Group Medical Expense Benefits, Managed Care Plans - Accreditation

As managed care matures and becomes more widespread, there is an increasing focus by government, employers, and consumers on quality. This has led many employers, particularly large employers, to require that managed care organizations for their employees meet some type of accreditation standards. Accreditation does more than just provide consumers with information about health plans. The process, which may cost a managed care organization several thousand dollars, compares it with what are considered benchmark standards of quality care. The organization knows where it stands in relation to its competitors and also what must be done to become accredited or to achieve a higher level of accreditation.

The leading organization for accrediting appears to be the National Committee for Quality Assurance (NCQA), an independent, not-for-profit organization that has been accrediting HMOs and POS plans since 1991 and plans to start accrediting PPOs. (It also accredits managed behavioral health care organizations, credentials-verification organizations, and physician organizations.) Unlike some accrediting organizations, NCQA makes detailed information available to the general public. The NCQA accredits managed care organizations by evaluating the following five areas of performance (the percentage weighting of each area in the overall accreditation decision is also indicated):

1. Access and service. Do health plan members have access to the care and service they need? For example, are physicians in the health plan free to discuss all treatment options available? Do patients report problems getting needed care? How well does the health plan follow up on grievances? (40 percent)

2. Qualified providers. Does the health plan assess each physician's qualifications and what health plan members say about their providers? For example, does the health plan regularly check the licenses and training of physicians? How do health plan members rate their personal physician or nurse? (20 percent)

3. Staying healthy. Does the health plan help people maintain good health and avoid illness? Does it give its physicians guidelines about how to provide appropriate preventive health services? Are members receiving tests and screenings as appropriate? (15 percent)

4. Living with illness. How well does the health plan care for people with chronic conditions? Does the plan have programs in place to assist patients in managing chronic conditions such as asthma? Do diabetics, who are at risk for blindness, receive eye exams as needed? (15 percent)

5. Getting better. How well does the health plan care for people when they become sick? How does the health plan evaluate new medical procedures, drugs, and devices to ensure that patients have access to safe and effective care? (10 percent)

From this information, the NCQA gives health plans one of the following accreditation outcomes:

Excellent

Commendable

Accredited

Provisional

Denied

The NCQA has also developed a set of performance measures that are designed to enable purchasers and consumers to have necessary information to reliably compare the performance of managed care plans. These measures are commonly referred to as the Health Plan Employer Data and Information Set, or HEDIS. The current version (which tends to change almost annually) has more than 50 measures that fall into the following categories:

Effectiveness of care

Access/availability of care

Satisfaction with the experience of care

Health plan stability

Use of services

Cost of care

Informed health care choices

Health plan descriptive information

Examples of a few of the measures that HEDIS reports, which then can be compared with suggested norms, are the following:

Percentage of adolescents receiving immunizations

Percentage of patients receiving beta-blocker treatment following a heart attack

Percentage of patients receiving appropriate treatment for asthma

Percentage of women receiving counseling at the onset of menopause

There are also other bodies that accredit various types of health care organizations, including managed care plans, and make their data available to consumers. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has accredited hospitals for many years. It also accredits health care networks (including PPOs), home care organizations, long-term care facilities, behavioral health care organizations, ambulatory care organizations, and clinical laboratories.

Another major accrediting organization is the American Health Care Commission/URAC, commonly referred to just as URAC. URAC focuses on accrediting specific aspects of managed care, such as utilization review. Managed care organizations, such as HMOs and PPOs, can have their own utilization review activities accredited if prescribed standards are met. In addition, URAC accredits the activities of organizations that specialize solely in utilization review and that sell their services to managed care plans that do not have their own utilization review staffs. URAC also accredits organizations with respect to the following: case management standards, health call center standards, health network standards, health plan standards and network credentialing standards.