157. Emphasize a systems and data driven approach

158. Require tailoring to meet individual plan needs and member populations

160. Explanatory back-up

161. Compliance guidelines

162. Scoring guidelines

164. NEW TECHNOLOGIES Low Cost Alternatives for Satisfying NCQA Requirements to Assess and Incorporate New Technologies or How to be Successful Using OPM* * OPM - Other People’s Money

165. Guideline Definition Systematically developed guides to assist providers and patients in making appropriate health care decisions in specific clinical circumstances

167. Increase cost-effectiveness of care

168. Optimize appropriateness of care

169. Improve health care outcomes and health status

171. The MCO must inform providers about the guidelines

172. Performance is assessed against the guidelines (population based studies for preventive health guidelines)

174. Lack of consistency of guideline programs across providers and settings

175. Missed populations

176. Adolescents

177. Mental health and substance abuse

178. Safety and accident prevention

179. enrolled but not reported (non-visitors)

180. Guidelines complex and/or not available

181. Claims policy (UM) used as clinical guideline

183. Experimental / Investigational The benefit exclusion for investigational treatment plans is made based on federal law passed after the Nuremberg trials and the American Tuskegee experiment. The provider is required by law to inform the patient of the status of the treatment. Failure to properly inform the patient could lead to malpractice litigation and failure to properly inform the medical department could be considered fraud on the part of the member and / or provider. The decision to apply the benefit exclusion is based on the medical determination made by the provider.

184. Guideline Sources Rand USPHSTF * ACP * HAYES Medical Directory Specialty Organizations AMA VHS “Home Grown” Many New Sources * Opportunity for access to medical director

185. Practice Guidelines Measurement and Feedback You cannot manage what you don’t measure CLOSE THE LOOP

186. “The God’s honest truth is it’s not that simple” Fruitcakes - Jimmy Buffett

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188. NCQA Accreditation The Plan’s Perspective Quality Improvement Standards Roger H. Strube, M.D. Managed Care Consultant

191. Comprehensive -- all aspects of the delivery system

193. NCQAReview of Delegation There is a written description of: the delegated activities; the delegate’s accountability for these activities; the frequency of reporting to the managed care organization; and the process by which the delegation will be evaluated. . There is evidence of approval of the delegate’s QI program and evaluation of regular specified reports.

194. NCQAReview of Delegation RED FLAGS Carve Outs Hospitals Mental Health Physical Therapy Home Health Agencies Vision Care Chiropractic Skilled Nursing Facilities Multispecialty Groups IPAsAncillary Services Single Specialty Networks

196. Data Collection

197. Audits

198. Standard / Criteria Development

199. Access

200. Clinical Guidelines

202. Benefits Determination

203. Referral Management

204. Concurrent Review

205. Discharge Planning

206. Complex Case Management

208. Data Collection

209. Primary Source Verification

210. Credentialing / Recredentialing Decision

211. Member Services

212. Complaint & Grievance First Level Review

214. Reporting methods and frequencies

215. Approval of delegate’s QI program, annual work plan and regular reports

216. Formal documents

217. Letters of agreement

218. Contracts

220. Reviews / site visits to the delegated entity

221. Corrective action plans developed

222. Documentation that follow-up actions result in improvement

224. QI 13.0 Delegation of QI Activity If the MCO delegates any QI activities, there is evidence of oversight of the contracted activity. QI 13.2 There is evidence that the managed care organization: QI 13.2.1 evaluates the delegated agency’s capacity to perform the delegated activities PRIOR to delegation; QI 13.2.2 approves the delegated agency’s QI work plan and QI program description annually; QI 13.2.3 evaluates regular reports as specified in QI 13.1.3; and QI 13.2.4 evaluates annually whether the delegated agency’s activities are being conducted in accordance with the managed care organization's expectations and NCQA standards.

228. NCQA AccreditationThe Plan’s Perspective Credentialing Roger H. Strube, M.D. Medical Director of Quality Improvement PHP Companies, Inc.

