The National Committee for Quality Assurance has come up with new, expanded accreditation standards for health plans that focus on results and require independent reporting of audits.
The new standards, called "Accreditation '99", include performance
measures from NCQA's Health Plan Employer Data and Information Set
(HEDIS), which the government uses in analyzing performance, trends
and outcomes. HEDIS results will initially count for 25% of a plan's
accreditation score, while the remaining 75% will be based on a plan's
compliance with NCQA standards.
NCQA said it plans to gradually increase the proportion of the
accreditation score based on performance and HEDIS results initially
will be evaluated relative to national and regional averages, as well as
national benchmarks.
The new standards also contain the redefined accreditation designations
of Excellent, Commendable, Acceptable and Denied. There also will be
five new performance-based reporting categories: Access and Service,
Qualified Providers, Staying Healthy, Getting Better and Living With
Illness.
"Only those plans that demonstrate excellence both in terms of their
quality improvement and consumer protection systems, and on important
measures of care and service, will achieve the highest levels of
accreditation," said Cary Sennett, M.D., NCQA executive VP.
"Accreditation '99" introduces new consumer protection standards. They
include prohibitions on financial incentives to encourage case managers
to deny or limit care, requirements that plans have a process for
approving exceptions to restricted drug formularies and for coordinating
medical and behavioral health care, and evaluations of whether plans
unduly limit access to emergency room care.
Plans also will be required to submit independently audited HEDIS
reports to NCQA annually, which will back up on-site surveys.
"Basing accreditation decisions on actual performance, using
standardized measures -- is a critical step towards moving the industry
from prevailing practices to best practices," said Robert Galvin, M.D.,
GE's director of health care. "That's what the quality movement is all
about."
Kathleen Angel, VP, Worldwide Benefits and Work Life Solutions, Digital
Equipment Corp., said working with health plans that have the highest
NCQA accreditation is good business "improves our ability to select the
best plans for our employees."
New advisory standards will look at health plan information systems and
the ability to routinely provide employers, consumers or care managers
with important data. New "Information Systems" standards will require
managed care organizations to ensure confidentiality of members' data,
link data from different databases, ensure the efficiency and
reliability of data and use the information to improve performance.
The standards have been mailed to 2,500 business coalitions, employers,
health plans, medical groups, associations and regulatory bodies. The
full text can be found on NCQA's web site at http://www.ncqa.org/accred/accred99.htm.
The comment period for the standards runs through May 15 and final
standards will be issued in August. More Insurance and Reimbursement News