WA: HCA selects external reviewer to streamline Apple Health

With cuts to Medicaid reimbursement tightening the budget, the Washington state Health Care Authority (HCA) and Department of Social and Health Services (DSHS) has selected Qualis Health, a Seattle-based nonprofit population health agency, to perform external quality reviews of Apple Health, the state’s Medicaid program, and state mental health services. Under a three year state contract, Qualis will review the care provided to Medicaid enrollees and the the efficiency of each organization’s spending.

“With the tremendous expansion of Apple Health following implementation of the Affordable Care Act, it’s more important than ever to assure health care quality and value for the Medicaid population,” said Jonathan Sugarman, MD, MPH, President and CEO of Qualis Health. “With these contracts, we are partnering with the State of Washington to ensure that healthcare system performance is objectively evaluated, and that the results of our external review are used for public accountability and on-going improvement.”

The largest share of Qualis Health’s market revenue, 35 percent, comes from its consulting work with Medicaid programs across the nation. It reviews quality and efficiency for Medicaid programs in Alaska, Alabama, the District of Columbia, Idaho, and New Mexico. 53 percent of its client work involves case management.


Qualis financial report–Revenue by Business Product; Revenue by Market Segment/ source: qualishealth.org


Within case management lies utilization management which locates areas of “overuse, misuse, and underuse of health services” in private and public sector companies. Qualis also co-developed a Patient-Centered Medical Home (PCMH) transformation framework in 2008 which was tested in 65 health care practices across the nation.

According to the HCA, the state is interested primarily in ensuring quality outcomes for its enrollees which currently equals 1,200,000 Washingtonians. Qualis’s contract with the DSHS Division of Behavioral Health and Recovery will include measuring the care provided by Regional Support Networks that provide community-based mental health services.

Qualis Health publishes much of its general findings in an annual Report to the Community.