Quality Assurance in the Managed Care of Chronic Conditions

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Table of Contents

Introduction
Nature of Chronic Illnesses & Obstacles in Ensuring Quality Care
Improvement of Care in Managed Care of Chronic Conditions
Recommendations for Improvement of Care
Conclusion
Reference List

Introduction

Health delivery systems are based on the principles of improving access and quality of health care and reducing the costs involved. Managed care which forms part of the health delivery system of the United States is founded on the basis of cost reduction, improvement of general well being and ensuring that the quality of care accorded is not compromised. The differences in the nature of health conditions in terms of the type of illness, care required, support and costs determine the quality of managed care when assessed on the perspective of different health conditions. Chronic conditions are different in nature from other acute illnesses thereby posing as a big challenge for managed care organizations. The organizations have to contend with the illnesses, maintain a competitive advantage in the profit-oriented industry while at the same time ensuring quality. The uniqueness of chronic illnesses requires more objective ways of addressing their nature and quality assurance in managed care.

Nature of Chronic Illnesses & Obstacles in Ensuring Quality Care

Chronic conditions are classified as health conditions of a physical or mental disorder nature which last for a very long time (Larsen & Lubkin, 2009). The nature of such conditions is unique in that they are classified by their duration although the manner of treatment and manifestation for them is different. Chronic conditions are not only medical but also psychological and affect people of all ages. The conditions may be influenced by factors such as age, race, and environmental conditions among others. While some are inherited, others develop in childhood or even later in adulthood.

Chronic conditions do not have any specific cause but are caused by a combination of multiple factors thus limiting their treatment (Larsen & Lubkin, 2009). The types of chronic illnesses depict their nature with the main classifications being: the life threatening conditions such as heart attacks or cancer; those that disable progressively such as multiple sclerosis; manageable illnesses such as diabetes; those with waxing and waning courses such as chronic fatigue syndrome; and those associated with childhood such as asthma, and other conditions such as obesity, epilepsy, sickle cell anemia, cerebral palsy and hemophilia among others (Larsen & Lubkin, 2009). Further, these illnesses do not have specific symptoms but rather different types of symptoms which may not be detectable and which vary with the stage of the condition.

The nature of such conditions is the unpredictability aspect which means that their onset cannot be established and treatment becomes difficult. This unpredictability aspect influences the powerless nature of the patients (Larsen & Lubkin, 2009). They do not have control over their illnesses and this uncertainty can be traumatizing and impact negatively on the patients’ social and vocational life. Unlike the acute illnesses whereby a patient is sure of returning to normal healthy state, chronic patients have to live with the condition for quite a significant part of their lives (Friedland & Feber, 1998). This also creates an opportunity for the onset of other conditions which mostly worsen the chronic conditions thus making treatment even more difficult.

The aim of managed care is to reduce the cost of treatment and improve quality and well being. In dealing with chronic conditions, managed care organizations focus on self management which requires constant visitations to the physician and major changes for the patient as well as discipline to remain healthy (Parker & Burke, 2005). This is a big challenge because of the individual differences and the powerless nature of the condition. Chronic patients have to adhere to the specifications of the doctor who has to be registered and specialized in the field. This increases the cost for managed care (Friedland & Feber, 1998). The self management treatment is challenging and greatly depends on the factors of the patient such as age. While self management is recommended, it requires support especially from family for the patient to be able to make changes and maintain a healthy state. The stigma associated with some diseases is very high and limits the self management of the patients and their determination especially if it is experienced both at home and work places (Parker & Burke, 2005).

Chronic conditions do not necessarily have complete cure and treatment. The statistics associated with the conditions and deaths from chronic illnesses are however alarming. For example, the number of people with diabetes was about 7% in 2005. Coronary heart disease is a leading cause of death for both men and women while the number of people suffering from obesity and HIV/AIDS continues to increase (Larsen & Lubkin, 2009). Another unique aspect of chronic conditions is the fact that there is limited research and cures for them.

Improvement of Care in Managed Care of Chronic Conditions

Managed care organizations acknowledge that chronic conditions require specialized care. These organizations are however business-oriented with the aim of making profit through cost reduction and other means. The attributes of chronic conditions however form part of the concern for such organizations as a significant number of enrollees are suffering from some form of chronic illness (Parker & Burke, 2005). The care given to such patients is thus based on long term relationships. The assessment of quality is usually done through organizations such as the National Committee of Quality Assurance through the use of health performance plans that are specific to the chronic condition. However, due to limited research on the conditions, quality assessment is also done through the Employee Value Surveys and Patient Surveys.

The care given to chronic patients has however been enhanced through the carve outs established by the MCOs which contract specialized organizations to deal with chronic illness programs with more concern by the employers to enroll their employees with chronic illnesses (Parker & Burke, 2005). This care has improved the aspect of self management but has also limited personal interactions of the patients with their physician. Care is also accorded through social and spiritual support groups.

Recommendations for Improvement of Care

The transformation of the care accorded to chronic patients requires a change in the healthcare delivery system based on cost reduction and acute illnesses. There is need to include programs for long term illnesses based not on cost reduction but on maintenance of a long-term relationship with the enrollee. The reactive nature of the health care system also needs to be transformed to be proactive where the health system aims at maintaining the overall health of a person. The limitations of research require a focus on the academic and medical field research with additional support from the government and non-governmental agencies to ensure objective emphasis on chronic conditions. Additionally, it is recommendable to ensure overall support of the community, managed care organizations and patients through increased awareness of the conditions. Further, employers have a role to play in ensuring that employees with chronic conditions are supported at their work places (Parker & Burke, 2005).

Conclusion

Health conditions that used to be acute, manageable and life threatening are today chronic long-term conditions. This paper has thus evaluated the unique nature of such chronic conditions and the obstacles that limit their management. The care accorded to the chronic patients has been reviewed with provision for recommendations to improve such care.

Reference List

Friedland, B., & Feber, L. (1998). Managed care for elderly people with disabilities and chronic conditions. Generations, 22(2), 51-57.

Larsen, P., & Lubkin, I. (2009). Chronic illness: Impact and intervention. Sudbury, MA: Jones and Bartlett.

Parker, F., & Burke, L. (2005). Employers, ethics, and managed care. Employee Benefit Plan Review, 59(9), 7-11.

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Quality Assurance in the Managed Care of Chronic Conditions

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