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This Web site is a component of the SAMHSA Health Information Network. |
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Organization & FinancingSAMHSA Managed Care Initiative Training SessionsJanuary 1997 Dates: January 8 and January 30, 1997 Title: HEDIS 3.0 and the Accreditation of Managed Behavioral Health Care Organizations Speaker: Margaret O'Kane, President, National Committee for Quality Assurance NOTE: Although presented in January 1997, this summary has been revised to include updated data. Summary: The National Committee for Quality Assurance (NCQA) is an independent, nonprofit organization that reviews and assesses the quality of managed care plans. Its mission is to examine health plan capability and managed care services, to provide information on quality to the marketplace, and to promote quality improvement. NCQA works to improve quality of care and services to employers, consumers, and regulators through instituting accountability measures for health plans, the majority of which are health maintenance organizations (HMOs). However, NCQA considers itself not a regulator of health care but an enhancer of the regulatory process. Today's health care system is more price driven than quality driven. NCQA strives to direct purchasers to include both value and quality in their contracting decisions, so that quality is passed on to the patient, NCQA's ultimate customer. NCQA's board of directors includes the NCQA president, six health plan administrators, six purchasers, two state health policy experts, one health lawyer, one union representative, two consumer representatives, one representative from the American Medical Association, one quality expert, and one representative from the American Association for Retired Persons. NCQA brings these board members together to achieve a consensus in defining quality. NCQA accreditation uses performance measures to continuously improve the level of patient care, provider network, and service responsiveness that is given by various health care organizations and plans. In addition to accreditation standards, NCQA uses HEDIS (Health Plan Employer Data and Information Set) version 3.0/1998, which is a national standard in performance measurement. HEDIS is a tool by which purchasers can glean information and assess health care value; it is a standardized information set for individual consumers to utilize; and it is a way for health plans to standardize and simplify measurement and reporting. HEDIS 2.0 was developed in 1993 by NCQA's Committee on Performance Measurement (CPM), with consultants from RAND, Harvard University, the Centers for Disease Control and Prevention, and the Agency for Health Care Policy Research. CPM comprises eight purchasers, five consumer/labor representatives, five health plans, and five measurement experts. These organizations solicited 1,700 organizations through questionnaires to gather their insights and recommendations for the development of measurements. HEDIS is used by 87 percent of HMOs today to report their data. Preferred Physician Organizations (PPOs) and other health plans are not yet evaluated by this measurement. HEDIS 3.0 was released in 1996, with an expansion to include Medicaid. The 3.0 version represents a dramatic enhancement. It is more result oriented, addresses the full spectrum of health care, integrates public and private measurement efforts, and includes processes for ongoing evolution. The next version is expected in 1999. NCQA will replace outdated measures from previous HEDIS versions. Specifically with regard to behavioral and mental health, HEDIS 3.0 includes:
HEDIS behavioral and mental health testing set measures include-
HEDIS includes measurements in the following areas:
HEDIS responds to major health issues, such as smoking, cancer (breast, cervical, colon, rectal), heart disease, diabetes, asthma, sexually transmitted diseases (HIV, chlamydia), as well as the care of seniors (health improvement, flu prevention), behavioral health (acute and chronic care), and public health concerns (immunizations, antibiotic resistance). The measurements for seniors were developed with the the Centers for Medicare and Medicaid Services (CMS). The use and visibility of HEDIS will increase with quality compass reports to be made available in summer 1997, the basis of other local and national plan report card initiatives, and the basis of cover stories in magazines: U.S. News and World Report, Newsweek Consumer Reports, and Health Pages. Ms. O'Kane expects that more than 60 percent of employers will be using HEDIS within the next two years. An additional impetus to its use is that CMS requires Medicare-related HEDIS 3.0/1998 measures for its HMOs. NCQA accredits/certifies HMOs and credentials cerification organizations. Beginning in 1997, NCQA launched programs for Managed Behavioral Health Organizations (MBHOs) and Preferred Provider Organizations. In its credentialing criteria, NCQA reviews quality improvement, utilization management, credentialing, members' rights and responsibilities, preventive health services, and medical records. Those wishing to receive certification must maintain an acceptable score in each area. As of the end of May 1998, 60 percent of those who attempted certification from NCQA received a 3-year approval, 30 percent received a 1-year approval with another visit from NCQA required within one year, 4 percent received provisional approval (a warning that a number of improvements are required before NCQA visits again), and 4 percent were denied. There is a growing interest in NCQA's accreditation results. There have been 15,000 phone requests per month for its accreditation status list. Hundreds of news articles per month reference NCQA's accreditation, including articles in Time, Money, and The Wall Street Journal. NCQA accreditation results have been featured on the Today Show, CNN, and other major broadcast outlets. Tens of thousands of people have accessed NCQA's information from its World Wide Web site (http://www.ncqa.org). Thousands of advertisements for HMOs and other health plans cite NCQA accreditation each year. Ms. O'Kane reports that over half of the Nation's 630 HMOs are in the process of receiving NCQA accreditation; 40 Fortune 500 Companies require NCQA accreditation of the health-care plans they utilize (for example, Xerox has 226 HMOs with NCQA approval in their network); 11 states require NCQA external review for health plans with which they do business. As of May 1998, nine states required external review as a condition of licensure. As the U.S. moves further into managed care, Ms. O'Kane predicts that more labor unions will require NCQA approval. While she believes that there will never be a standardization of medical necessity, meaning that certain diseases or ailments will not require the same treatment by all providers, she has observed that there is a higher degree of consensus among practitioners today than in the past. However, as an example of nonconsensus of treatment, Ms. O'Kane cited the recent debate among researchers regarding mammography. She explained that some studies are finding early cancer detection through mammography screening beneficial in women of younger ages, while other studies see no advantage in screening women before they have reached a later age. As a result, Ms. O'Kane believes that health care quality suffers if parties do not agree on appropriate treatment and testing for a prevelant problem, such as breast cancer. The 1997 Measurement Advisory Panels have established goals to-
NCQA enhances accessibility and ease of use to its members with plan-specific, comparative, and customized reports. NCQA's newest method for disseminating accreditation and HEDIS information to a wider audience is through Quality Compass, a CD-ROM available for purchase. The future for NCQA includes developing accountability strategies for the full spectrum of managed care delivery, integration of accreditation/certification and HEDIS activities, and making quality information ever more accessible and useful for purchaser and consumer decision makers. Ms. O'Kane was pleased to announce that NCQA has formed subcommittees on behavioral health care to proactively search for new measures to include in HEDIS, as well as to screen existing measures. Committees also have been formed for chronic diseases, women's health, and child health. For further information on the health care plans and organizations that have received accreditation from NCQA and for a copy of NCQA's current testing measures, contact the NCQA office in Washington, D.C., at 202-955-3500, or visit their web site at http://www.ncqa.org.
