When the going gets tough . . . the tough share the pain?
That seems to be the game plan for HMOs and other managed-care organizations that are struggling to meet the accreditation requirements of the National Committee for Quality Assurance. They are spreading the task of documenting performance among the physician groups that treat HMO enrollees.
By sharing the load, the HMOs don't have to gather as much data or accumulate as much documentation to secure NCQA accreditation. On the other hand, the strategy forces physician groups to spend time and labor reproducing documentation for each HMO with which they contract.
NCQA accreditation was undertaken in an effort to help employers and other purchasers measure the care offered by health plans. As healthcare evolves into a consumer-driven system that prizes value, specific provider information becomes crucial to the measurement process.
To ease the burden of meeting accreditation requirements, representatives of physician groups are working with the Washington-based NCQA to develop a plan that would allow for certification that would be a one-time stamp of approval, good for all the HMOs with which a group contracts. Besides streamlining a group's paperwork, that kind of certification also would assist the HMOs' accreditation efforts.
An initial version of the certification requirements still is being discussed but was expected to be released sometime this month. The committee may begin reviewing physician groups later this year, according to NCQA spokesman Barry Scholl.
"Everything is still pretty tentative because we don't know what obstacles might arise in this process," Scholl says. "It's too premature to say exactly what the physician groups will have to do. However, we've always said that physician groups that want to contract with NCQA-accredited HMOs would do well to familiarize themselves with the committee's existing standards, such as HEDIS 3.0."
HEDIS 3.0 is the third and latest version of NCQA's Health Plan Employer Data and Information Set, the industry-standard performance measurement blueprint.
The NCQA physician group certification program isn't intended to produce a list of certified physician groups for consumers. "This product is designed to streamline the quality oversight process by giving HMOs seeking NCQA accreditation the confidence that they are contracting with physician groups that are also meeting NCQA standards," Scholl says. "This group greatly reduces the due diligence tasks that the HMOs now have to complete."
Physician group representatives also see potential benefits in NCQA certification, in part because they have had a voice in developing certification requirements. For instance, representatives helped ensure the new rules were based on consistent definitions of care, says Julie Sanderson-Austin, vice president for quality at the American Medical Group Association.
"HMOs and insurers may define a successful vaginal delivery a little bit differently, and so having consistent definitions in the NCQA's requirements will help prevent misunderstandings," she says. "I think our groups will welcome NCQA certification because it will mean less work overall."
The fact that the effort is cooperative also is a plus, as is the fact that the end result will be a more streamlined procedure for medical groups. In the short term, however, many groups will have to make significant changes to secure the benefits of certification.
For example, although they won't have to reproduce documentation for multiple HMOs, they will have to meet NCQA requirements for the services they deliver, says Michael Lynch, M.D., vice president of medical affairs at Dean Health Plan.
The health plan is the HMO division of Dean Health Systems, a large physician group in Madison, Wis.
"Substantial infrastructure changes will likely be needed to achieve the kind of data gathering, documentation and performance the NCQA is expected to require of its certified physician groups. These could include extensive changes in operating procedures, due process and any other tasks the HMO may delegate to the physician group," Lynch says.
Lynch adds that the NCQA might require physician groups that want certification to incorporate certain procedures, such as ways to evaluate patient satisfaction, specific quality improvement programs, better utilization management programs, individual performance assessment of physicians and standardized severity-adjusted outcomes measures to gauge the group's overall performance.
"This is still conjecture, but I think the physician groups will generally have to show they have a useful continuous quality improvement program in order to get NCQA certification. So, setting up a quality improvement program could be a good place for many physician groups to start until the NCQA releases its standards for the groups," Lynch says.
For starters, groups should gather such data as their rate of immunizations, rate of mammograms, use of beta-blocker drugs for heart attacks and use of preventive services.
Because their size allows them to operate their own HMOs, Dean and other large physician groups have been dealing with NCQA requirements for several years.
Dean has been preparing for its NCQA accreditation review for two years; the review is scheduled for March 1998.
Sheryl Thies, vice president for marketing and planning at Dean, says the NCQA's requirements for HMOs are far more stringent than accreditation requirements for hospitals and other healthcare providers have been in the past.
"The NCQA requirements are a lot more process oriented and analyze what we do a lot more closely than other accreditation surveys that just check off whether we're doing a particular procedure or not," Thies says. "The NCQA really looks at where we're at, where we're going, and what we're doing about specific situations."
Besides preparing for certification, Thies says Dean is working to implement three main quality improvement projects: a program for improving clinical care, an outcomes project for measuring performance and a patient satisfaction mechanism.
The satisfaction data is doctor-specific, and Thies says some physicians were "truly shocked that they weren't as excellent as their peers."
She adds that Dean's physicians are using their early data to build new and better measures for the future. For example, a small group of physicians meets regularly in an effort to tackle issues upfront, rather than waiting for surveys to reveal problems after the fact.
Thies believes it doesn't matter whether performance improvement is driven from an external source or an internal group. "All providers used to like to say they delivered quality healthcare, but now purchasers are asking us to prove it," she says.