Quality improvement interventions focused on Medicaid beneficiaries with high-risk, high-cost conditions that are associated with avoidable emergency room and inpatient utilization may offer the best opportunities to demonstrate a business case for quality, according to a study released in the October/December 2008 Health Care Management Review. The study reports lessons from CHCS’ Business Case for Quality (BCQ) initiative, a multi-site demonstration project evaluated by the University of North Carolina at Chapel Hill. BCQ was funded by the Robert Wood Johnson Foundation (RWJF) and The Commonwealth Fund (CMWF).

The BCQ demonstration, originally launched in April 2004, was designed to test the existence of a business case for quality for Medicaid managed care organizations. Ten Medicaid managed care entities implemented pilot interventions, with quality improvement projects across a range of clinical conditions and intervention strategies. Interventions with positive results included: a complex case management program for adults with multiple co-morbidities; case management for children with high-risk asthma; a community-based outreach program for high-risk pregnant women; and a care management program for adults with diabetes. The evaluation suggests that interventions with the following focus areas may hold greater promise for demonstrating short-term financial returns:

  • High-risk, high-cost target populations;
  • Conditions that have greater near-term ROI potential, e.g., childhood asthma or high-risk pregnancy; and
  • Conditions associated with avoidable acute care utilization.

See also BCQ II, the second phase of the project that tested the business case for quality for multiple stakeholders across the health care system.