pharm mfgr advise1998

ENTERING INTO VALUE-ADDED

PARTNERSHIPS WITH YOUR HMOs

Roger H. Strube, M.D.Managed Care Consultant

The Cost and Cost Containment of Medical Care


The Cost = 18% of GNP

$2.3 Trillion

16

15

14

13

12

11

10

9

8

7

6

1970 1975 1980 1985 1990 1995 2000

National Health expenditures as apercent of gross national product.

Calendar Year

Percent

Source: Health Care Financing Administration, Office of the Actuary.Data from the Division of National Cost Estimates.

NATIONAL HEALTH EXPENDITURES AS APERCENT OF GROSS NATIONAL

PRODUCT BY YEAR

Cost of Medical Care

The issue is not the cost of

Coronary SurgeryThe issue is the cost ofdiagnosing and treating

Chest Pain

Sample of Actual Medical Knowledge(Tested Knowledge)

Knowledge Test Score

Age (years)

100%

75%

50%

25%

20 40 60 80 1000%

25%

50%

75%

100%

A

B C

D

Theoretical Test Scores

“Changes over time in the knowledge base of practicing internists”Paul G. Ramsey et al, JAMA, August 28, 1991 - Vol 266, No8 pp 1103

A B C D

B C

0%0

100% Efficient Health Care*

A Judgment AloneMaximumqualityattainableusingmemorybasedsystem

Quality of Care - Memory Base System

* Most cost efficient, medically necessary, effective and best expected result for the patient.

TIME

COMMUNITY HEALTH STATUSvs.

UTILIZATION and EXPENDITURE RATE

B C

DA

$/C

H

ConservativeStyle

ElaborativeStyle

UnderserviceRange of

Acceptable Practice Overservice

SERVICES and EXPENDITURES PER CAPITA

Source: Booz, Allen and Hamilton Inc.

HEALTHSTATUS

of thePOPULATION

EPIPHANY

A spiritual eventin which

the essence of a truthappears to the subject

as in

a sudden flash of recognition

A New ParadigmThe Hypotheses is

an Iconoclasm

It is impossible for physicians to makeappropriate medical decisions using thepresent memory-based system

The information is too great and the medicalknowledge too broad for the mind to manage

All physicians are on Mission Impossible

TONS

TIME

Tons ofPaper

Printed inMedical

Journals

NotShinola

Shinola

Growth of Medical Publishing

Growth of Medical Knowledge

Managed CareManaged care is not the cause of thephysician’s problems, it is a response to thecost and quality issues resulting from thefailure of the memory based medical decisionmaking process. Managed care is not simplyanother iteration of insurance or administration. It is the major catalyst and driving force behindthe most significant, positive changes in theAmerican medical delivery system in thiscentury. It is the agent of change which willfundamentally alter how medicine is delivered.


B Judgment & Feedback


Augmentedmemorybasedsystem

+ Other Feedback


Outcomes


TIME

B C

DA

Q

O

PRESSURE TO SATISFY PATIENTS

Q = QUANTITY OF MEDICAL SERVICES

CONFLICTING PRESSURES ON THEHEALTH SERVICE DELIVERY SYSTEM

O = CLINICAL OUTCOME

PLATEAU OF COMPARABLE OUTCOMES

PRESSURE TO CONTROL COST

Malpractice The “Malpractice Crisis” is not caused by the

litigious society or too many lawyers. It is the response of the patient to the errors which result from the failure of the memory based

medical decision making process. Half of the medical care delivered in America ($500

Billion Dollars) is unnecessary, inappropriate, ineffective or harmful. “Defensive Medicine”

is no defense as excessive testing and procedures do not result in better decision

making and could do harm to the patient. The solution is through electronic decision

support tools applied in real time.

Continuous Quality Improvement

The Application of CQI to the Medical Care Delivery System

Roger H. Strube, M.D.

Quality Assurance Model

STRUCTURE PROCESS OUTCOME

Are the right Are variables monitored Are the results ofpeople in the and reports evaluated treatments monitoredproper positions by the right people or

recommendationswith the appropriate and are appropriate followed up andauthority to recommendations made? re-evaluated?evaluate care?

Credentials Committees Catastrophes

Quality Assurance Model

Regulator’s (& Hospital) Paradigm(Old Testament -- Individual Crime & Punishment -- Find the Bad Apple Model)

· Use professionally developed standards· Satisfy regulatory requirements· Identify errors (crisis management)· Influence through committee and peer

pressure· Draconian tools (fines, cease & desist orders)· Rely on individual case review

Business Value Based Limited Resource Model

Purchaser's Paradigm

· Employers demand the appropriate, effective, & efficient delivery of health care & preventive services

· The management of all employee benefits (medical, workers comp, EAP, disability, etc.) will be awarded to a single full service financially sound entity

· Purchasers are willing to pay for quality & value for the employee - if the health plan has the lowest price

· Business awarded based on proof the MCO can deliver quality care at low cost (NCQA certification, HEDIS data, recommendations from Consultants -RFP/RFI*)

* RFP/RFI = questions consultants pirate from NCQA & HEDIS

An Introduction to Total Quality Management

( TQM )and the

Deming Philosophy


The Study of Quality is the First Step in the Never Ending Journey of Continuous

Quality Improvement

TQM is a set of enabling components and a value systemapplied by the people in an organization which leads to acycle of continuous improvement of the quality of theprocesses and and resulting outputs (outcomes) of theentity.

