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Strengthening the Market to Improve Quality
Key Organizations and Their Activities
Quality oversight organizations
|Information on health plans, facilities, and professionals||Specify aims for improvement and goals for measuring and reporting performance information on health plans, facilities, and individual providers||Implement a quality measurement and reporting strategy to make information on quality available on all sectors of the industry to the public at large||Require reporting of information as part of their contracting requirements; participate in and support the work of the Forum||Work collaboratively with the Forum and each other to implement quality reporting requirements; assess compliance of health care organizations with reporting requirements|
|Choice of health care providers||Track implementation and report progress in its annual report||Offer health plans that provide adequate choice of providers||Encourage and assess compliance through standards and review processes|
|Access to emergency services||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan contracts||Encourage and assess compliance through standards and review processes|
|Participation in treatment decisions||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Respect and nondiscrimina- tion||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Confidentiality of health information||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Complaints and appeals||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Patient responsibilities||Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities||Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities||Assist in educating employees regarding their rights and responsibilities||Encourage and assess compliance through standards and review processes|
While a number of QOOs already have exercised leadership nationally in the development of core quality measurement sets, by bringing together the strongest possible group of stakeholders committed to quality measurement, the Forum can bring to bear greater expertise, resources, and support for the activities of existing QOOs. QOOs that may not have had the resources or the authority to advance the practice of quality measurement as fast as they may have liked would now have the commitment and influence of the Forum to assist them in their efforts to develop the strongest possible quality measurement data sets. Because of this, the Forum and QOOs will need to create a strong partnership that builds on the quality measurement and oversight expertise that the QOOs already have and aids them in taking the next steps to implement even stronger measures of quality for all sectors of the health care industry.
Enhancing Public Confidence
Public confidence in the assurances offered by quality oversight organizations is not always high. This may stem in part from some aspects of the process used to oversee quality, limitations in public participation and openness of their processes, and the appearance of conflict of interests. QOOs can increase public confidence in their oversight processes by addressing these issues.
Countering Conflicts of Interest
Conflicts of interest can arise from multiple sources. For example, private sector accrediting bodies have as one of their customers the entities that the organization accredits. The organizations to be accredited sometimes are the same organizations that created or fostered the creation of the accrediting entity and often are necessarily involved in identifying the standards to which they will be held accountable.
An accrediting organization can be faced with the contradictory pressures of setting standards high enough to be credible but not so high that a large number of entities will not meet the standards. This is particularly true when accreditation is voluntary and paid for by the entity seeking review. These customers understandably are upset when the entity that is supposed to serve their needs and that they chose to be reviewed by, for which they will incur large costs not incurred by entities not willing to be reviewed, treats them in a punitive fashion, such as when accreditation is denied or other sanctions are taken (Brennan and Berwick, 1996) or when they believe the standards are inappropriately high.
Quality oversight organizations also have a second set of customers -- health care consumers -- who depend on the work of these organizations to make comparative judgments about the quality of certain types of health care organizations. This is particularly true when public regulators use accreditation as a means of meeting public standards (e.g., when JCAHO-accredited hospitals are deemed to have met Medicare Conditions of Participation). Consumer advocacy organizations become concerned when the accrediting organization seems overly solicitous of the views of the industry or when very few organizations have their accreditation denied (Scholsberg and Jackson, 1996; Dame and Wolfe, 1996).
Strengthening the methods used by quality oversight organizations and operating in a stronger climate of public participation and disclosure can reduce real or apparent conflicts of interest. This can be accomplished by (1) expanding the representation of health care consumers, public purchasers, and regulators on governing boards and the committees that establish standards and make accreditation decisions; (2) expanding public input into the standard-setting process through public review and deliberation on existing and proposed standards; (3) making standards and survey protocols used to reach accreditation decisions, as well as detailed information from the accreditation surveys, available to the public at low or no cost; (4) using unannounced inspections for some elements of the survey process; (5) making full disclosure of funding sources; and (6) creating alternative funding mechanisms that reduce potential conflicts of interest.
