Developing, assessing, and refining quality of care criteria for a CHAMPUS mental health services demonstration.
CHAMPUS established a contracted provider arrangement demonstration in the Norfolk, Virginia area. This article describes the development, assessment, and refinement of the quality monitoring criteria used to assess quality of care. Of 3,303 cases reviewed, 66% failed one or more criteria in two levels of review by nonphysician reviewers and were referred to peer reviewers. The referral problem was confirmed by the peer reviewer in at least 57% of the 2,177 cases. The criteria should undergo complete specificity and sensitivity testing, be expanded to include more outcome measures, and be applied to other geographic areas before use by other third party payors.
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Health Care Policy Research Division, SysteMetrics/McGraw-Hill, Inc, Washington, DC.
Moynihan
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D002985:Clinical Protocols / Q000592:standards; D006264:Health Benefit Plans, Employee / Q000592:standards*; D006778:Hospitals, Psychiatric / Q000592:standards*; D006801:Humans; D007345:Insurance Claim Review / Q000592:standards; D001523:Mental Disorders / Q000145:classification; D010347:Patient Care Planning / Q000592:standards; D011785:Quality Assurance, Health Care / Q000592:standards*; D014481:United States; D014600:Utilization Review / Q000592:standards