A tool for organizational learning - the way anorganization re-engineers their business to meetcustomer needs and expectations.

Components of theHealth Care Industry

· Customers· Suppliers· Managers· Workers· Investors· Materials· Machines

The ultimate goal of TQM is the satisfaction of the customer

Internal customers External Customers Other Departments Members Fellow Employees Members‘ Families Plan Management Physicians Corporate Facilities Management Home Health Other Plans Agencies Community

CorporatePlan Management

Plan Supervisors

Workers

Customers

- NEXT -- TOPIC -

W. Edwards Deming

Continuous Quality ImprovementManagement Theory

for theTRANSFORMATION OF BUSINESS

THROUGHAPPLICATION OF THE FOURTEEN

POINTS


The W. Edwards Deming Story· Invited to Japan after WWII by a General McArthur

staffer to advise on restoration of the phone system· invited back in 1950 by JUSE to consult on improving

the quality of Japanese exports· Dr. Deming provided the quality improvement roadmap

an promised, if followed, they would dominate world trade

· Emperor Herohito awarded him the Second Order Medal of the Sacred Treasure for his efforts

· The Japanese government created the coveted DEMING PRIZE which was awarded to Florida Power & Light several years ago

POINT ONE

Create constancy of purpose toward improvement of product (medical care) and service, with the aim to become competitive

and to stay in business, and to provide jobs.

· Reflect a total commitment to constantly improving quality in all ways

· Look at the long term view for the organization

· Develop a mission statement and make it a living document

POINT TWO

Adopt a new philosophy. We are in a new economic age (managed care). Western management must awaken to the

challenge, must learn their responsibilities, and take on leadership for change

· Customer satisfaction is the focus of corporate thinking· Your goal should be to provide your “customers” with

the best possible care in the most appropriate setting· Use industry standards and guidelines (“emenarem”*) to

fulfill your customers’ reasonable expectations and constantly improve the services you provide

* “emenarem” derived from the Milliman & Robertson criteria sets, as in “The director of cost containment told the UR nurse to ‘emenarem’ out of the hospital.”

POINT THREE

Cease dependence on inspection ("Quality Assurance") to achieve quality. Eliminate the need for inspection on a mass

basis by building quality into the product(medical care) in the first place.

· “Inspection with the aim of finding the bad ones and throwing them out is too late, ineffective, costly.

· Quality comes not from inspection but from improvement of the process.”

- W. Edwards Deming

POINT FOUR

End the practice of awarding business on the basis of price tag. Instead,

minimize total medical cost (eliminate unnecessary procedures.) Reduce the number of suppliers for any one service (limited provider network) on the basis of a long-term relationship

of loyalty and trust.

POINT FIVE

Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly

decrease costs

· Standardize many of your processes and train employees in quality improvement methods

· PLAN - DO - STUDY - ACT· PLAN: Collect data to determine a plan of action· DO: Take those actions that further the plan· STUDY: Study the results of the actions by collecting data to measure achievements· ACT: Make the changes to the plan that will better achieve customer satisfaction and further the successful aspects

Practice Guidelines

Measurementand

FeedbackYou cannot manage

what you don’t measure

CLOSE THE LOOP

SEVEN QUALITY CONTROL TOOLS

Cause and Effect Diagrams (Fish Bone diagram)Flow Chart ( How work gets done )Pareto Chart ( y = # , x = type )Run Chart ( y = measure, x = time )Histogram ( y = #, x = measurement )Control Chart ( y = #, x = time + SD limit lines )Scatter Diagram ( v1 vs v2, plot the dots - trend? )

POINT SIX

Institute training on the job

POINT SEVEN

Institute leadership (see point 12). The aim of leadership should be to help people and machines and gadgets to do a better job. Leadership of management (government, insurance companies,

H.M.O.s) is in need of overhaul, as well as leadership of production workers (providers)

· An organization’s leadership should motivate employees to participate in the constancy of purpose adopted by the organization

· It is the responsibility of the employees to try out and trust the new environment and polices, to learn skills, and to develop a different way of relating to their supervisors

POINT EIGHTDrive out fear, so that everyone may work

effectively for the company.