229. Cr 1.0 CredentialingPolicies and Procedures The MCO Documents the mechanism for the credentialing and recredentialing of MDs, Dos, DDSs, DPMs, DCs, and other licensed independent practitioners who fall under its scope of authority and action

230. Credentialing Standards CR 2.0 The MCO designates a credentialing committee that makes recommendations regarding credentialing decisions CR 3.0 The MCO documents primary source verification or attestation of credentials and past history CR 4.0 The applicant completes an application for membership attesting to fitness to practice

231. Initial Credentialing CR 3.0 At the time of credentialing, the managed care organization verifies information from primary sources CR 3.1 Current valid license to practice CR 3.2 Clinical privileges at a network hospital CR 3.3 Valid DEA or CDS certificate CR 3.4 Graduation from medical (dental, podiatric, chiropractic) school and completion of a residency or board certification CR 3.5 Board certification if the practitioner states he/she is board certified on the application CR 3.6 Work history CR 3.7 Current, adequate malpractice insurance according to the MCO policy CR 3.8 Professional liability claims history

232. Initial Credentialing CR 4.0 Applicant completes an application for membership. The application includes a statement by the applicant regarding: CR 4.1 Reasons for any inability to perform the essential functions of the position CR 4.2 Lack of present illegal drug use CR 4.3 History of loss of license and/or felony convictions CR 4.4 History of loss or limitation of privileges or disciplinary activity CR 4.5 Attestation to the correctness / completeness

233. Initial Credentialing CR 5.0 Evidence the MCO requests information on the practitioner from recognized monitoring organizations, that the information has been received PRIOR to making the credentialing decision CR 5.1 National Practitioner Data Bank CR 5.2 State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations (if available) CR 5.3 Review for prior sanction by Medicare & Medicaid

234. Initial Credentialing CR 6.0 There is an initial visit to the offices of all potential PCPs and OB/GYNs CR 6.1 Documentation of a structured site review per MCO standards CR 6.2 Documentation of compliance with the MCO’s record keeping standards

235. CR 7 Recredentialing Standards There is a formal process for periodic verification of credentials (recredentialing, reappointment, or recertification) that is ongoing, up-to-date and occurs every two years, minimally. The process includes the same primary source verification as credentialing where applicable. Data from member complaints, quality reviews, UM and member satisfaction is considered.

236. CR 7 Recredentialing Standards CR 7.0 Every two years the MCO shall formally recredential all practitioners through verification of information from primary sources: CR 7.1 current valid license to practice; CR 7.2 clinical privileges at a network hospital; CR 7.3 valid DEA or CDS certificate; CR 7.4 board certification if the practitioner states he/she is board certified on the application; CR 7.5 current, adequate malpractice insurance as per MCO policy; CR 7.6 history of professional liability claims that resulted in settlements or judgments paid; and CR 7.7 a current, signed attestation statement by the applicant: CR 7.7.1 reasons for inability to perform essential functions, and CR 7.7.2 lack of present illegal drug use.

237. CR 8 Recredentialing Standards CR 8.0 Evidence the MCO requests information on the practitioner from recognized monitoring organizations, that the information has been received PRIOR to making the recredentialing decision. CR 8.1 National Practitioner Data Bank CR 8.2 State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations (if available) CR 8.3 Review for prior sanction by Medicare & Medicaid

238. CR 9 Recredentialing Standards The MCO incorporates the following data in its recredentialing decision-making process for PCPs: CR 9.1 member complaints; CR 9.2 information from quality improvement activities; CR 9.3 utilization management; CR 9.4 member satisfaction; CR 9.5 medical record reviews conducted as part of MR 2.1; and CR 9.6 the site visits conducted as part of CR 10.1

239. CR 10 Recredentialing Standards There is a visit to the offices of all the PCPs, all OB/GYNs, and all High Volume Specialists CR 10.1 Documentation of a structured site review per MCO standards CR 10.2 Documentation of compliance with the MCO’s record keeping standards

240. Altering the Conditions of Practitioner Participation Standard CR 11 The managed care organization has policies and procedures for altering the practitioner’s participation with the managed care organization based on issues of quality of care and service. These policies and procedures define the range of actions that the managed care organization may take to improve performance prior to termination.

