Discharge Planning Advisor-Consumers tuning in to plans' quality ratings
Accreditation focusing more on outcomes
Among the influences driving health plans to be more accountable and consumers to be better informed are the health care industry's various rating systems.
While employers and individuals typically choose health plans primarily on price, several experts in the field say that is changing, partly because of the information that is more readily available regarding company performance.
"Traditionally, consumers don't look at their policy until they get sick," says Peter Moran, RN, MS, CCM, Cm, president of the Case Management Society of New England and staff nurse case manager for Harvard Pilgrim Healthcare in Portland, ME. "As consumers get more educated, we're going to see that they will shop for quality."
Some of the pressure toward measuring health plan performance is coming from more enlightened purchasing groups, Moran notes. "There is a large group of Massachusetts employers, the MassHealth Purchasing Consortium, that decided because they purchase so much health care, they would look at keeping prices down. Now they're also looking at outcomes."
Industry ratings, such as those from the National Committee for Quality Assurance (NCQA) in Washington, DC, don't address the specifics of discharge planning but are becoming more oriented toward care outcomes, says Sandra Lowery, RN, BSN, CRRN, CCM, president-elect of the Little Rock, AR-based Case Manage ment Society of America and president of CCMI Associates, a case management consulting firm in Francestown, NH. "Recently, because of consumer protests and anti-managed care backlash, [NCQA] has been pressured to change its criteria to include outcomes," she adds. "So it's better than it used to be."
NCQA, a watchdog organization that evaluates the quality of health care, issues regular reports, updated monthly, rating health plans. Although 75% of the weight of the NCQA survey is on the plan's systems and processes, including such issues as how physicians are credentialed, the remaining 25% is now focused on patient outcomes, says NCQA spokesman Brian Schilling.
The Utilization Review Accreditation Com mission (URAC) in Washington, DC, has been accrediting organizations that do utilization review since 1991, says Valerie Nosek, a URAC accreditation reviewer. In June 1999, URAC, also known as the American Accreditation Healthcare Commission, issued its first report on case management companies, Nosek adds.
"We have an accreditation program for organizations that provide telephonic or on-site case management services in conjunction with a privately or publicly funded benefits program," she says. That includes stand-alone case management companies, as well as health plans with a case management department, Nosek says.
"Discharge planning is covered globally but not specifically under our standards," she says. "The standard that would most apply is for the plan of care. [The organization being accredited] would have to document a case management plan for each client that talks about long-term and short-term goals, what resources should be utilized, time frames for follow-up and evaluation, and how long services should be provided."
Meanwhile, physicians are developing a better understanding of the need to use resources effectively. This shift in physician attitudes is making reviews by insurance plans redundant, says Lois Pabst, RN, MBA, CNAA, A-CCC, director of care management for Eastern Connecticut Health Network in Manchester. "Physicians are changing their behavior through risk contracting and from learning about best practice. There is a lot of information published showing that long [hospital] stays don't equal better care."
Pabst applauded the November announcement by UnitedHealthcare that it was freeing physicians of the need to get approval for medical treatments and hospitalizations. "It's a trend that should be happening," she says.
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