Involving Workers in Quality Oversight
At the present time, there are no quality oversight organizations that have procedures for incorporating the views of a representative sample of health care workers into the accreditation process. The establishment of such procedures would ensure that quality oversight organizations would obtain a more complete picture of the organizations that they oversee. QOOs that accredit health plans, facilities, and networks often interview a number of individuals in key management positions. While these individuals may have a firm grasp of the management processes that govern their organizations, they may not always be aware of problems that are obvious to those who work with patients on a daily basis. A related problem is that frontline health care workers who are aware of quality problems at a plan or facility may not come forward because they fear being disciplined or even terminated (go to Chapter 13).
Addressing the Needs of Vulnerable Populations
Many of the standards used by QOOs to assess and improve the quality of care for the general population are not as effective for populations with special needs. These populations include individuals who are economically vulnerable and therefore may encounter financial barriers to care; those who are vulnerable because of health status, such as the mentally or physically disabled and the chronically ill; and those who are vulnerable because of communication barriers, such as language.
One of the key challenges in this area is the development of accreditation standards that can assess whether health plans, facilities, integrated delivery systems, and other providers have the structures in place to care for different vulnerable populations. Although accreditation and licensure standards often address areas such as the availability of interpreter services for patients who speak languages other than English and physical accessibility, greater attention should be focused on assessing the adequacy of care management processes and specialized delivery programs (e.g., whether a health plan has appropriate services for members with a particular disabling or chronic condition).
Efficiency of Oversight and Accountability Processes
As the number of quality oversight organizations has grown, and as their requirements have expanded, many entities on the receiving end of quality oversight have voiced concern about the problems of multiple and overlapping standards and levels of accountability. A managed care health plan, for example, may be held to a wide range of standards, including State licensing requirements, Medicare and Medicaid contracting requirements, NCQA accreditation standards for managed care organizations, JCAHO network accreditation standards, and URAC network accreditation standards. This can result not just in increasing administrative burden to the plans, facilities, and providers who must comply with these different standards, but can divert resources away from quality improvement initiatives or other areas of the health care system needing resources (e.g., expanding coverage). Two ways that greater efficiency can be introduced into quality oversight are to move to a common set of standards and to coordinate the review of health care entities.
Common Sets of Standards
In some sectors of the health care system, different QOOs are moving to reduce inconsistency among their standards for health care entities. The Federal Government in the past year began an initiative to develop common standards for Medicare and Medicaid contracting health plans. The National Association of Insurance Commissioners tries to achieve consistent standards across States by promulgating "Model Acts" for use by States. The NCQA, in its third version of HEDIS, achieved consistency across performance measures for Medicaid, Medicare, and commercial populations. In spite of these achievements, there still is room for reducing inconsistency.
For example, the standards used by States for licensing HMOs are not always the same as those used by private accrediting organizations or those used by Medicare or Medicaid. Across private accrediting organizations, managed care plans can be accredited against very different sets of standards. While it may be healthy to have different entities developing standards (in the same way that it may be desirable to have different entities develop stronger performance measures), more collaboration and coordination of quality standards used by quality oversight organizations could result in greater efficiency in the health care system. A process for jointly testing and implementing new standards could allow the development of stronger standards while reducing unnecessary inconsistency.
Coordinated Quality Oversight
Once common standards are more widely adopted, QOOs should begin to design and test ways to reduce duplicative reviews. For example, if a health plan has been found to meet quality standards for State Medicaid contracts and these are identical to standards for Medicare contracting (if the process for determining compliance has integrity), should a health plan undergo a separate, duplicative review for Medicare contracting? Such a situation was addressed by the Balanced Budget Act of 1997, which permits, at the option of a State, a health plan that is engaged in Medicare to be exempt from certain Medicaid quality reviews under certain circumstances. Precedent for such coordinated quality reviews was created in the Medicare program. Hospitals accredited by JCAHO or the American Osteopathic Association are deemed to have met conditions of participation for Medicare. Accepting one QOO's determination to satisfy another's has gone by the name of "deeming."