TYPES OF FEAR· Fear of change 1 Lack of job security· Fear of making mistakes 2 Performance appraisal· Fear of punishment 3 Ignorance of company· Fear of being powerless goals to control the aspects of 4 Poor supervision your professional life 5 Lack of operational because of the following: definitions 6 Not knowing the job 7 Being blamed for system problems

POINT NINE

Break down barriers between departments. People in research, design, sales, enrollment, claims processing, information systems, medical management, and delivery of care (providers) must work as a team, to foresee problems of production and in use that may be encountered with the product or service.

POINT NINE

Causes for barriers between departments:· Lack of or poor communication between departments· Ignorance of the organization’s mission and goals· Competition between departments, shifts, or areas· Decisions or policies lacking specificity· Too many levels of management that filter information· Fear of performance appraisals· Quotas and numerical work standards· Decisions and resource allocation without regard to

memory· Jealousies over status and salary· Personal grudges

POINT TEN

Eliminate slogans, exhortations, and targets for the work force (days/K) asking for zero defects and new levels of productivity

Such exhortations only create adversarial relationships because most causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force

POINT ELEVEN

11a. Eliminate work standards (quotas -- days/K, claims/hour, etc.) on the factory floor (insurance company or HMO production areas). Substitute leadership.

11b. Eliminate management by objective, Eliminate management by numbers, numerical goals. Substitute leadership.

POINT TWELVE

· 12a. Remove barriers that rob managed care workers of their right to pride of workmanship. The responsibility of managers must be changed from sheer numbers (days/K) to quality

· 12b. Remove barriers that rob people in management and delivery of care of their right to pride of workmanship. This means complete abolishment of the annual or merit rating and of management by objective, management by numbers

· Deming believed that performance appraisals destroy teamwork and focus on the short term

· People must be viewed as the most valuable resource a company possesses

· Pride in their work is the essential, most important attribute of a highly productive worker

POINT THIRTEEN

Institute a vigorous program ofeducation and self-improvement

for everyone

Educate everyone in thenew philosophy

POINT FOURTEENPut everybody in the medical care system to work to accomplish

the transformation. The transformation is everybody's job

· Management must demonstrate an unequivocal commitment to TQM, which should be driven by conviction

· Management should drive out fear and eliminate other inhibitors and barriers to quality improvement

· Quality improvement must be proceeded first by education of employees on what quality means and the needs of the customers

· Quality is not a department function· Quality improvement is a never-ending process· Inspection by the government or any other agency does not mean

quality control· Quality improvement cannot be accomplished without the total

involvement of employees

- NEXT -- TOPIC -

Memory Based Medical Model

· .

Provider’s Paradigm

· Meet physician perception of patient needs· Achieve desirable clinical outcome· Care based on professional judgment· Care plan managed by command· Rely on past clinical experience and

education

Components of Quality

Provider’s View Judgment Technique Style

Purchaser’s View Appropriateness Effectiveness Efficiency

Institutional View Structure Process Outcome

CQI Input Process Output

* Access is becoming a central issue

Quality Management Viewpoint Analysis Grid

CQI QA Medical

Focus Customer Standards of Patient needs

expectations practice

Goals Standards and Identification and Diagnosis and

process improvement elimination of errors treatment of illness

Methods Statistical analysis Disaster Analysis Memory based

decision making

Management Participative line Staff Activity Hierarchical line

Style Activity activity

Data Analysis Statistical analysis Individual case Outcome analysis

of process review

Continuous Quality Improvement Model

The New & Improved NCQA Methodology

· Exceed customer expectations· Delight the customer (member)· Minimize Variation (critical paths)· Improve the process· Manage through participation

(the Doctor as Quarterback of the Team)· Monitor using statistical methods

(Plot the Dots)

Continuous Quality Improvement Model

General CQI Concepts

· Focus on the customer· Analyze and fix the process, not the people· Invest in your people -- training and education· Do it right the first time· Work as a team· Use data analysis to continuously improve

the process

The Realities of Clinical Practice are Changing

· The patient must define personal values and goals· The data will define potential (acceptable) outcomes· The knowledge based computer programs will present

alternatives (cook book)· The physician must negotiate the ambiguities with the

patient (informed consent)· The patient and the physician will agree on the most

acceptable treatment (disease state management)· The outcome of the interaction will become part of the

disease state data base (determine best practices)· The decision support tools (cook book) will be updated

to incorporate best practices (close the loop)

Quality ImprovementRoadblocks and Challenges

· The single most important cultural change which must occur is from a QUALITY ASSURANCE, find the bad apple, mind set to the QUALITY IMPROVEMENT, improve the crop, paradigm.

· The focus on the customer & process, measurement of standard elements, empowerment of the workers, and constant environmental change is resisted by many middle managers in business and most medical professionals.

