The first 2 categories, quality improvement and credentialing, account for 35% and 25% of the evaluation, respectively. Plans are rated in each of these categories on a scale ranging from 0 to 5 points (Fig. 1). When making purchasing decisions, many companies question whether plans have attained NCQA accreditation or still require accreditation. To receive accreditation, a health plan must include adult and pediatric medical/surgical services, obstetrics, mental health care, and preventive care. It must provide ambulatory and inpatient services and is required to have been in operation for 2 years.
Figure 1. From Merck-Medco Managed Care, Copyright © 1997.
Average scores for 83 managed care organizations, with summary reviews in 6 categories of NCQA accreditation standards (July 1995 to November 1996).
From Merck-Medco Managed Care, Copyright © 1997.
The levels of NCQA accreditation are as follows:
Full Accreditation is granted for a period of 3 years to plans that have excellent programs for continuous quality improvement and meet NCQA's rigorous standards.
One-Year Accreditation is granted to plans that have well-established quality-improvement programs and meet most NCQA standards. NCQA provides the plans with a specific list of recommendations and reviews the plans again after a year to determine whether they have progressed to the level of Full Accreditation.
Provisional Accreditation is granted for 1 year to plans that have adequate quality-improvement programs and meet some NCQA standards. These plans must demonstrate progress before they can qualify for higher levels of accreditation.
Denial is given to plans that do not qualify for any of the categories mentioned.
Under Review status is given to plans for which an initial accreditation determination has been made but that are under review at the request of the plans.
About half of the country's HMOs are participating in the NCQA accreditation process. As of the end of February 1997, about half (121) of the 248 plans that had been surveyed had full 3-year accreditation and one third (82) had 1-year accreditation (cover figure). Twenty-one plans were in provisional status, and 24 plans had been denied accreditation. An initial decision is pending for 21 additional plans, and an initial review is scheduled for 58 additional plans. As of February 1997, 5 plans were under review.
The NCQA also provides patients and benefit administrators a means of comparing managed health care plans using the Health Plan Employer Data and Information Set (HEDIS) performance measures. (See DRUG BENEFIT TRENDS, November 1996). The latest iteration of these performance measures came with the release of HEDIS 3.0 in November 1996.
Sources include the Center for Outcomes Measurement and Performance Assessment, a new unit of Merck-Medco Managed Care LLC, Montvale, N.J., developed to assist MCOs in gaining accreditation status, and the NCQA. More information on the NCQA is available on the organization's Web site at http://www.ncqa.org.