Plans now require peer review
QIOs still in the loop
Quality improvement organizations (QIOs) will maintain a role in monitoring Medicare managed care plans, according to the federal Balanced Budget Act, passed in August. Earlier this year, it looked as though plans would be allowed to bypass external quality review as long as they were accredited by the National Committee on Quality Assurance (NCQA) in Washington, DC.
The Health Plan Employer Data and Information Set (HEDIS) review is focused on how data goes into a plan’s system, how it comes out, and its impact on the plan’s HEDIS report. NCQA’s review is more broadly system-oriented and covers processes. Excluding peer review would have saved the government $100 million over the next four years, and some plan administrators felt it would be expensive, burdensome, and duplicative to have to demonstrate competence to both accreditation bodies and QIOs. (See article on IPROs, p. 179.) Others disagree, and find it helpful to go through the audit using the new HEDIS standards.
"Since the inception of our plan, the Texas Medical Foundation [the state peer review organization] has been regularly reviewing its policies and procedures," says Pam Mahaney, RN, clinical quality director at NYLCare Health Plan of the Southwest in Irving, TX. "This is the first year Medicare managed care plans have had to report HEDIS status, and this is the first year HCFA [the Health Care Financing Administration] has contracted with QIOs to audit how we prepare our Medicare HEDIS report for HCFA. It’s been very helpful. We try to adhere to the specifications regardless of whether we anticipate an audit."
Joseph N. Cheek, MD, chief medical officer and vice president of medical affairs at NYLCare, concurs: "Having HCFA contract with PROs to audit Medicare managed care plans is entirely appropriate. The auditors simply validated our methods of gathering information for the reporting instrument. Our perception based on this single opportunity to interact with IPRO’s reviewers of the HEDIS standards is that they were quite knowledgeable."
Cheek did voice some concern about the HCFA reviewers who look not at HEDIS data, but at data on the management of the plan. "By virtue of the risk contract we have," he explains, "HCFA annually audits all our policies and procedures basically how the plan meets the needs of the Medicare beneficiaries." Those audits safeguard beneficiaries’ rights within the Medicare program. HCFA regularly reports its findings.
"Based on our contacts thus far with some of those auditors, our concern is that the PROs themselves are struggling to understand managed care," says Cheek. The auditors’ ability to be objective and produce constructive comments to the benefit of the program could be in question, he says, and that could produce some confusion and the potential for misinterpretation. "That’s just a knowledge gap that the PROs need to close."
The Balanced Budget Act stipulates that as of next year, HMOs begin submitting to HCFA inpatient hospitalization utilization reports. The Act states that plans must have internal quality assurance programs and undergo external quality reviews by PROs or independent review organizations. (You can look at the entire Balanced Budget Act of 1997 by going to http://www. house.gov/radanovich/record/cr052097.htm on the Internet.)
"Monitoring the quality of care that’s provided to Medicare patients is an important component of the federal government’s oversight role," says Patrice Spath, ART, a health care consultant in Forest Grove, OR. Medicare patients, both those in managed care plans and in traditional ones, she says, should benefit from the evaluation activity.
"One advantage of including managed care patients in the quality review activities of peer review organizations is that consumers will eventually have access to that quality of care data. They can then use that information to compare process and outcome measurement results between traditional Medicare insurance coverage and that provided to managed care patients. Such comparisons could help consumers decide which type of coverage is most appropriate for them."
Previously, QIOs were only responsible for looking at quality and appropriateness for traditional Medicare plans, and not for Medicare HMOs. As they were set up, Medicare HMOs required an internal system of utilization review and quality management at the provider level. Providers were expected to set up their own UR/QA committees and review themselves internally. According to Josef Reum, the association’s executive vice president, the budget law makes clear the distinction between accreditation a snapshot and quality review a longer examination.
Overlap in quality review seen as positive
"I don’t agree that accreditation is merely a snapshot," argues Ilene Morgan, RN, quality improvement manager at Secure Horizons, the Medicare program of PacifiCare, an HMO in Lake Oswego, OR. "NCQA doesn’t look just at how an organization is doing today. The accrediting body looks at how the organization did two years ago as well, and what it did over the last two years to improve in different areas. HEDIS measures do provide a snapshot; they measure, for example, how many people within a brief period of time had a certain procedure. NCQA and HCFA will continue to overlap in reviewing our quality, but we see that as a good thing."
Secure Horizons collected HEDIS data on its Medicare population as a participant in the HCFA project. PacifiCare has a regulatory/compliance department that provides staff with information on new requirements and recommendations from HCFA and from state regulatory agencies. "We work closely with that department to make sure we meet all state and federal requirements," says Morgan. "Most of what they’re asking for, we’re already doing. We take a proactive stance."
Morgan’s quality department collected data between April and June 1997. "The system was rigorous," she says. "If the data wasn’t within the correct time frame, it wasn’t accepted into the database." Secure Horizons uses HEDIS qualifiers to see where improvements can be made. "We’re very focused on quality here. The benchmarking stats are interesting to us for comparison purposes, but this is for the most part a self-improvement tool."
Oregon is saturated with HMOs, and several have Medicare populations. "We share a lot of our physicians," says Morgan. "We’re not a staff model HMO like Kaiser. Most of our physicians belong to an average of 3.6 health plans."
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