Evaluating Managed Care Proposals: Quality Assurance

Traditional indemnity health plans do not actively monitor the quality of care being delivered. Members select the providers, and the providers are responsible for the quality of care. The growth of managed care has spawned increased interest in quality assurance. Because much of the cost savings from managed care comes from restricting the utilization of unnecessary services, MCOs must ensure that standardized UM controls and rules do not interfere with appropriate health care delivery. Thus, insurers and HMOs are investing in methods to measure quality and ensure that quality health care is being provided. In evaluating MCO proposals, quality assurance programs are a critical component. 

Assuming that the general network configuration matches well with employee locations, the plan sponsor must next understand how the managed care company selects its network providers and what types of quality assurance mechanisms are incorporated into network management. The provider is "front line" with plan members, and members' overall plan satisfaction level is often determined by their interaction with providers. This point cannot be overstated since the principal element in managed care plans is the deliberate alignment of contracted providers with membership. Not surprisingly, therefore, many quality assurance programs place considerable emphasis on the selection and credentialing process for providers.

Selection is primarily focused on ensuring that there are sufficient numbers of providers within a geographic area to ensure adequate availability of providers to patients. The plan also must ensure that there is a sufficient mix of PCPs and specialists to meet membership needs.

Credentialing helps ensure that providers meet acceptable levels of expertise and professionalism. While each managed care company has its own set of credentialing requirements, the following are representative of some of the standard areas considered:

Sample Physician Guidelines

1. Graduation from an accredited medical school.
2. Valid state license/Drug Enforcement Administration (DEA) registration.
3. Clinical privileges at a licensed participating hospital.
4. Current malpractice coverage/history.
5. Federation check of state licensure.
6. No mental/physical restriction on performing necessary services.
7. No prior disciplinary action/criminal conviction or indictment.
8. No prior involuntary termination of employment or contract.
9. No evidence of inappropriate utilization patterns.
10. Agreement to follow utilization programs, including periodic on-site review of procedures and adherence to contractual obligations.

Sample Hospital Credentialing Guidelines

1. Joint Commission on Accreditation of Hospitals (JCAHO) accreditation.
2. Contractual warranty of state license.
3. Agreement to participate in the various utilization control programs.

While credentialing does not guarantee the provision of quality medical care, it is an important indicator of the managed care company's commitment to provide high-quality levels of care for plan members. Several national independent organizations have evolved to monitor and establish criteria for health plan evaluation. The best known national organization is the National Committee on Quality Assurance (NCQA) which began accrediting HMOs in 1991. More than 70 percent of all HMO members are currently in NCQA-accredited plans across the country. NCQA also began accrediting PPO plans in 2000 and now also offers accreditation of Managed Behavioral Health Organizations (MBHOs).

NCQA accreditation is granted for a period of three years to new health plans that have in place sound organizational structures and processes to monitor and improve the quality of care and service provided to its members and meet NCQA's rigorous standards, which fall into five broad areas:

1. Access and Service: Do health plan members have access to the care and service they need? Does the health plan resolve grievances quickly and fairly?
2. Qualified Providers: Does the health plan thoroughly check the credentials of all of its providers?
3. Staying Healthy: Does the health plan help people maintain good health and avoid illness?
4. Getting Better: How well does the plan care for people when they become sick?
5. Living with Illness: How well does the plan help people manage chronic illnesses?

While NCQA accreditation is completely voluntary, most HMOs and other managed care plans actively seek accreditation. An increasing number of large employers now require managed care plans to either have received NCQA accreditation or have an established plan towards gaining accreditation in order to be offered to plan members. Thirty states now recognize NCQA accreditation as meeting regulatory and licensing requirements for health plan. NCQA accreditation has become a way for plan sponsors to measure the performance of a health plan and assess the value of their health care purchase.