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Appendix: Sources of Information

There is little consensus on how to define and measure quality health care. Research in this area is in its early stages and is often influenced by special interest groups like insurance companies, hospital organizations or doctors’ groups. One way of evaluating quality is through the use of accreditation reviews. There are several private accreditation organizations including the National Committee on Quality Assurance (NCQA), the American Accreditation Health Care Commission (AAHCC), and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO). Accreditation is voluntary but health care organizations have reason to seek accreditation. For example, some employers and unions require that plans covering their employees and members be accredited. Hospitals may seek JCAHO accreditation in order to meet Medicare conditions of participation, state licensure requirements and/or to lower liability insurance premiums. What follows is information on accreditation organizations and other quality assessment tools that can be helpful in evaluating managed care plans.

NCQA

The National Committee on Quality Assurance is an independent non-profit organization that conducts accreditation reviews of managed care plans, mostly HMOs. NCQA measures health plan performance in two ways — through accreditation and Health Employer Data Information Set (HEDIS) performance measures.

Accreditation: NCQA evaluates how well a health plan manages its network. Evaluators look at whether a plan has safeguards in place to protect patients, how effectively a plan monitors the care provided, and how a plan uses the information it gathers to improve health care for its members. In other words, the review focuses on how capable a plan is of delivering quality health care. NCQA evaluations are based on 60 standards in 6 major categories:

  • quality management and review
  • utilization management
  • physician credentials
  • member rights and responsibilities
  • preventive health services; and
  • medical records.

There are three levels of accreditation — full, one year and provisional.

  • Full Accreditation is granted for three years to plans that meet NCQA standards and have excellent programs for continuous quality improvement. Half of the plans recently reviewed received full accreditation.
  • One-Year Accreditation is granted to plans that are in significant compliance with NCQA standards and have well-established quality improvement programs. NCQA provides plans receiving one-year accreditation with specific recommendations for improvements, and then reviews the plan again after a year. Thirty-eight percent of recently reviewed plans received one-year accreditation.
  • Provisional Accreditation is granted for one year to plans that are in partial compliance with NCQA standards and have adequate quality improvement programs. These plans have one year to achieve full
    compliance. Five percent of recently reviewed plans received provisional accreditation.
  • Denials/Revocation of Accreditation - Six percent of recently reviewed plans were either denied accreditation or had their accreditation revoked and one percent were under review when these statistics were compiled.

    If a plan does not receive full accreditation in its first attempt, it does not necessarily mean that it does not provide quality health care. If a plan has failed to receive accreditation, ask for the reasons for denial and ask whether the plan intends to resubmit for accreditation. Many plans with full accreditation received lesser accreditation, or even failed altogether, on their first attempt.

NCQA initiated behavioral health accreditation in 1997. The accreditation focuses on the following areas:

  • Quality Management and Improvement
  • Accessibility, Availability, Referral and Triage
  • Utilization Management
  • Credentialing and Recredentialing
  • Members’ Rights and Responsibilities
  • Preventive Behavioral Health Services; and
  • Clinical Evaluation and Treatment Records.

Although NCQA’s behavioral health accreditation program is a positive step, some experts believe that the current measures are inadequate and need much improvement.

NCQA periodically revises its standards. To obtain a current copy of the NCQA standards, write to: NCQA, 2000 L Street, N.W., Suite 500, Washington, D.C. 20036, or call 1-800-839-6487 and ask for a copy of the NCQA Information Packet, or download the information from the NCQA Web site at http://www.ncqa.org/. NCQA will also provide an accreditation status list (ASL) and accreditation summary reports (ASR). The ASL shows plans with current accreditation status, plans with decisions pending and plans with reviews scheduled during the next 18 months. The ASR provides a limited summary of accreditation results by comparing how a plan scores against overall plan averages. These lists can be obtained through the Web site or by calling 1-888-275-7585.

NCQA is the lead organization accrediting managed care plans. While the NCQA quality measures are helpful, they do not address many of the concerns of health care consumers. For example, NCQA standards do not adequately address access to health care services, patient satisfaction, consumer protections, or the information needs of consumers. While the NCQA does look at the credentials of physicians, it does not evaluate the skill or staffing levels of all medical staff. Likewise, NCQA requests information on preventive services but does not measure how well health plans deliver services to hospitalized or chronically ill patients, or the outcomes of medical treatments. While NCQA standards require that the health plan have a grievance and appeals process, they do not set time limits or require written notification or even expedited review for life-threatening conditions.

While health care purchasers should not use NCQA accreditation as the sole criteria for decisions, the fact that a plan is accredited or seeking accreditation should be one factor in the decision-making process.

Plans not included on the NCQA list have not been reviewed and are not scheduled for review — possibly because they do not meet NCQAs eligibility criteria but more likely because they have not applied for accreditation. Although there are a number of eligibility criteria that must be met, two of the main reasons that may preclude a plan from applying are length of time in business and cost. A plan must have been in operation for at least 18 months to be eligible for application. There is a $1,500 application fee, and the survey fee varies based on the size and complexity of the plan. If the fee is too expensive, some smaller plans may not have the funds to apply.

