Insurers – The Healthcare Quality Book- Vision, Strategy, And Tools

Prior to the emergence of HMOs, insurers were regulated primarily though state insurance laws. Through the 1980s, accountability for HMOs, which emerged in the late 1970s and early 1980s and combine insurance with varying degrees of oversight of clinical delivery functions, remained largely within an insurance regulatory framework. Accountability for care in HMOs that employed physicians or ran hospitals was subject to the same licensing and accreditation standards as for other hospitals and physicians. Initially, there was little or no oversight for the HMO functions related to utilization or quality management or contractually imposed controls on physicians or other providers. In the face of these limited regulatory requirements, HMO accountability grew largely out of market forces, specifically pressures from the purchasers of healthcare for more detailed information on the quality of services provided by HMOs. One manifestation of this pressure was the creation of a voluntary accreditation process by the National Committee 418 The Healthcare Quality Book for Quality Assurance . While other organizations accredit HMOs , the majority of accredited HMOs are accredited by NCQA. While some large employers and the Federal Office of Personnel Management require accreditation, relatively few other employers do so. Largely because voluntary accreditation by NCQA and others developed before the move by states to increase regulation of HMOs, about 25 states recognize private accreditation as fulfilling all or part of state HMO licensure requirements. In addition, in 2000, CMS issued rules that will allow HMOs to substitute deemed status for most CMS requirements related to HMO participation in the Medicare+ Choice program. However, because Medicare is a much smaller, and declining, proportion of HMO enrollment, Medicare requirements for HMOs— or deemed status for these requirements—are unlikely to have a significant effect on accountability. Thus, in contrast to the nearly universal hospital accreditation, only slightly more than half of all HMOs are accredited by a private accrediting group. Finally, for non-HMO forms of managed care, such as the rapidly growing preferred provider organization market, virtually no accountability for quality exists beyond the market and basic state insurance regulations. Although NCQA and other accreditors offer voluntary accreditation programs for PPOs, fewer than 10 percent of PPOs are accredited. Like most other accrediting bodies, NCQA began as part of a trade organization related to health plans—the Group Health Association of America, the predecessor of the current Association of American Health Plans . However, in addition to the interest from health plans themselves, NCQA’s early development was strongly influenced by private purchasers’ demands for accountability. As a result, NCQA became independent of AAHP in 1990 and has evolved independently such that its current board of directors includes a broad array of representatives from consumer, purchaser, provider, and other healthcare sectors. Only one of the 18 board members is affiliated with an HMO or other organization now accredited by NCQA—a board composition that is unusual among accrediting organizations. Another factor that marked the early development of NCQA was the development and implementation of a set of clinical performance measures called the Health Plan Employer Data and Information Set . This data set was started by a small group of HMO leaders, with input from clinicians and purchasers. The goal was to create a reliable, valid, and standard set of measures of clinical performance that would provide useful information on quality for purchasers and at the same time limit the unco Accreditation 419 ordinated and disparate demands by large purchasers for clinical information from HMOs. Beginning in 1999, NCQA accreditation has changed in important ways. First, the HEDIS measurement set has been substantially expanded, with the addition of measures related to management of major chronic illnesses. In addition, HEDIS now includes a version of the Consumer Assessment of Health Plans Survey developed by a research team coordinated and funded by the Agency for Healthcare Research and Quality. More than 80 percent of HMOs, including plans that do not opt for NCQA accreditation, now report most or all of the HEDIS measures annually to NCQA . While not all measures are reported by all plans , the population base of the plans that do report a given measure usually exceeds 50 million people. Beginning in 1999, NCQA began to incorporate performance on selected HEDIS measures as an integral and substantial portion of the overall accreditation score. This represents a major change in accreditation practice. As noted previously, nearly all accreditation and certification have relied exclusively on adherence to standards or on cognitive testing, rather than on an analysis of quantitative measures of performance. A major criticism of accreditation is that little empirical evidence links compliance with accreditation standards to outcomes of the service or care delivered. The inclusion in the accreditation process of reliable measures of clinical processes and outcomes of care increases the likelihood that accreditation status is a valid indication of the quality of care delivered. NCQA accreditation decisions are now reported on a public web site as excellent, commendable, accredited, provisional, or denied . The web site also includes plan-specific information about performance on accreditation standards and HEDIS measures grouped in five categories understandable to consumers . The NCQA report card is also linked to major commercial web sites, such as Medscape, America Online, and Compuserve. This level of reporting begins to provide the amount and type of detail that purchasers or consumer can use to select health plans based on differential quality. NCQA has also created a web-based reporting and self-assessment system for many of its accreditation processes, minimizing the need for onsite review of materials and programs. Finally, like the Joint Commission, NCQA has expanded its scope of accreditation programs to include managed behavioral health, disease management, and physician group practices. The Joint Commission and NCQA also have a joint venture for accreditation of human subject research protection programs. 420 The Healthcare Quality Book In summary, for HMOs, the market—driven primarily by private purchasers and voluntary accreditation—has played a stronger role in the evolution of accountability than in the physician or hospital sectors. Regulation by state and federal governments is clearly moving beyond insurance regulation but is still not widespread or consistent, and, beyond HMOs, little accountability of insurers exists.

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Insurers – The Healthcare Quality Book- Vision, Strategy, And Tools

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