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I have a strong interest in the real-world uses of biostatistics to evaluate and enhance healthcare quality as I begin my career in the field. The required external quality review procedures for Medicaid managed care organizations and prepaid inpatient health insurance are one topic of special attention. I studied the EQRO report for my state, which I got from the official government website, to learn more about this topic.
A fascinating feature of the EQRO research examined Medicaid members’ patterns of healthcare consumption, with a particular emphasis on preventative care services, using statistical approaches. The research analyzed and aggregated preventive care use rates across several demographic groups using descriptive statistics, and the results showed notable differences. Interestingly, the use of preventive care was more common among older persons and non-minority groups than among younger people and members of certain racial/ethnic minority groups. This emphasizes how critical it is to implement focused interventions to close these gaps, enhance all Medicaid beneficiaries’ accessibility to preventive treatment, and improve their overall health outcomes (Ireys & Krissek, 2008).
Medicaid members of all ages, genders, and racial/ethnic origins were included in the EQRO study. A wide range of socioeconomic backgrounds, cultural connections, and health literacy levels were represented in the research population. Cultural factors played a significant role in the study’s consideration of the potential effects of communication styles, healthcare preferences, and language barriers on the use of preventive care. It was essential to take these cultural factors into account in order to guarantee the precision and tactfulness of data gathering and analysis (Bethancourt et al., 2003; Smedley, Stith, & Nelson, 2003).
It is crucial to comprehend the variety of statistical techniques used in the EQRO report because it provides insight into the ways in which various groups get preventative treatment. Managed care companies and state health officials may greatly benefit from the report’s insights about the healthcare habits of Medicaid members, which are obtained via the use of inferential statistics and the summarization of use rates across demographic categories. In order to enhance overall health outcomes and lessen inequities, managed care organizations may use the report as a standard for performance evaluation, identify care obstacles, and implement customized interventions (Smith et al., 2015). Conversely, state health authorities may use the results to guide resource allocation plans and policy choices that seek to improve healthcare accessibility and quality for all populations (Jones & Brown, 2019).
If I were speaking on behalf of the managed care company, I would use this data to create focused campaigns that would encourage members to use preventative care more often. Creating outreach initiatives that are culturally appropriate, increasing access to preventative care in underprivileged regions, and encouraging partnerships with neighborhood groups are a few possible strategies. We may endeavor to enhance the health and well-being of our participants and thus contribute to improved community health outcomes by proactively addressing inequities in preventive care.
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After collecting data, the data needs to be organized and then described by computing averages (Salkind & Frey, 2022). A toolkit to help state Medicaid agencies on how to use external quality review organizations (EQROs) to help improve the quality of preventative and developmental services for children that are enrolled in Medicaid (Krissik et al., 2008). In California the EQRO prepares the annual independent external quality review and technical reports. The California Department of Health Care Services (DHCS) provides a number of reports within the 2022-23 External Quality Review Technical Report (n.d.). Identifying barriers and strategies can help advance equity, by creating quality improvement initiatives by acknowledging that what gets measured gets improved (O’Kane, 2021).
Locate a section of the report that used statistical methods and summarize the methods and results.
The report used various statistical methods to evaluate the performance of Medi-Cal managed care plans. Statistics was used to summarize the data and provide an overview of the performance measures, while also observing changes in performance measure over time. For example, the report provides measurements on immunizations for adolescents from 2020- 2022; where it found the measurement rate in 2020 at just over 43% but lower each following year with a 2021-22 rate difference of 0.74 (The California Department of Health Care Services, 2024).
Include the target subjects or participants and possible cultural factors (e.g., customs, preferences, communication styles, or heritage).
The report focuses on Medi-Cal managed care plans and their enrollees. Specific populations such as children, adults, seniors, and those with disabilities are included in the analysis. The National Committee for Quality Assurance (NCQA) required race and ethnicity for additional measures (The California Department of Health Care Services, 2024).
Include data analysis tools used and how this report can make an impact on health care.
The report uses Healthcare Effectiveness Data and Information Set (HEDIS) which provide performance rates of managed care plans during the reporting year and trends using the previous years’ data, while also comparing to aggregated rates to national benchmarks (The California Department of Health Care Services, n.d.). In addition, the report uses Consumer Assessment of Healthcare providers and Systems (CAHPS) survey, Encounter Data Validation (EDV) study reports, Managed Care Accountability Sets (MCAS), and health disparity reports (The California Department of Health Care Services, 2024). By using these tools, both DHCS and Medi-Cal managed care plans can better understand where to focus their resources to continue improving the quality of care that is provide to the patients.
After reviewing the information, determine why it would be of interest to managed care organizations and the state health organization.
There are a number of reasons why the information in the EDRO report should be of interest to managed care organizations (MCOs) as well as state health organizations. The report provides detailed analysis of the quality, access, and timeliness of care that is provided by MCOs.  The EQRO also provides compliance reviews. There are also performance measures that are validated, ensuring that the data reported by the MCOs is accurate and reliable.
If you were representing the managed care organization, explain how you would use this information to improve your enrollees’ health status.
The report provides recommendations for improving the quality strategy of DHCS, and it would benefit MCOs to align their practices with the state goals to help improve overall care to all their enrollees.