Citing the need for increased efficiency, the nation's two leading hospital associations have joined the American Association of Preferred Provider Organizations in its call for universal PPO credentialing standards.
But some questioned whether the groups' newly voiced support was as much a well-disguised jab at the Joint Commission on Accreditation of Healthcare Organizations as it was a policy endorsement.
The Washington-based AAPPO last week announced that it won the backing of the American Hospital Association and the Federation of American Hospitals in its effort to compel the nation's top three accrediting bodies-the JCAHO, the National Commission for Quality Assurance and URAC-to collaborate on a single set of provider credentialing standards for PPOs.
Credentialing is the process by which health plans establish and verify the qualifications of their network providers. It's a key facet of the broader accreditation process, which the AAPPO also ultimately would like to see standardized for PPOs.
Currently, the JCAHO, the NCQA and URAC are vying for control of the burgeoning PPO accreditation market, with each touting their own quality measures and guidelines. This hodgepodge of standards, though, is inflating costs and creating regulatory headaches for the PPO industry and healthcare purchasers, the AAPPO said.
"Ideally, we'd like to see the entire accreditation process unified, but we're taking it one step at a time," said AAPPO spokesman Chris McNamara. "Credentialing is a logical place to start because it's a critical component (of accreditation) and a key quality measure."
Both the AHA and the federation have asserted that creating universal credentialing standards would reduce the provider confusion and administrative costs associated with meeting the varying requirements of multiple accrediting bodies.
"These efforts clearly benefit our shared goals of applying resources efficiently to ensure quality healthcare and of maximizing the resources devoted to direct patient care," AHA Executive Vice President Richard Pollack wrote in a Feb. 4 letter to the AAPPO.
The support, though, came just weeks after the JCAHO formally teamed up with the Leapfrog Group, a consortium of 96 large healthcare purchasers, to release a controversial report on how well hospitals are meeting the purchasing group's independent patient-safety standards.
The report rankled the AHA and federation because it evaluated hospitals by using criteria that differ from those they are proposing. The hospital associations criticized some of the criteria as too stringent and said they hoped Leapfrog, the JCAHO and others would prevent confusion by using the patient-safety standards developed for the hospital groups by Santa Barbara, Calif.-based consulting firm Protocare.
Both the AHA and the federation denied that their backing of universal credentialing was a sign of growing tension between the hospital associations and the Oakbrook Terrace, Ill.-based JCAHO. They pointed out that it was the AAPPO that solicited outside support in order to time it with the AAPPO's annual forum last week.
"I'm very aware of the timing of all this, but there was certainly no ulterior motive here," said Karen Fernandes, chairwoman of the federation's quality committee. "The issue (of universal credentialing) was presented to us, and we felt that it was of great importance to support."
The JCAHO and its competitors, nevertheless, could have much to lose if they agree to create a uniform set of credentialing standards. At stake is the potentially lucrative-yet still largely untapped-PPO market. Roughly 110 million Americans are enrolled in some 500 PPOs nationwide and the market is expected to expand an average of 15% annually during next five years (See chart, p. 10).
Currently, the JCAHO, the NCQA and URAC can each charge the same PPO significant fees for their review processes. But if a uniform standard were in place, PPOs would have to be accredited only once-thereby drastically diminishing the pool of potential customers.
"It's true that by eliminating competition you're eliminating some business opportunities," said Margaret Van Amringe, the JCAHO's vice president of external relations.
That's not to say, though, that the accrediting agencies have been dragging their feet, Van Amringe is quick to add. The three organizations have been meeting since last year-well before the AAPPO launched its effort-to discuss ways to unify their credentialing standards.
"They didn't drive us to the table. We were already at the table," Van Amringe said.
But the negotiations haven't been easy, she said. After reviewing 33 general credentialing areas, the agencies found that they held the same standards for only four of them. These included relatively simple issues such as how often to require recredentialing.
The organizations are now working to hammer out uniform standards for 11 other "relatively flexible" areas by this summer. The remaining 18 areas, however, "will be the real toughies," Van Amringe said.
"We've grown up with different histories. We each have different philosophies and issues that are especially important to us," Van Amringe said of the three accrediting bodies. "That's where it becomes difficult to reach an agreement."
Some managed-care leaders have said they don't want to see PPO accreditation dominated by the JCAHO, an organization that has made its mark accrediting hospitals. The JCAHO now accredits 75 HMOs and PPOs, while the NCQA accredits 282, or roughly half of the nation's health plans. URAC accredits 85 health plans.
Ultimately, though, the AAPPO doesn't care which organization takes the lead as long as a uniform, industrywide set of standards is established.
"Right now, I don't think any of them alone are addressing all of the concerns of the PPO industry," McNamara said. "The JCAHO isn't, the NCQA isn't, and URAC isn't. It's going to have to be a mutual effort."