Never mind the plummeting enrollment numbers-two second-tier managed-care accreditors see the shaky Medicare+Choice program as their ticket to the big time.
The Joint Commission on Accreditation of Healthcare Organizations and the Accreditation Association for Ambulatory Health Care have applied for government approval to accredit HMOs and PPOs participating in the Medicare managed-care program.
But some healthcare purchasers, which have nurtured the popular managed-care accreditation programs run by the National Committee for Quality Assurance, frown on competition when it comes to accreditation. The market-leading NCQA has also applied for the government's deeming authority to accredit Medicare managed-care plans.
Health plans satisfy Medicare quality standards if they are accredited by a private agency that has been granted deeming authority.
That all these accreditors are chasing a market of health plans that will soon be less than half of what it was three years ago does not seem to significantly concern them. In 1998, there were 346 health plans contracting with Medicare; in 2002, only 157 plans will do so. The managed-care industry has blamed this high dropout rate on the failure of Medicare's payment rates to keep up with cost increases.
"We are hoping that being recognized by the Medicare program will help us get more HMO business," said Margaret Van Amringe, vice president of external relations at the JCAHO.
The Oakbrook Terrace, Ill.-based JCAHO says it accredits 75 HMOs and PPOs, of which nine participate in the Medicare+Choice plan. The AAAHC, based in Wilmette, Ill., accredits 20 HMOs, of which six are Medicare+Choice plans, and no PPOs. Both lag the Washington-based NCQA, which large healthcare purchasers helped create more than a decade ago. The NCQA accredits 282 plans, including 75 in Medicare+Choice.
Because purchasers tend to be more familiar with the NCQA accreditation for health plans, which uses the popular Health Plan Employer Data and Information Set (HEDIS) measurement system to track how well plans deliver care to beneficiaries, health plans interviewed said they now find greater value in picking the NCQA. "At the end of the day, the marketplace seems to place more credibility on the NCQA stuff than the JCAHO," said a managed-care lobbyist who requested anonymity.
In fact, at least one purchaser has been outspoken in saying that the JCAHO, which has deemed status by Medicare to accredit hospitals, should not be in the business of HMO accreditation. "To have competing accreditors is very dysfunctional in my opinion," said Bruce Bradley, director of managed care at General Motors Corp. GM provides health benefits for more than 1.2 million employees, retirees and their families.
Bradley's chief concern is that inconsistent approaches to accreditation make comparison of plans more difficult for purchasers.
The JCAHO and the AAAHC contend that though their approaches to accreditation may be different, the standards used by the three bodies are consistent.
"I think that someone who is in business, like Bruce Bradley, would understand that competition is a good thing and that competition makes all accreditors better," Van Amringe said.
But the competition will be over pieces of a rapidly shrinking pie. Next year will be the fourth in a row that the number of plans participating in Medicare+Choice has fallen.
Accreditors and the managed-care industry, bolstered by recent commitments from the Bush administration to fight for more money from Congress for Medicare+Choice, are undaunted. "I think there have been clear signs from the administration and members of Congress that they are recognizing that this is an industry that has been overregulated and underfunded," said Susan Pisano, spokeswoman for the American Association for Health Plans.
The managed-care industry has pushed for the Centers for Medicare and Medicaid Services to give deemed status to accreditors so that plans participating in Medicare+Choice would not have to complete both an accreditors' survey to satisfy private purchasers and the CMS' own quality inspection to satisfy the government. Once an accreditor has that status, its accreditation of a health plan means the plan also meets Medicare's quality standards.
If more than one of the accreditors' applications are approved by the CMS, they will compete for Medicare+Choice plans' business. Plans interviewed for this article said they are likely to select only one accreditor.
Although giving private accrediting bodies deemed status in the Medicare+Choice plan was approved by Congress as part of the Balanced Budget Act of 1997, it is only now being implemented. The CMS received completed applications from the AAAHC, the NCQA and the JCAHO during the past 21/2 months and is expected to make its decision on which will get deemed status by spring 2002.