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WASHINGTON -- The National Committee for Quality Assurance will begin distributing reports next year that aim to provide consumers more complete and understandable information on health plans.
The reports also are intended to help consumers discern the industry's top performers.
Last week, the Washington-based NCQA released its prototype consumer report, which is based on Accreditation '99, its new oversight accreditation program that will be implemented next July.
The reports will be organized by region and product type: private commercial insurance, Medicare or Medicaid. They will show how HMOs ranked on five factors expressed in terminology familiar to laypeople: access and service; qualified providers; staying healthy; getting better; and living with illness. An overall accreditation status for each plan also will be shown. The new accreditation categories are: excellent, commendable, accredited, provisional and denied.
The reports available next year will be the first to integrate NCQA's Health Plan Employer Data and Information Set measures with accreditation information. Additionally, they will be the first reports to convey data audited to standards launched by NCQA last year. The accreditation score also will reflect the results of consumer surveys administered by NCQA-certified vendors. NCQA has merged its HEDIS Member Satisfaction Survey with that of the federal Agency for Health Care Policy and Research to have a standardized industry survey covering commercial, Medicare and Medicaid products.
"Today, we believe, marks the start of a new era of accountability in managed care, which will have a profound effect in the years to come on the 80 million Americans enrolled in HMOs," NCQA President Margaret E. O'Kane said at a July 28 news conference.
Traditionally, NCQA's HEDIS and accreditation programs have been separate. Accreditation involved reviewing an HMO's structure and processes, examining issues such as grievance procedures, physician credentialing and the way decisions are made for medically appropriate care.
HEDIS is a set of report card-type performance measures. Revised HEDIS measures will be released this month, and those that initially will be incorporated into Accreditation '99 are related to effectiveness of care, access to care and member satisfaction (BI, April 27).
Combining the two programs offers a complete review that can tell consumers a plan has good systems in place and is performing well, Ms. O'Kane said. "It's a much more coherent way of telling the story."
According to the NCQA, many employers, unions, consumer groups and other organizations have publicly supported Accreditation '99. Employer representatives at the news conference who have worked with NCQA said the audited data and new report will help them in their missions to provide quality, cost-effective care to their employees.
Lee Saviola, human resources director of AT&T Corp. in New York, said the new report "translates technical and clinical data into usable consumer information."
Barbara Brickmeier, manager of health benefits programs at Armonk, N.Y.-based International Business Machines Corp., said that "adding performance measures to the accreditation process gives a complete picture of how the plan is operating." Having such data, she said, enables IBM to "keep drilling down" into its layer of employees not yet in managed care. Of IBM's 220,000 active employees and retirees covered by health benefits, almost 88,000 are in managed care, Ms. Brickmeier said.
Dr. Cary Sennett, NCQA executive vp, said that of the five measures the new report will show, "the single most important category quantitatively is access and service." The combined HEDIS and accreditation score in this category will account for 40% of the weight in the overall accreditation decision.
Access and service provides a "global view" of a plan, reflecting NCQA's evaluation of systems and key performance measures. This category answers the general questions of whether health plan members have access to the care and service they need. It also factors in how members rate service and whether they have problems getting care.
Terms previously used, such as "credentialing" and "utilization management," are meaningful "for those of us inside the industry," Dr. Sennett said, "but we learned these are not terms that consumers understand."
The new terms were developed in conjunction with the Foundation for Accountability, a Portland, Ore.-based employer group, and tested on focus groups. "It's very clear to us that this is how people think about quality," Dr. Sennett said.
Among the accreditation categories, "excellent" will be reserved for plans that are considered benchmarks because of consistent delivery of the highest levels of care and service that far exceed NCQA requirements. About 10% of accredited plans will earn this designation, Dr. Sennett said. "Commendable" will signify that the plan exceeds NCQA requirements, "accredited" will mean that a plan meets NCQA requirements, and "provisional" will mean the plan is in partial compliance with standards but that there is, in NCQA's judgment, no deficiency that poses a significant risk to care. "Denied" will signify a seriously flawed plan. The current categories are: full, one-year, provisional and denied.
Plans with an initial review in July 1999 or later will be able to earn the "excellent" designation. Plans that received full accreditation prior to the 1999 launch of the new categories and that have at least one year before another review can try to move into the "excellent" category by submitting audited HEDIS data. In the first year of the program HEDIS measures will be used only to help, not hurt, an accreditation decision.
The American Assn. of Health Plans welcomes the changes. "Both payers and health plans will benefit by getting better access to reliable and accurate information," according to a spokesman for the Washington-based association. The new accreditation terminology "better expresses the benchmarking process," and from a health plan perspective, the audited data "will help level the playing field." Plans will be more willing to participate because they will know that the data competitors are submitting is audited, the spokesman explained.