The Realities of Clinical Practice are Changing

The physician must transition from

Captain of the Ship to

Quarterback of the Team

Why Invest inContinuous Quality Improvement?

· “Inspection with the aim of finding the bad ones and throwing them out is too late, ineffective, costly.

· Quality comes not from inspection but from improvement of the process.”

· - W. Edwards Deming

- NEXT -- TOPIC -

NCQA AccreditationThe Plan’s Perspective

A Walter Mitty* Story

Fantasy vs Reality

Roger H. Strube, M.D.

* “The Secret Life of Walter Mitty” -- James Thurber

NCQA

· An independent non-profit organization that assesses the quality of managed care plans

· A partnership among purchasers, consumers, and health plans

NCQA Board of Directors

· NCQA president· Purchasers· Health plans· Union representative· Consumer advocate· Health lawyer· AMA· Quality expert· State legislator

States Mandating NCQA Accreditation

· Florida· Kansas· Maryland· Massachusetts· Michigan· Minnesota· Oklahoma· Pennsylvania· Vermont

Employers Mandating NCQA Accreditation

AlliedSignal PepsicoAmeritech UPSCHAMPUS USAirGTE XeroxMercantile IBMBristol-Myers Squibb General ElectricNew York Ohio

The Problem -- Complexity

· Multiple levels of review for managed care organizations· State Licensure· Federal Qualifications· Medicare Certification (HCFA)· PRO Review - Medicare· Medicaid (AHCA)· Employer Specific ( RFP / RFI )

“Everybody wants to get into the act!” - Jimmy Durante

· Inadequate information for purchasers and consumers

Health Plan Accountability

· NCQA performance Program· Measures performance of individual health plans, and

eventually compares them· HEDIS 3.0· Report card · Annual Member Health Care Survey· Special Medicare & Medicaid Requirements

· NCQA Accreditation Program· Evaluates plans’ quality management activities

· The majority of the Nations’ 550 plans have been reviewed by NCQA

· Reports accreditation decisions· Results available on the Web ( http//:www.ncqa.org )

NCQAAccreditation Standards

· Quality Management and Improvement· Utilization Management· Credentialing· Members’ Rights and Responsibilities· Preventive Health Services· Medical Records

NCQA Quality Improvement Standards

· Organized to assess structure, process, and outcome of QI program

· Require integration of clinical and service issues

· Emphasize a systems and data driven approach

· Require tailoring to meet individual plan needs and member populations

· Emphasize results and impact

NCQA Quality Improvement Standards

Critical Tools · The Reviewer Guidelines

· Explanatory back-up· Compliance guidelines· Scoring guidelines

· HEDIS 3.0

Practice Guideline Development

ApplyingContinuous Quality Improvement

Principlesto

Medical Practice


NEW TECHNOLOGIES

Low Cost Alternatives for

Satisfying NCQA Requirements to Assess and Incorporate New Technologies or

How to be Successful Using OPM*

* OPM - Other People’s Money

Guideline Definition

Systematically developedguides to assist providers andpatients in making appropriatehealth care decisions inspecific clinical circumstances

Guideline Goals

· Decrease variability of care· Increase cost-effectiveness of care· Optimize appropriateness of care· Improve health care outcomes and

health status· Primary, secondary and tertiary

prevention

Guidelines - Key Issues

· Providers need to be involved in the development and/or adoption process

· The MCO must inform providers about the guidelines

· Performance is assessed against the guidelines (population based studies for preventive health guidelines)

· Results are reported to providers and members (close the loop)

Guidelines - Pitfalls· No systematic approach to topic selection· Lack of consistency of guideline programs

across providers and settings· Missed populations

· Adolescents· Mental health and substance abuse· Safety and accident prevention· enrolled but not reported (non-visitors)

· Guidelines complex and/or not available· Claims policy (UM) used as clinical guideline· PHS only guidelines present

Medical Necessity The determination of “Medical Necessity” is

benefit determination, not the practice of medicine. The determination is made by the medical department when the provider has justified the proposed treatment by documenting that the member’s medical findings meet national criteria and / or standards. These standards are generated by the AMA, NIH, and various private organizations and are applied to the determination of benefits after the plan provider’s representatives on the QIC have recommended their use.

Experimental / Investigational

The benefit exclusion for investigational treatment plans is made based on federal law passed after the Nuremberg trials and the American Tuskegee experiment. The provider is required by law to inform the patient of the status of the treatment. Failure to properly inform the patient could lead to malpractice litigation and failure to properly inform the medical department could be considered fraud on the part of the member and / or provider. The decision to apply the benefit exclusion is based on the medical determination made by the provider.

