NCQA setting standards for PPO accreditation
PPOs will use patient surveys to judge quality
The quest for accountability and quality standards is expanding as the National Committee for Quality Assurance (NCQA) in Washington, DC, launches an accreditation program for preferred provider organizations (PPOs).
Meanwhile, NCQA is shifting some health plan indicators to biennial measurement to make room for more detailed, clinically-oriented measures on diabetes, cardiovascular disease, and other conditions.
Pressure from large employers and consumer organizations, along with a changing marketplace, led NCQA to adapt its program that until now targeted only health maintenance organizations. While 80 million Americans belong to some 650 HMO plans, 89 million are enrolled in 1,034 PPOs.
"Although the number of individuals in managed care is increasing, the number in some kind of PPO or choice plan is increasing at a more rapid rate," says Gary Krieger, MD. Krieger is a pediatrician in San Pedro, CA, and a member of NCQA’s Committee on Performance Measure-ment, which guides the development of quality of care measures.
"The consumer public has indicated in so many ways that it does want more choice," he says. "But at the same time, these entities need some standards and parameters of quality."
The PPO program presents some dilemmas in designing a program that assesses outcomes and quality of care. Some standards, such as credentialing and members’ rights and responsibilities, can be adapted easily, notes NCQA spokesman Brian Schilling. But PPOs don’t attempt to manage care through a primary care physician. PPOs would find it difficult, if not impossible, to obtain information through medical record reviews, as health plans do.
"A PPO wouldn’t be able to report on its mammography or C-section rate," says Schilling. "They can’t give us the kind of performance data that an HMO can. They would have a lot more difficulty getting the information they need from a loosely affiliated network of providers."
Assessing PPOs with modified CAHPS
Instead, NCQA will adapt its Consumer Assessment of Health Plans survey to gauge the patient’s experience of care at PPOs. The survey, which is also used by HMOs, will allow a true comparison of the two insurance types, in addition to comparisons among individual payers, says Schilling.
The new PPO accreditation program isn’t likely to have a significant impact on medical groups, says Mike Ralston, MD, director of quality demonstration for The Permanente Medical Group in Oakland, CA. But it does mean that medical groups with that contract with PPOs will find a greater emphasis on patient satisfaction, he says.
"The medical groups will for the first time have external forces bringing [patient satisfaction] information to evaluate their performance," says Ralston, who is also a member of NCQA’s Committee on Performance Measurement. Such information could be become an issue in contract negotiations, he says.
The final standards for the PPO accreditation program will be developed by the summer of 2000, Schilling says. The first surveys will occur about three months after that, he adds.
There is great interest in PPO accreditation, including some PPOs that want to distinguish themselves as quality payers, says Schilling.
"We expect that there will be some large employers who will require PPOs to begin collecting this information," he says.
Measures shift to biennial reporting
In another development, the NCQA will begin staggering the collection of HEDIS effectiveness of care measures. (See charts on HEDIS measures for 2000 and 2001, p. 100.) The change will allow NCQA to monitor meaningful changes in performance while allowing the agency to implement new measures, says Schilling.
"Immunization and mammography rates aren’t likely to jump or slide a significant amount in a year," he says. Yet annual measurement of a large number of measures becomes a heavy financial burden on health plans.
"When you [look at] the collection of data and the time it takes to analyze and report them, you’re almost halfway through the next data collection period," says Krieger.
Yet annual measurement won’t halt for all health plans. Federal law requires Medicare managed care plans to report on performance indicators on a yearly basis, and some states and larger employers may require annual reporting as well, says Krieger.
New measures such as "cholesterol management after acute cardiovascular events" initially will be reported every year. One measure proposed for HEDIS 2000, "emergency room visits for people with asthma," has been postponed for technical reasons.
HEDIS Measures Reported in 2000
- Childhood immunizations
- Adolescent immunizations
- Well-child visits in the first 15 months
- Well-child visits for ages 3, 4, 5, and 6
- Adolescent well-child visits
- Cholesterol management
- Controlling high blood pressure
- Beta-blocker treatment after an acute cardiac event
- Comprehensive diabetes care
- Management of menopause
HEDIS Measures Reported in 2001
- Cervical cancer screening
- Breast cancer screening
- Prenatal care in the first trimester
- Follow-up after discharge for mental illness
- Advice to quit smoking
- Comprehensive diabetes care
- Management of menopause
- Controlling high blood pressure
- Cholesterol management
- Initiation of prenatal care
- Frequency of prenatal care
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