The National Committee for Quality Assurance wants to modernize its health plan accreditation program with a range of new requirements that in some cases mirror trends in regulatory scrutiny.
Some 136 million Americans are enrolled in health plans accredited by the NCQA and report HEDIS (Healthcare Effectiveness Data and Information Set) data, but the non-profit organization argues that the current system, developed in 1999, has some limitations.
For one thing, health plan organizations are not rescored annually on the same set of measures during the three year-accreditation cycle. "This limits, albeit only slightly, consistent comparison of performance across health plans," the NCQA wrote in its proposal for new accreditation criteria.
And health plans "tend to focus improvement efforts on measures being scored for accreditation," the organization said. "It may take several years for new measures to be included for scoring across all plans. This lag slows the spread of improvement initiatives focused on new measures, such as those related to value."
In particular, the NCQA is focusing on two areas: provider networks, something federal regulators are promising more oversight for, and provider quality, something that both insurers and regulators are trying to more effectively communicate to members and insurance exchange shoppers.
With narrow networks accounting for half of public exchange plans in at least 13 states, according to McKinsey & Company estimates, and with many exchange shoppers willing to accept narrow networks if they bring affordability, according to a Kaiser poll, the NCQA "feels it is necessary to introduce a standardized method of monitoring the quality of these networks."
The organization is proposing adding two general accreditation categories for narrow networks: requiring health plans to monitor member experiences with networks and be transparent about coverage for services from out-of-network.
For network adequacy, the NCQA is recommending that health plans with narrow networks (defined as an array of providers comprising 80 percent or less overlap with the broadest network) or "tailored networks," "tiered-networks" or "high-value networks" annually measure member experience, practitioner quality and hospital quality.
"Organizations will be required to analyze and compare results in these three areas with the performance of their broadest network," the NCQA wrote, arguing that this approach is "more flexible and preferable to setting specific time and distance standards."
Requiring more transparency, broadly defined, for member access to and financial responsibilities for out-of-network providers would "simultaneously address consumer- advocate concerns about coverage, inform health plan members who may be unaware of existing policies and highlight opportunities for benefit plans where this provision does not exist."
For provider quality measurement -- something exchanges like Covered California want to incorporate into the shopping experience -- the NCQA is proposing to require health plans to use "valid and reliable methods" to develop quality scores for primary care physicians, high-volume specialists and hospitals. Health plans would then have to offer members a description of the measures in "clear, understandable language." (Organizations with NCQA Physician Quality certification would be eligible for automatic credit.)
The new proposed accreditation system would start in 2015, with all health plans seeking accreditation brought into the new system by 2018, the NCQA said. The organization is taking public comment on the proposal through April 3.