HEDIS

The Health Plan Employer Data and Information Set is a set of performance measures developed by NCQA and completed by HMOs. The first version of HEDIS was developed in 1989. Since that time, HEDIS has been updated twice (HEDIS 2.5 and 3.0). HEDIS 3.0 includes 71 quality measures and also includes measures for the Medicare and Medicaid populations. Similar to the NCQA accreditation criteria, HEDIS measures focus on how a plan actually performs in specific areas, such as how frequently members are provided with certain types of preventive care. While the latest HEDIS version does include a few outcome measures, most of the HEDIS measures are still process oriented. HEDIS is designed to be used in conjunction with NCQA accreditation. Performance is measured in six areas:

  • Quality of Care
  • Membership Access
  • Membership Satisfaction
  • Utilization
  • Enrollment/Disenrollment Data; and
  • Finance.

HEDIS is in the early stages of development, so the ability to use HEDIS results to compare plans is limited at this time. Also, HEDIS data is generally self-reported and no audit process is currently in place. Improved information systems and data collection methodologies may eventually enable health care purchasers and consumers to use HEDIS results as a comparison tool. You can obtain a current copy of the HEDIS standards by writing or calling NCQA, or downloading as noted above.

Quality Compass

The Quality Compass is a new NCQA database that combines accreditation information and HEDIS results from plans that choose to participate. The report includes national and regional benchmarks and the goal of Quality Compass is to provide a means of comparing health plans. NCQA’s report “The State of Managed Care Quality” partially summarizes Quality Compass findings. The Quality Compass database is available via CD ROM and electronic file. For ordering information call NCQA’s toll-free publication number, 1-800-839-6487.

FACCT

The Foundation for Accountability is an independent not-for-profit organization that is dedicated to holding health plans accountable for quality health care. To accomplish its mission, FACCT promotes improved consumer information systems and educational programs. FACCT also develops and endorses health system performance measures that focus on the outcomes of health care for sick populations. FACCT has endorsed measurement sets for asthma, breast cancer, diabetes, major depressive disorder, health risks, health status of seniors, health status under age 65, and consumer satisfaction. FACCT is developing measures for alcohol abuse, coronary artery disease, pediatric care, HIV/AIDS and care at the end of life. For more information on FACCT write to: Foundation for Accountability, 520 S.W. Sixth Avenue, Suite 700, Portland, Ore. 97204, call (503) 223-2228 or access information through the Internet, http://www.facct.org/.

JCAHO

The Joint Commission on Accreditation of Healthcare Organizations is the oldest of the accrediting organizations. JCAHO accredits hospitals and other entities, including clinics, mental health facilities, nursing homes, ambulatory care centers, laboratories, and home health agencies. Recently, JCAHO accredited a small number of managed care networks.

There are five levels of accreditation that show how well an organization performed in specified areas and how likely the organization is to provide quality care. They are as follows:

  • Accreditation with Commendation
  • Accreditation
  • Accreditation with Type I Recommendations
  • Provisional Accreditation; and
  • Conditional Accreditation.


Most organizations (89 percent) receive Accreditation With Type I Recommendations. Organizations receive this rating when they have unsatisfactory compliance in a specific area. To maintain accreditation, recommendations made must be complied with within a specified period of time. Only 1 percent of applying organizations were denied accreditation or had their accreditation revoked. JCAHO evaluations are scheduled six months in advance and survey preparation manuals are available to hospitals and health care organizations. Accreditation is generally valid for three years.

The criteria for accreditation requires that organizations meet a minimum standard of care in the three areas: patient-focused functions, organization functions, and structures within functions. Beginning in 1998, JCAHO is requiring that hospitals and networks report on a small number of outcomes and other performance measures. While this is a step in the right direction, the value of this new requirement is questionable since JCAHO is allowing the organization to select the measures that it reports on.

To obtain JCAHO standards, write to: JCAHO, One Renaissance Blvd., Oakbrook Terrace, Ill. 60181 or download information on the Web: http://www.jcaho.org/. Performance Reports on individual organizations, which summarize the Accreditation Decision Report, can be obtained by calling (630) 792-5800. JCAHO will provide up to 10 reports within 90 days at no charge.

AAHCC

The American Accreditation Health Care Commission, originally incorporated as the Utilization Review Accreditation Commission, began by accrediting utilization review programs, which are programs that review the appropriateness of care provided to patients. The name change reflects the organization’s expansion into accreditation of a broad range of network and workers’ compensation managed care plans. AAHCC has separate standards for three programs: utilization management, provider networks and workers’ compensation. Accreditation is based on a pass/fail system and is given for two years.

Utilization management standards cover the following eight areas:

  • confidentiality
  • staff qualifications and credentials
  • program qualifications
  • quality improvement programs
  • accessibility and on-site review procedures
  • information requirements
  • utilization review procedures
  • appeals

Network accreditation standards cover the following areas:

  • participation and management
  • utilization management
  • quality management
  • provider credentialing
  • member participation and protection

Workers’ compensation standards address the following five main areas:

  • network management
  • quality management
  • practitioner credentialing
  • access and availability
  • grievance procedures and marketing

AAHCC is developing a set of performance and outcome measures for workers’ compensation managed care programs and a set of PPO credentialing standards.

To receive a copy of AAHCC’s reports on accredited utilization management, workers’ compensation and/or network programs, write to AAHCC, 1130 Connecticut Avenue, N.W., Suite 450, Washington, D.C. 20036 or call (202) 296-0120. AAHCC does not have information available on the Internet.

State Agencies

Because state regulation of HMOs and other managed care plans varies substantially and is changing rapidly, information on these activities is not covered in this manual. However, information on regulatory developments is available through AFSCME’s Department of Research and Collective Bargaining Services. For assistance in negotiating managed care plans, or for more information on issues addressed in this manual, contact this department at (202) 429-1215 or e-mail research@afscme.org.

Department of Research and Collective Bargaining Services, 12/98