241. Altering the Conditions of Practitioner Participation Standard CR 11 CR 11.1 The MCO has procedures for, and evidence of implementation of, as appropriate, reporting of serious quality deficiencies that could result in a practitioner’s suspension or termination to appropriate authorities. CR 11.2 The managed care organization has an appeal process for instances in which the managed care organization chooses to alter the conditions of practitioner’s participation based on issues of quality of care and/or service. The managed care organization informs practitioners of the appeal process.

242. CR 12 Initial Credentialing The MCO has written policies and procedures for the initial and ongoing assessment of organizational providers with which it intends to contract. Providers include hospital, home health agencies,skilled nursing facilities and nursing homes, and free-standing surgical centers CR 12.1 The MCO confirms standing with state & federal regulators; and CR 12.2 The MCO confirms accrediting body approval; or CR 12.3 If no accrediting body approval, the MCO develops and implements standards of participation. CR 12.4 Confirmation by the MCO at least every three years that the provider remains in good standing with state, federal and accrediting bodies.

243. CR 12 Initial Credentialing CR 12.1 The MCO should confirm review & certification by a recognized accrediting body, and is in good standing with state and federal regulatory bodies; and CR 12.2 Confirms that the provider has been approved by an accrediting body confirms that the provider has been reviewed and approved by an accrediting body; or CR 12.3 If the provider has not been approved by an accrediting body, the managed care organization develops and implements standards of participation CR 12.4 At least every three years, the managed care organization confirms that the provider continues to be in good standing with the state and federal regulatory bodies and, if applicable, is reviewed and approved by an accrediting body.

244. CR 13 Delegated Credentialing If the managed care organization delegates any credentialing and recredentialing activities, there is evidence of oversight of the delegated activity CR 13.1 A mutually agreed upon document describes: CR 13.1.1 the responsibility of the managed care organization and the delegated agency; CR 13.1.2 the delegated activities; the process by which the managed care organization evaluates the delegated agency’s performance; CR 13.1.3 the process by which the managed care organization evaluates the delegated agency’s performance; and CR 13.1.4 the remedies, including revocation of the delegation; available to the managed care organization if the delegated agency does not fulfill its obligations.

245. CR 13 Delegated Credentialing If the managed care organization delegates any credentialing and recredentialing activities, there is evidence of oversight of the delegated activity CR 13.2 MCO retains the right to approve new providers & sites, and to terminate or suspend individual providers. CR 13.3 There is evidence that the managed care organization: CR 13.3.1 evaluates the delegated agency's capacity to perform the delegated activities PRIORto delegation; and CR 13.3.2 evaluates annually whether the delegated agency’s activities are being conducted in accordance with the MCO’s expectations and NCQA standards.

247. Delegation by delegate’s

248. Coordination of UM, member satisfaction, QI, and appeals/complaints with the recredentialing process (where’s the file?)

250. “Yellow Pages Credentialing”

251. Provider contracting and servicing are different functions

252. Where do the contracting people report?

253. Where does the Network Management Department report?

256. Love - Hate relationship between the “Medical Management” and “Member Services” departments.

257. Member Services director reports to Claims V.P. reports to Sr. V.P. of Operations (where MIS usually reports)

260. Contract exclusions and limitations easy to administer -- “medical necessity” based on criteria and standards of care more difficult -- sometimes decisions (approval or denial) not justifiable in the contract or medical criteria (Good ol’ boy decision making)

262. Member services performs satisfaction and accountability studies and generates reports - knows the skeletons

264. Dislike administrative activities

265. Are skeptical about statistical methods

266. Are uncomfortable with rigid controls

267. Are uncomfortable accepting ownership (blame)

268. Prefer linking process to outcome

269. Emphasize needs, not expectations

270. Recognize only external customers

271. Not sensitive to internal customers

273. The Lightat the End of the Tunnelis not a TrainComing the Other Way or Is There Indemnity After Managed Care After Indemnity?