Guideline SourcesRand

USPHSTF *ACP *

HAYES Medical DirectorySpecialty Organizations

AMAVHS

“Home Grown”Many New Sources

* Opportunity for access to medical director

Practice Guidelines

Measurementand

FeedbackYou cannot manage

what you don’t measure

CLOSE THE LOOP

“The God’s honest truth is it’s not that

simple”

Fruitcakes - Jimmy Buffett

- NEXT -- TOPIC -

NCQA Accreditation The Plan’s Perspective

Quality ImprovementStandards


NCQA Definitions

· Oversight

The monitoring and direction ofa set of activities by individualsresponsible for the execution ofthe activities, resulting in theachievement of desired outcomes.

Quality Oversight Should Be:

· Balanced -- quality of care, service

· Comprehensive -- all aspects of the delivery system

· Positive -- provide incentive to continuously improve

NCQA Definitions· Delegation

A formal process by which a managed care

organization gives a contractor the authority to

perform certain functions on its behalf, such ascredentialing, utilization management, and qualityimprovement. Although a managed care organizationcan delegate the authority to perform a function, it

cannot delegate the responsibility for assuring

the function is performed appropriately.

NCQAReview of Delegation

There is a written description of: the delegated activities; the delegate’s accountability for these activities; the frequency of reporting to the managed care organization; and the process by which the delegation will be evaluated.

.

There is evidence of approval of the delegate’s QI program and evaluation of regular specified reports.


RED FLAGSCarve Outs Hospitals

Mental Health

Physical Therapy Home Health AgenciesVision Care

Chiropractic Skilled Nursing Facilities Multispecialty Groups IPAs Ancillary ServicesSingle Specialty Networks


Functions Frequently Delegated

· Quality Improvement· Data Collection· Audits

· Standard / Criteria Development· Access· Clinical Guidelines· Preventive Health Guidelines



· Utilization Management· Benefits Determination· Referral Management· Concurrent Review· Discharge Planning· Complex Case Management· First Level Appeals



· Credentialing· Data Collection· Primary Source Verification· Credentialing / Recredentialing Decision

· Member Services· Complaint & Grievance First Level Review· Member Satisfaction Surveys


Oversight Function Documented· Written description of delegated activities and

responsibilities· Reporting methods and frequencies· Approval of delegate’s QI program, annual

work plan and regular reports· Formal documents

· Letters of agreement· Contracts· Board of Directors minutes / QIC minutes


Oversight Function Documented

· Committee cross-representation· Reviews / site visits to the delegated entity· Corrective action plans developed· Documentation that follow-up actions result

in improvement · The delegated activities meet NCQA

standards

QI 13.0 Delegation of QI Activity

If the MCO delegates any QI activities, there isevidence of oversight of the contracted activity.

QI 13.1 A mutually agreed upon document describes:QI 13.1.1 the responsibilities of the MCO & delegated agency;QI 13.1.2 the delegated activities;QI 13.1.3 the frequency of reporting to the MCO;QI 13.1.4 the process by which the MCO evaluates the delegated agency’s performance; andQI 13.1.5 the remedies, including revocation of the delegation, available to the MCO if the delegated agency does not fulfill its obligations.

QI 13.0 Delegation of QI Activity

If the MCO delegates any QI activities, there isevidence of oversight of the contracted activity.

QI 13.2 There is evidence that the managed care organization:

QI 13.2.1 evaluates the delegated agency’s capacity to perform the delegated activities PRIOR to delegation;

QI 13.2.2 approves the delegated agency’s QI work plan and QI program description annually;QI 13.2.3 evaluates regular reports as specified in QI 13.1.3; andQI 13.2.4 evaluates annually whether the delegated agency’s activities are being conducted in accordance with the managed care organization's expectations and NCQA standards.


· The single most important cultural change which must occur is from a QUALITY ASSURANCE, find the bad apple, mind set to the QUALITY IMPROVEMENT, improve the crop, paradigm.

· The focus on the customer & process, measurement of standard elements, empowerment of the workers, and constant environmental change is resisted by many middle managers in business and most medical professionals.

UM 9.0 Delegation of UM Activity

If the MCO delegates any UM activities to contractors, there is evidence of oversight of the contracted activity

· There is a written description of: delegated activities; delegate’s accountability for activities; frequency of reporting to the MCO; and process by which the delegation will be evaluated.

· There is evidence of: approval of the delegate’s UM program; and evaluation of regular specified reports.

Utilization ManagementRoadblocks and Challenges

The upper management of most MCOs believethat Utilization Management is one of their corecompetencies. The function is only delegated

as a last resort to gain access to a providernetwork or sell the plan to a specific purchaser. In reality, many plans require complex, difficultutilization processes and the contract / benefitdecision making process is hopelessly flawed.

1

NCQA AccreditationThe Plan’s Perspective

Credentialing

Roger H. Strube, M.D.Medical Director of Quality Improvement

PHP Companies, Inc.