Question and Answer Session I
1. A: HEDIS stands for Health Plan Employer Data and Information Set and is a national standard for performance measurement. The 3.0/1998 version is the latest version, and although it's not perfect, no other sets of measurement have evolved to the degree of this HEDIS version. HEDIS is used by 87 percent of HMOs today to report their data to NCQA and other accreditation agencies.
2. A: No, we will probably never be there. For a denial of care, however, our plan requires that appropriate specialists be consulted. This also applies to behavioral health. There is a higher degree of consensus in the medical community for what should be done for a specific condition. We don't have this consensus in the behavioral medical field currently. I'd like a platform for agreement in the medical community on this issue.
3. A: Representatives from the plans report their own medical record results. However, due to NCQA's newly developed audit requirements, NCQA has encouraged health plans and hospitals to use a third party to report results.
4. A: Our measures relate to acute care, but not tertiary. However, we are working to add tertiary care.
5. A: Yes. We look at measures and realize that some don't make sense and that we need to restructure them to reflect our current needs. An example is our low birth-weight measure. Reporting was not above 50 percent, so we took it out.
6. A: Most measures would no be affected by risk adjustment. However, we are currently working with Harvard and RAND on developing these standards. Risk adjustment is important when studying different populations.
7. A: No. Please call NCQA at 202-955-3500 and ask for a list of testing measures. Our Web site-http://www.ncqa.org-offers general information. Please visit it.
8. A: Yes. Chemical dependency is one of eight measures for the behavioral health testing set.
9. A: NCQA assesses the quality of treatment and not the programs themselves.
10. A: We work with CMS on certain measures, such as measurements for seniors, but we are not as large as CMS. We accredit 400 organizations and health plans each year; CMS accredits over 7,000 each year.
Question and Answer Session II
1. A: Yes, they apply to all organizations we accredit. We developed our accreditation program targeting MBHOs. We are not making it mandatory for all managed care organizations (MCOs) to comply to all of our standards at this time. We will do so in the future, however.
2. A: There are many out there and I don't know much about them. What makes NCQA different is that we have the purchasers and consumers involved in the design of the programs right from the beginning. The general tradition of accreditation in this country is that the profession takes it upon itself or the provider to define standards. But we found it dissatisfying for the measurement of health care quality.
3. A: It is very hard to segregate by particular diseases and we do expect there to be some crossovers. How do we select these measures? It's not a very systematic process. We are looking for experts: clinicians, clinical researchers, some members of the providers organizations, and consumers. The problem is that we have such a wide variety of types of people to include, that we could not include them all.
4. A: There is a geriatric advisory measurement panel forming currently. As we all know, this is a very important area to cover.
5. A: For the physicians, you can look in the CMSS (Council for Medical Specialists Society) manual. Basically, we ask organizations if they checked the findings they are reporting, and how can they prove that they checked them.
6. A: If we believe there are no problems and they have received a full approval, we will not go back for three years. I have to admit that I think three years is a long time, especially in this marketplace. If things change within the plan, if it merges, or it they have a high turnover of consumers, they have to notify us and we do a discretionary review. We also perform a discretionary survey for a complaint or other problem, and are not required to inform the organization when we do so. During this review, we look at patient satisfaction surveys to see what they have done to improve quality and examine files to see how patients were handled. Was the patient referred to a clinician or a specialist? Did the health care provider take action? We have seen grievances where terrible quality issues were present, and therefore, we take this part of the survey very seriously. It is a comprehensive review, because this process is one way that patients are reassured that if the health care process breaks down, they will get the care they need.
7. A: In our group presently, we include representatives from Digital Corporation, a leader in setting high standards for behavioral health care services; a representative from the American Psychological Association; four or five psychiatrists; social workers; a representative from a chemical dependency association; and consumer representation. Therefore, we have a diverse group who are trained to deal with these technical issues.
8. A: We go in and testify and often we are invited by the states. Our standards are much tougher than any state regulatory standards. We have routinely flunked plans that states have no problems with, and we have flunked plans that have been certified by the Medicare programs.
9. A: In our processes, we decide which accrediting organizations we will recognize. The Joint Commission on Healthcare Organizations is one. Behavioral health care measures have gotten us involved in accrediting measures we have not worked with before.
10. A: We do not accredit individual providers. We are focused on managed care and work with more complex delivery systems.
11. A: We do not have standards for these issues. Our standards, however, take into consideration the cultural constitution of the population to be sure we have providers that care for these groups' particular needs.
12. A: No, not as of yet. Generally, my staff feels that it's a wonderful group to bring together.
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