The nation's state insurance commissioners are getting into the act alongside federal policymakers and accrediting bodies in the effort to regulate quality assurance and outcomes reporting by health plans.
A draft of a model regulation for quality assurance is being circulated for comment by the National Association of Insurance Commissioners. The association said a revised draft is expected to be ready for discussion at its Sept. 18-21 meeting in Minneapolis.
State regulators have focused on such issues as solvency and insurance rating, but now the national trade group says it's time to establish baseline performance standards for all health plans.
"As the market moves more towards managed care, with or without federal healthcare reform, the need to assure minimum performance standards and provide greater disclosure from all types of health payers-such as HMOs, Blue Cross plans, PPOs and indemnity insurers-increases," said James Long, North Carolina's insurance commissioner.
Mr. Long chairs the group working on the quality regulations as well as performance-monitoring initiatives involving utilization review, provider credentialing and grievance resolution.
The model regulations made use of existing standards of private accrediting bodies, then incorporated comments from state insurance and health regulators as well as federal officials and industry representatives, Mr. Long said.
Under a draft issued in mid-June, each health plan would have to establish and operate a management process to assess quality of care provided to enrollees. A written description of the program would be submitted to the insurance commissioner. Health plans would have to comply with any state regulations that set forth the definition, collection and reporting of quality-related information.
A "drafting note" suggests that states might want to rely on "recognized private accreditation or data-reporting entities" for enforcing such standards. The state could periodically affirm that the accreditor's standards are at least equal to those established by the state.
Among functions recommended for inclusion in the quality-improvement system are:
An analysis of patterns of care as they relate to the care process and outcomes-to ensure that the monitored patterns and diagnoses are chosen because they're important and appropriate to the population served.
Documentation of efforts to improve quality and outcomes of healthcare, by comparing progress with internal goals and external benchmarks of care adopted by the health plan.
Written procedures for taking action when collected information indicates quality problems or areas that need improvement.
The draft also calls for a health plan to include information about its quality assurance and improvement systems in marketing materials and in the handbook provided to new enrollees.