Cr 1.0 CredentialingPolicies and Procedures

The MCO Documents the mechanism for the credentialing and recredentialing of MDs, Dos, DDSs, DPMs, DCs, and other licensed independent practitioners who fall under its scope of authority and action

Credentialing Standards

CR 2.0 The MCO designates a credentialing committee that makes recommendations regarding credentialing decisions

CR 3.0 The MCO documents primary source verification or attestation of credentials and past history

CR 4.0 The applicant completes an application for membership attesting to fitness to practice

Initial Credentialing

CR 3.0 At the time of credentialing, the managed

care organization verifies information from primary sources

CR 3.1 Current valid license to practiceCR 3.2 Clinical privileges at a network hospitalCR 3.3 Valid DEA or CDS certificateCR 3.4 Graduation from medical (dental, podiatric, chiropractic) school

and completion of a residency or board certificationCR 3.5 Board certification if the practitioner states he/she is board certified on the applicationCR 3.6 Work historyCR 3.7 Current, adequate malpractice insurance according to the MCO policyCR 3.8 Professional liability claims history


CR 4.0 Applicant completes an application for membership. The application includes a statement by the applicant regarding:

CR 4.1 Reasons for any inability to perform the essential functions of the positionCR 4.2 Lack of present illegal drug useCR 4.3 History of loss of license and/or felony convictionsCR 4.4 History of loss or limitation of privileges or disciplinary activity

CR 4.5 Attestation to the correctness / completeness


CR 5.0 Evidence the MCO requests information on the practitioner from recognized monitoring organizations,

that the information has been received PRIOR to making the credentialing decision

CR 5.1 National Practitioner Data BankCR 5.2 State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations (if available)CR 5.3 Review for prior sanction by Medicare & Medicaid


CR 6.0 There is an initial visit to the offices of all potential PCPs and OB/GYNs

CR 6.1 Documentation of a structured site review per MCO standards

CR 6.2 Documentation of compliance with the MCO’s record keeping standards

CR 7 Recredentialing Standards

There is a formal process for periodic verification ofcredentials (recredentialing, reappointment, orrecertification) that is ongoing, up-to-date andoccurs every two years, minimally.

The process includes the same primary sourceverification as credentialing where applicable.

Data from member complaints, quality reviews,UM and member satisfaction is considered.


CR 7.0 Every two years the MCO shall formally recredential all practitioners through verification of information from primary sources:

CR 7.1 current valid license to practice;CR 7.2 clinical privileges at a network hospital;CR 7.3 valid DEA or CDS certificate;CR 7.4 board certification if the practitioner states he/she is

board certified on the application;CR 7.5 current, adequate malpractice insurance as per MCO

policy;CR 7.6 history of professional liability claims that resulted in

settlements or judgments paid; andCR 7.7 a current, signed attestation statement by the applicant:

CR 7.7.1 reasons for inability to perform essential functions, and

CR 7.7.2 lack of present illegal drug use.


CR 8.0 Evidence the MCO requests information on the practitioner from recognized monitoring organizations,

that the information has been received PRIOR to making the recredentialing decision.

CR 8.1 National Practitioner Data BankCR 8.2 State Board of Medical Examiners, Federation of State Medical Boards, or the Department of Professional Regulations (if available)CR 8.3 Review for prior sanction by Medicare & Medicaid


The MCO incorporates the following data in its recredentialing decision-making process for PCPs:

CR 9.1 member complaints;CR 9.2 information from quality improvement activities;CR 9.3 utilization management;CR 9.4 member satisfaction;CR 9.5 medical record reviews conducted as part of MR 2.1;

andCR 9.6 the site visits conducted as part of CR 10.1


There is a visit to the offices of all the PCPs, all OB/GYNs, and all High Volume Specialists

CR 10.1 Documentation of a structured site review per MCO standards

CR 10.2 Documentation of compliance with the MCO’s record keeping standards

Altering the Conditions of Practitioner Participation

Standard CR 11

The managed care organization has policies and procedures for altering the practitioner’s participation with the managed care organization based on issues of quality of care and service.

These policies and procedures define the range of actions that the managed care organization may take to improve performance prior to termination.

Altering the Conditions of Practitioner Participation

Standard CR 11

CR 11.1 The MCO has procedures for, and evidence of implementation of, as appropriate, reporting of serious quality deficiencies that could result in a practitioner’s suspension or termination to appropriate authorities.

CR 11.2 The managed care organization has an appeal process for instances in which the managed care organization chooses to alter the conditions of practitioner’s participation based on issues of quality of care and/or service. The managed care organization informs practitioners of the appeal process.

CR 12 Initial Credentialing

The MCO has written policies and procedures for the initial and ongoing assessment of organizational providers with which it intends to contract. Providers include hospital, home health agencies,skilled nursing facilities and nursing homes, and free-standing surgical centers

CR 12.1 The MCO confirms standing with state & federal regulators; andCR 12.2 The MCO confirms accrediting body approval; orCR 12.3 If no accrediting body approval, the MCO develops and implements

standards of participation.CR 12.4 Confirmation by the MCO at least every three years that the provider

remains in good standing with state, federal and accrediting bodies.

