Accreditation gaining importance to MCOs
Companies also are focusing on local markets
(Editor’s note: This is the first in a two-part series on staying ahead in the managed care game. This month, we discuss trends in the managed care market and how they affect your business. Next month we will list the services managed care companies want from their providers.)You might not need Medicare certification to get managed care contracts in the future, a plus for private duty agencies who have the certification just to get MCO business. But you certainly won’t be able to compete for contracts without some type of quality accreditation.
"It’s time for providers to get wise to the fact that they need to get out and get accredited as quickly as possible," says Mark Deutsch, MBA, director of new business development for Market Share Plus, a health care management and marketing firm in Chesterfield, VA. He often gives talks on the topic of managed care sales and marketing.
As managed care companies pursue accreditation from the Washington, DC-based National Committee for Quality Assurance (NCQA), — the accrediting body for health plans — and as NCQA, in turn, requires Health Plan Employer Data and Information Set (HEDIS) standardized performance measurements, the companies are looking for providers with quality assurance systems in place.
One method is to ensure the providers are accredited. Either the managed care company develops an internal process to do so, or they use programs from such organizations as Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, or the Community Health Accreditation Program (CHAP) in New York City.
Managed care company administrators’ lives become much simpler if they only work with accredited providers, which many are choosing to do, he says. Some companies, though, have developed their own programs.
"The managed care companies are choosing to protect themselves. [They’re saying] we’re doing everything possible to ensure choice and ensure quality by only using providers that are accredited themselves.’"
Most agencies serving managed care contracts are Medicare certified, and many also are accredited. The emphasis on Medicare certification may change, however, as Medicare becomes more privatized to involve more managed care products, Deutsch says.
"I would envision providers just needing to be accredited somehow — through Joint Commission or CHAP or someone else. That’s going to become much more important than Medicare certification," he says. "Over time, I think [Medicare certification] will phase itself out because the more [recent] restrictions and regulations are through Joint Commission."
Managed care companies are requesting more information from their providers in terms of accreditation and credentialing, he adds. Some companies, for example, are starting to do on-site audits. "Sometimes they will let you know, and sometimes they won’t."
Here are some other trends Deutsch sees in managed care:
• Regionalization of managed care organizations.
Managed care companies are finally realizing that home care services are a local market, says Deutsch.
Instead of having one national office, managed care companies are starting to build offices closer to home. That means the companies will react more quickly to needs of local providers, including private duty home health agencies. Agencies without contracts also will have a better idea of what local services are needed in the marketplace and can approach the companies with an offer to provide them.
"[The companies] may have centralized some of their processes, but they are now going back to a model where they at least have a state or regional office so they can more quickly react to the local marketplace," he says. "They’re getting closer to the grass-roots level."
The HMO market is getting much more competitive than it has been, he says. "Last year was the first year many of them started to slide in terms of membership." In the past, managed care companies put a lot of money into building new facilities. "Now they want to get back to basics and know the local marketplace."
• Competition between self-insurers’ health systems and commercial HMOs and other managed care programs.
Hospitals trying to be vertically and horizontally integrated have proved to be big competition to many HMOs, Deutsch says. "Hospitals can provide everything and essentially be the insurer and go directly through employers. This eliminates HMOs altogether."
Connect with the local market
Already having connections in the community, most self-insured providers — hospital systems — can be more in contact with the local marketplace than the managed care companies. This can result in higher customer satisfaction.Private duty home health agencies need to become involved in this issue, he says. "If they aren’t, they are going to get locked out of those contracts. The hospital is going to look to include everything in its organization so it can go directly to the insurer," he continues. "But most hospitals don’t have all the [home health] resources they need, so if private duty agencies can approach hospitals prior to that process happening, they might be able to establish themselves and become fully integrated."
To do this, agencies should approach hospitals that don’t provide a lot of private duty services and proactively offer to design a package of the services to offer exclusively through the hospital. (For more information about private duty opportunity in hospitals and hospital-based home health agencies, see next month’s Private Duty Homecare.) Otherwise hospitals will find other ways to provide the services, and agencies will be locked out of the contracts altogether.
Down the road, Deutsch envisions self-insured systems and HMOs merging. "There is going to be some initial competition, but in the long run, the managed care companies are going to be folding these organizations into their own systems," he says.
"As HMOs become more regionalized and get more in contact with the local marketplace, they’ll be able to compete head-on with those folks," he adds.
• Developing standards for provider etworks.
Managed care companies are looking at ancillary providers a little differently than most of their other providers, Deutsch says. "[Managed care companies] are defining standards, looking at access and quality of care issues for their ancillary providers. Some one-stop shop providers are having difficulty with their payers because they did not have standards in place to handle the contracts, he adds.
Some payers also are buying home care players so they can monitor them internally. "That tells me [the payers] are seeing promise in the marketplace."
Can you meet the QA challenges?
In addition to being accredited, therefore, private duty agencies will need to be aware of companies’ standards and make sure they can meet the quality assurance challenge. This includes being accessible at all times to health plan members, keeping patient satisfaction high, collecting outcomes data, and staying financially sound.• More reform in the managed care marketplace.
Legislative reform is changing how managed care companies deliver care, says Deutsch. For example, there is the legislation mandating insurance coverage for a minimum 48-hour hospital stay for newborns. Legislators also are working on longer lengths of stay for mastectomy patients.
In addition, managed care companies are offering their providers different incentives. "They’re giving incentives to providers based on patient satisfaction and re-enrollment rather than for reducing the level of care."
In this time of reform, the way to stay on the good side of managed care is to keep an eye on reform and react quickly to it. Reform gives agencies an idea of what types of patients managed care companies are pushing into the homes and what patients, such as new mothers, are being pushed to stay in the hospital, he explains. Then agencies can develop a program of services for the first type of patients and approach the managed care companies.
"You can either be proactive or reactive to the market," Deutsch says. "Keep an idea on the reform so you can be ahead of the game and already have a program in place prior to it happening. Then you are ready to address it if does happen. "Be a product of change and make that change happen instead of a product of the afterward. Then you have to scramble to survive."
[For more information about Market Share Plus, call Mark Deutsch at (804) 897-0466.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content