Discussions of deeming often are contentious. Many consumer advocates, for example, are concerned about the use of private accreditation as a replacement for government regulation (Scholsberg and Jackson, 1996; Scholsberg, 1997; Dame and Wolfe, 1996). Some of their concerns include (1) the lack of independence of private accrediting bodies; (2) decreased accountability to the public when the raw data from the accreditation process are not as available to the public as the findings of licensing or Medicare and Medicaid reviews; (3) reduced public participation in the development of private standards, as compared to the public's role in establishing government standards; and (4) diminished access to standards and the results of accreditation surveys. Accrediting bodies generally charge the public for their standards, while government agencies provide them free of charge.
Addressing these concerns while pursuing ways to increase the coordination of quality oversight activities is a worthy goal. Federal and State governments may want to use demonstration projects to test new approaches to deeming that can address these questions. The Health Care Financing Administration currently is pursuing a modified approach to the deeming of Medicare managed care plans through an initiative known as "Enhanced Review." Under this approach, HCFA plans to use select results from private accreditation surveys to supplement its own work. If HCFA determines that the methodology used in a private accreditation survey is equal or superior to its own, HCFA has the option of using that information instead of doing its own review. Health plans will participate on a voluntary basis. Plans that choose not to participate or have not received an accreditation from an organization participating in this project will continue to have complete reviews of their operations by HCFA.
In addition to such coordination between public and private oversight entities, private accrediting bodies could also make use of deeming to simplify their own work. An organization that accredits health plans, for example, could make use of accreditation decisions or survey results from the organizations that accredited the hospitals, clinics, and medical groups affiliated with that health plan.
Holding Entities Accountable
Although licensing, accreditation, and certification standards are abundant, they cannot offer the public assurances about the quality of health care overall. Indeed, many of the problems cited in Chapter 1 have occurred in entities that meet licensing, accrediting, and certification standards. Recognizing this, most quality oversight organizations are moving to incorporate quality improvement as a major focus of their standards. However, even focusing to a greater degree on quality improvement will not offer uniform assurances about quality, as long as some entities do not choose to meet applicable quality standards.
Accreditation of health plans or facilities (e.g., long-term care facilities) often is voluntary, although less so to the extent that a given marketplace requires accreditation as a condition for receiving contracts. In addition, as newer types of health care delivery organizations are created (e.g., provider-sponsored organizations), and as different types of entities are held accountable for care delivery (e.g., medical groups), it is difficult for licensing, accrediting, and certification entities to keep up with the evolution of new health care delivery models and entities in the marketplace. In order for greater uniformity of assurance to be offered to the marketplace, all types of health care plans and care delivery organizations should comply with common standards for quality.
Compliance with such standards can be achieved in a variety of ways. Many health care entities choose to meet quality standards to live up to their own internal commitment to pursue excellence, as well as to distinguish themselves in the marketplace, as entities offering high-quality health care. In instances in which a health care entity may not perceive the need to adhere to external quality standards, group purchasers can require compliance with quality standards as a condition of doing business with any given health care entity. Licensure and other regulatory approaches can also be utilized. While the Commission hopes that quality standards will be embraced voluntarily, there is a need to monitor the achievement of compliance through voluntary and marketplace incentives. For this reason, it is recommended that the Advisory Council on Health Care Quality be established and charged with monitoring the Nation's progress in improving care and recommending when approaches are needed to stimulate additional mechanisms for quality improvement (go to Chapter 5).
Brennan, Troy A., and Donald M. Berwick, New Rules: Regulation, Markets and the Quality of American Health Care (San Francisco: Jossey-Bass, 1996).
Dame, Lauren and Sidney Wolfe, The Failure of Private Hopsital Regulation (Washington, DC: Public Citizen, 1996).
Schlosberg, Claudia, Privatizing Government Regulation of Publicly Funded Health Plans: The Limits of Private Accreditation (Washington, DC: National Health Law Program, Inc., July 7, 1997).
Schlosberg, Claudia, and Shelly Jackson, "Assuring Quality: The Debate Over Private Accreditation and Public Certification of Health Care Facilities," Clearinghouse Review 30(7):699-719, November 1996.
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Last Revised: Sunday, July 19, 1998
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