CR 12 Initial Credentialing CR 12.1 The MCO should confirm review & certification by a recognized accrediting body, and is in good standing with state and federal regulatory bodies; and CR 12.2 Confirms that the provider has been approved by an accrediting body confirms that the provider has been reviewed and approved by an accrediting body; or CR 12.3 If the provider has not been approved by an accrediting body, the managed care organization develops and implements standards of participation CR 12.4 At least every three years, the managed care organization confirms that the provider continues to be in good standing with the state and federal regulatory bodies and, if applicable, is reviewed and approved by an accrediting body.

CR 13 Delegated Credentialing

If the managed care organization delegates any credentialing and recredentialing activities, there is evidence of oversight of the delegated activity

CR 13.1 A mutually agreed upon document describes:

CR 13.1.1 the responsibility of the managed care organization and the delegated agency;

CR 13.1.2 the delegated activities; the process by which themanaged care organization evaluates the delegatedagency’s performance;

CR 13.1.3 the process by which the managed care organization evaluates the delegated agency’s performance; and

CR 13.1.4 the remedies, including revocation of the delegation; available to the managed care organization if the delegatedagency does not fulfill its obligations.

CR 13 Delegated Credentialing

If the managed care organization delegates anycredentialing and recredentialing activities, there isevidence of oversight of the delegated activity

CR 13.2 MCO retains the right to approve new providers & sites, and to terminate or suspend individual providers.

CR 13.3 There is evidence that the managed care organization:CR 13.3.1 evaluates the delegated agency's capacity to perform

the delegated activities PRIOR to delegation; and

CR 13.3.2 evaluates annually whether the delegated agency’s activities are being conducted in accordance with the MCO’s expectations and NCQA standards.

Health Plan Credentialing Roadblocks & Challenges

· Ivory tower demigods (academics and large clinic physicians) object to mere mortals questioning their credentials

· Delegation by delegate’s· Coordination of UM, member satisfaction, QI,

and appeals/complaints with the recredentialing process (where’s the file?)

· Credentialing process requires cooperation across reporting lines and corporate functions

Health Plan Credentialing Roadblocks & Challenges

· Leadership required to focus the committee on legal process (not a good ol’ boy meeting)

· “Yellow Pages Credentialing”· Provider contracting and servicing are

different functions· Where do the contracting people report?· Where does the Network Management Department

report?· Who does recredentialing - Service? - Contracting?

Members’ Rights and Responsibilities

RR 7.0 The MCO has written confidentiality policies & procedures and acts to ensure that specified patient information is protected and only released with consent.

RR 8.0 The MCO ensures communication with prospective members regarding benefits and operating procedures of the MCO.

RR 9.0 The MCO has written policies and procedures, and evidence oversight is preformed, for any delegated activities.

Member Rights & Responsibilities Roadblocks & Challenges

· Highly regulated area of insurance and HMO law. In general, no mass produced marketing material is ever presented to a member without sign off by some government bureaucrat (HCFA, AHCA, DOI, etc.)

· Love - Hate relationship between the “Medical Management” and “Member Services” departments.

· Member Services director reports to Claims V.P. reports to Sr. V.P. of Operations (where MIS usually reports)

· “A paid claim is a happy claim”


· Member Service Director may report to the V.P. of Marketing/Sales at same level as the Marketing Service Director/Reps -- customer is the Purchaser’s Human Resource/Benefits department head -- “A paid claim...”

· Member Service department (customer service) low grade level (low pay) with little or no medical knowledge -- expertise and knowledge base is Member Handbook, Brochures, form notification letters and the Plan Service Agreement (Contract) -- they function as patient/member advocates (there are a million sad stories in the naked city)


· Medical Management Department staffed with professionals with varying degrees of medical expertise -- usually less Plan Contract / Law knowledge -- many also patient advocates

· Contract exclusions and limitations easy to administer -- “medical necessity” based on criteria and standards of care more difficult -- sometimes decisions (approval or denial) not justifiable in the contract or medical criteria (Good ol’ boy decision making)

· Poor decisions lead to messy appeals and conflict between departments

Members Rights and Responsibilities

WHAT CAN YOUDO TO ASSIST THE MCO WITH

NCQA ACCREDITATION?

· The director of Member Services is usually on the MCO NCQA preparation task force and has the responsibility for all communications with members - get to know him/her

· Member services performs satisfaction and accountability studies and generates reports - knows the skeletons

· Member Services director usually manages the early parts of the appeals / grievance process - you are part of this system


Conflict may develop because some clinicians:

· Are reluctant to share power· Dislike administrative activities· Are skeptical about statistical methods· Are uncomfortable with rigid controls· Are uncomfortable accepting ownership (blame)· Prefer linking process to outcome· Emphasize needs, not expectations· Recognize only external customers· Not sensitive to internal customers· Fear computers

Why Invest inContinuous Quality Improvement?

