Qualified Health Plan Accreditation Metrics: Prepared to Pass an Auditor’s Scrutiny?

Jodi JohnsonJanuary 19, 2017

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You’ve likely heard the saying, “the one constant in life is change.” That quote originated with the Greek philosopher Heraclitus, who lived around 500 B.C. and wrote that “change is the only constant in life.”

However you paraphrase it some 2,500 years later, the enduring truth in that statement is validated again and again.

Whatever the nature of change that Heraclitus may have contemplated those many hundreds of years ago, I’m quite certain it had nothing to do with the potential repeal of the Affordable Care Act or the incoming U.S. administration’s policy changes and their broader impact on healthcare. As of this writing, we have pundits and politicians and predictors galore, parsing what those changes will actually be. When the dust finally settles and we catch our collective breath, the healthcare industry will react and adapt, as it has always done and will continue to do.

When Change is Evolutionary

The fact is, the healthcare industry is always changing—that’s evolution. And evolution is, by its very nature, a largely positive force, impelled to develop better organisms, products, or processes. The most basic driver of evolutionary change is the imperative of survival, but a multitude of incremental changes take place in support of that foundational goal.

In the recent evolution of healthcare, there have been many drivers of change. Technology obviously comes to mind, but cost, consumerism, and competition are also critical drivers. They have impacted every role in the healthcare delivery system, from payer to provider to patient. Healthcare delivery systems have changed, reimbursement models have shifted, but no matter the latest trend or buzzwords—whether they be “value-based care” or “population health”—one word has echoed through every concept as a call for consistent improvement in healthcare: quality.

A recent Google search for simply “quality 2017” found that among the top 20 results, more than 75% of the returned sites related to healthcare. The healthcare industry is quality obsessed, with good reason. Improving the quality of service and healthcare among providers can literally save lives.

But quality is critical for payers and health plans as well. Fierce competition and the need to protect or expand market share means that any opportunity to demonstrate timely, accurate, quality delivery of services is more important than ever. But how is quality defined? How is it measured? And how do you demonstrate or report on the quality of your programs and services?

Accreditation: A Stamp of Quality

Entities that measure and mark a health plan as one that meets standards of quality and accountability have existed for nearly 30 years. At the beginning, accreditation was seen as an indicator of those plans that exceed in delivering quality services and products. Today, the Affordable Care Act (ACA) requires that any issuer on the health insurance exchanges must be accredited by an accrediting entity approved by the U.S. Department of Health and Human Services (HHS) to be considered a “Qualified Health Plan.” Two accrediting agencies have been so designated by HHS.

The National Committee for Quality Assurance (NCQA) is a private organization founded in 1990 and dedicated to improving the quality of healthcare across the industry. Long considered the gold standard of industry accreditation, NCQA today offers a number of accreditations for health plans and provider organizations. NCQA also developed and maintains the Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are used in NCQA’s own accreditation process and across the industry to evaluate and compare health plan performance.  The NCQA accreditation process evaluates a wide spectrum of quality measures, including the HHS Agency for Healthcare Research and Quality (AHRQ) and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

URAC is another leader is healthcare accreditation, making its biggest impact in the areas of clinically-focused programs such as case management, disease management, and utilization review. This non-profit was also founded in 1990 under the name “Utilization Review Accreditation Commission,” which was shortened in 1996 to reflect expansion from its clinical roots as it began accrediting health plans and provider organizations. URAC’s quality measures closely align with AHRQ initiatives as well, including the CAHPS survey/measures and the National Quality Strategy.

While both accrediting bodies use their external auditors or surveyors for audit or inspection to verify that all service and clinical quality standards are met, it is important for health plans to maintain a rigorous, continuous internal quality improvement program. Such a program helps ensure standards for both continued accreditation, as well as compliance with other external quality measurement programs to which they may be subject.

External Quality Measurements & Reporting

In addition to accreditation, there are many health plans that are subject to external quality measures, such as Medicare Star Ratings for Medicare Advantage drug plans. Medicare Star Ratings are critically important to health plans, and are based on a one-to-five star scale in five distinct weighted categories:

  1. Staying healthy: screenings, tests, and vaccines
  2. Managing chronic (long-term) conditions
  3. Plan responsiveness and care
  4. Member complaints, problems getting services, and choosing to leave the plan
  5. Health plan customer service

Medicare Advantage Organizations (MAOs) that fail to achieve the highest ratings are subject to financial penalties in the form of reduced rebates or withheld bonus payments. Consistently low scores can result in sanctions or removal from the program. It is easy to see the importance of consistent quality monitoring in every category to ensure that quality is accurately measured, and that quality standards are maintained across an organization.

Another example of external quality standards comes from the Blue Cross Blue Shield Association (BCBSA), which has long been an industry leader in innovation and driving positive change in healthcare. Demanding the highest standards of quality from its member companies, the BCBSA implemented its Member Touchpoint Measures (MTM) program, which sets rigorous standards for quality, timeliness and accuracy for enrollment, claims adjudication, and member services. Plans under the Blue Cross Blue Shield umbrella must meet or exceed an evolving set of quality benchmarks. Noncompliance or failure to meet standards can result in penalties and sanctions as severe as potential loss of BCBS affiliation.

Practical Steps for Quality Assurance

Every health plan has a plan for quality improvement, and should view accreditation and quality measurement reporting as an enterprise-wide initiative. From a historical perspective, many of these quality measures may have revolved around clinical practice and preventive guidelines, or provider credentialing and access, but quality measures are also increasingly focused on member satisfaction—not just from a care perspective, but also appeals/grievances and member services interactions. Quality measurement and improvement requires cross-functional effort and coordination to ensure members are receiving the highest level of service, and that your plan is properly rewarded with the highest ratings for quality.

Every payer knows this is no small task. It takes continuous effort, and resources, and perhaps some blood, sweat and tears. But there’s a way to simplify your quality monitoring and improvement efforts. From data validation and integrity, to increased automation, efficiency or accuracy, an enterprise data analysis platform is a solution that equips payers to:

  • Streamline the Audit Process. Many plans today conduct internal audits, whether for external reporting or strictly for internal quality improvement purposes. Either way, you can improve your audit process from capturing sample data and data integrity assurance, to automated audit workflow and audit, to visibility into every stage of audit status and productivity.
  • Automate Quality Measurement and Reporting. Quality assessment requires analysis of data from across your enterprise. An automated solution can capture a superset of data, calculate quality measures, and provide visibility into trending measures. It can even automate external reporting of audit and quality measure results.
  • Leverage Quality Results. Quality measurement is only one part of the equation. The other part is the practical application of those results to improve measures such as data timeliness and accuracy.

Bringing automation, data validation, and increased visibility to your processes could save your organization both money and headaches when it comes to accreditation and quality reporting. As Aristotle, another Greek philosopher said long ago, “Quality is not an act, it is a habit.” The healthcare industry has certainly made quality a habit. Now we need to look at ways that make it an easy habit that deters complacency.

You’re not alone in turning data into accurate metrics. Explore a story of how a leading insurer fixed a gaping data integrity liability in the nick of time.

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