274. ParticipatoryWork Group Session Determine Tactics to use in Strategically Applying CQI and NCQA Principles to the Schubert’s “Unfinished Symphony”

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276. NCQAandThe Evolving Role of Information Technology Roger H. Strube, M.D. Managed Care Consultant

277. NCQA Accreditation The Plan’s Perspective Medical Records Roger H. Strube, M.D. Managed Care Consultant

278. NCQA Medical Records Standards Medical Records are maintained in a manner that is current, detailed, organized, and permits effective patient care and quality review. The records reflect all aspects of patient care, including ancillary services. Records are available to health care practitioners at each encounter and to NCQA reviewers.

279. NCQA Medical Records Standards The MCO sets standards for medical records, systematically reviews the records for conformance, and institutes corrective action when standards are not met. Documentation of items on the NCQA Medical Record Review Summary Sheet demonstrates that medical records are in conformity with good professional medical practice and appropriate health management.

280. Medical RecordsThe State of the Art The vast majority of physicians world wide use recording tools and techniques which are hundreds, if not thousands of years old. Whether using a feather quill pen, a Mont Blanc fountain pen or a lap top computer, the format has not changed much in several hundred years. The power of the new tools (the computer) has not been tapped and the computer has not significantly changed the way we work. The present applications have merely provided us with chaos at light speed and a more efficient way to detect human error.

281. Medical RecordsThe State of the Art The knowledge base of medicine is so large no human can master the knowledge needed to make proper medical decisions. Physicians seldom take the time to gather and record the needed information from the patient even if they could integrate that information with the medical knowledge base so that a proper decision regarding the care of the patient could be made. The literature suggests that half of medical care delivered in the USA in unnecessary, ineffective or harmful. There is $500 Billion to be saved in America.

282. Medical RecordsThe State of the Art NCQA is attempting to move medical care into the 21st century by demanding ever more complex CQI statistical analysis of the system as the first step. Most of the payor industry is not capable of providing sound data. The medical record keeping of most physicians would have been state of the art 100 years ago. To satisfy the needs of NCQA, an army of record reviewers is needed to collect the data. The data is needed, the reports will be generated and the system will evolve, but...to what? and at what cost?

284. Old, cumbersome software

285. Inadequate, inaccurate medical records

286. Provider fear of cookbook medicine

287. General computer illiteracy

288. Cost of new hardware and software

289. Cost and frustration of data conversion

290. Resistance to change

292. Standards for electronic transfer of data (ASTM)

293. Configured to facilitate decision making and document rational for decisions

294. Generate information for disease, drug, procedure, critical path specific data bases for outcomes analysis

295. Decision Support Tools

296. Electronic knowledge base

297. Electronic medical Artificial Intelligence decision assistance to establish working diagnosis

298. Selection of Treatment Paths, drugs, procedures presented electronically to physician and patient

300. NCQAValue Added Partnering Do not wait to be asked by your MCO for documentation of activities you know are required by NCQA. Provide the information regularly and before you are asked.

301. NCQAValue Added Partnering Work toward a Total Quality Management (TQM) corporate culture using Continuous Quality Improvement (CQI) process improvement techniques. Your activities will be directly applicable to your business need to cooperate with the NCQA requirements placed on your partner MCO. Learn and apply as much as you can about the Quality Improvement Process. The success of your company and your personal security depend on it.

302. NCQAValue Added Partnering Learn as much as you can about the basic benefit plan of your MCO partners. Do not offer opinions about what the patient’s health care plan “should” cover. Refer the patient to the MCO member service department for benefit clarification. If a service is limited or denied feel free to discuss the medical necessity decision with the medical director. Direct the patient to the member services department to discuss the appeals process. Patient advocacy is OK. Do not become an adversary to the MCO.

303. 100% Efficient Health Care* A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System TIME * Most cost efficient, medically necessary, effective and best expected result for the patient.

304. 100% Efficient Health Care* B Judgment & Feedback Augmented memory based system Outcomes + Other Feedback A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System TIME * Most cost efficient, medically necessary, effective and best expected result for the patient.

305. 100% Efficient Health Care* C Judgment & Computer Physician Judgment + Computer decision support Computer Assisted Physician Judgment B Judgment & Feedback Augmented memory based system + Other Feedback Outcomes A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System TIME * Most cost efficient, medically necessary, effective and best expected result for the patient.