“You do not have to do this;Survival is not compulsory.” - W. Edwards

Deming

The Lightat the End of the Tunnel

is not a TrainComing the Other Way

or

Is There IndemnityAfter Managed Care

After Indemnity?

ParticipatoryWork Group Session

Determine Tactics to use in Strategically Applying

CQI and NCQA Principles to the Schubert’s

“Unfinished Symphony”

- NEXT -- TOPIC -

NCQAand

The Evolving Role of Information Technology


NCQA Accreditation The Plan’s Perspective

Medical Records


NCQA Medical Records Standards

Medical Records are maintained in a manner that is current, detailed, organized, and permits effective patient care and quality review. The records reflect all aspects of patient care, including ancillary services. Records are available to health care practitioners at each encounter and to NCQA reviewers.

NCQA Medical Records Standards

The MCO sets standards for medical records,systematically reviews the records forconformance, and institutes corrective actionwhen standards are not met. Documentation ofitems on the NCQA Medical Record ReviewSummary Sheet demonstrates that medicalrecords are in conformity with goodprofessional medical practice and appropriatehealth management.

Medical RecordsThe State of the Art

The vast majority of physicians world wide use recordingtools and techniques which are hundreds, if notthousands of years old. Whether using a feather quillpen, a Mont Blanc fountain pen or a lap top computer, theformat has not changed much in several hundred years. The power of the new tools (the computer) has not beentapped and the computer has not significantly changedthe way we work. The present applications have merelyprovided us with chaos at light speed and a moreefficient way to detect human error.


The knowledge base of medicine is so large no humancan master the knowledge needed to make propermedical decisions. Physicians seldom take the time togather and record the needed information from thepatient even if they could integrate that information withthe medical knowledge base so that a proper decisionregarding the care of the patient could be made. Theliterature suggests that half of medical care delivered inthe USA in unnecessary, ineffective or harmful. There is $500 Billion to be saved in America.


NCQA is attempting to move medical care into the 21stcentury by demanding ever more complex CQI statisticalanalysis of the system as the first step. Most of thepayor industry is not capable of providing sound data. The medical record keeping of most physicians wouldhave been state of the art 100 years ago. To satisfy theneeds of NCQA, an army of record reviewers is needed tocollect the data. The data is needed, the reports will begenerated and the system will evolve, but...to what? andat what cost?

Medical RecordsRoadblocks & Challenges

· Inaccurate and incomplete data in MCO· Old, cumbersome software· Inadequate, inaccurate medical records· Provider fear of cookbook medicine· General computer illiteracy· Cost of new hardware and software· Cost and frustration of data conversion· Resistance to change· Fear of the future

Medical Records - The Future -

· Problem Oriented Electronic Medical Record· Standards for electronic transfer of data (ASTM)· Configured to facilitate decision making and document

rational for decisions· Generate information for disease, drug, procedure,

critical path specific data bases for outcomes analysis

· Decision Support Tools· Electronic knowledge base· Electronic medical Artificial Intelligence decision

assistance to establish working diagnosis· Selection of Treatment Paths, drugs, procedures

presented electronically to physician and patient

· Physician will be valued for good judgment and technical skill

NCQAValue Added Partnering

Do not allow your businessentity to suffer because the

MCO staff lacks theknowledge or budget tosurvive an NCQA review.


Do not wait to be asked by yourMCO for documentation of activities

you know are required by NCQA. Provide the information regularly

and before you are asked.


Work toward a Total Quality Management (TQM) corporate culture using Continuous Quality Improvement (CQI) process improvement techniques. Your activities will be directly applicable to your business need to cooperate with the NCQA requirements placed on your partner MCO.

Learn and apply as much as you can about the Quality Improvement Process. The success of your company and your personal security depend on it.


Learn as much as you can about the basic benefit plan of your MCO partners. Do not offer opinions about what the patient’s health care plan “should” cover. Refer the patient to the MCO member service department for benefit clarification. If a service is limited or denied feel free to discuss the medical necessity decision with the medical director. Direct the patient to the member services department to discuss the appeals process. Patient advocacy is OK.

Do not become an adversary to the MCO.





TIME





+ Other Feedback


Outcomes


TIME


C Judgment & Computer




PhysicianJudgment +Computerdecisionsupport

Computer

Assisted Physician Judgment

+ Other Feedback


Outcomes


TIME

pharm mfgr advise1998

Documents

efficient health care

cost of medical carethe

managed caremanaged

managed care consultant3

medical decisionmaking

cost ofdiagnosing

memory base systemtime

community health statusvs