QUALITY

How Can I Judge the Quality of My Health Plan?

There is no easy way to assess the quality of care provided by different health plans. However, some information is available to help consumers.

Nationally there are two organizations that accredit HMOs or other managed care organizations: The National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO). While most HMOs that seek accreditation do so from NCQA, some HMOs are beginning to seek accreditation from JCAHO. In North Carolina, all of the health plans that have sought accreditation have done so from NCQA. The accreditation status of a managed care organization can be obtained from NCQA’s web site.

NCQA looks at five categories in its accreditation process: access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. Once a review is completed, a health plan will be given an accreditation decision. Health plans that exceed NCQA’s standards receive an Excellent status. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA’s standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied.

In North Carolina, the following health plans have received NCQA accreditation:

• Blue Cross and Blue Shield of North Carolina Personal Care Plan (Commendable)
  
• Cigna HealthCare of North Carolina (Commendable)
  
• Healthsource of North Carolina (Commendable)
  
• Partners National Health Plan of North Carolina (Commendable)
  
• Prudential Health Care—Charlotte (Provisional*)
  *Previously earned one-year accreditation but currently under review due to merger of Charlotte and Raleigh operations.
  
• United HealthCare of North Carolina (Commendable)
  

What does it mean if a health plan is not accredited?

Accreditation is just one way to assess the quality of a health plan. However, not all health plans seek accreditation. The accreditation process is very expensive and some plans choose not to participate. This does not necessarily mean that the HMO is bad, but it does make it more difficult to judge the quality of care provided by the plan.

• Health Plan Employer Data and Information Set (HEDIS®): HEDIS® is a standardized set of performance measures that consumers and other purchasers can use to compare health plans. Information about HEDIS® can be found on NCQA’s website: www.ncqa.org. In 1998, HEDIS® covered seven general areas of performance: effectiveness of care, access to and availability of care, member satisfaction, health plan stability, use of services, cost of care and health plan information. In general, accreditation standards examine the health plan’s process for providing care and the HEDIS® reporting requirements examine the health plan’s actual performance.
  
  A new North Carolina law requires that each HMO report its HEDIS® data to the Department of Insurance beginning in July of 1999. Information is available from the NC Department of Insurance or its web site (see back of this booklet for contact information).
  
  
• Disenrollment: In theory, disenrollment numbers, or the numbers of members and providers who leave a plan, may give an indication of satisfaction—or dissatisfaction—with a health plan. If large numbers of members leave a health plan, for example, it may indicate dissatisfaction customer service or problems with the quality of care delivered by a plan. This is also true if a large number of providers leave a health plan.
  
  HMOs are required to submit data to the Department of Insurance on the number of individuals and groups that withdraw from their health plan. HMOs are also required to report data on the numbers of providers who left a plan voluntarily or those who were terminated from the plan by the HMO. However, the number of people or providers who leave an HMO may be misleading. HMOs with greater numbers of members will likely have more people leave in a given year than a plan with fewer members. It is important to compare disenrollment rates (ie, the number of people who left in a year divided by average number of members enrolled during the year) in order to compare numbers across plans. Disenrollment information is available in the NC Department of Insurance’s 1999 Managed Care Handbook which can be obtained from the NC Department of Insurance or its web site.
  
  Disenrollment figures should be read with caution. People may leave health plans for a variety of reasons. For example, a health plan may have raised its premiums, forcing an employer or individual members to choose a lower-cost plan. An HMO may stop covering a particular part of the state, forcing some members to choose another plan. Physicians may leave the plan because they are unhappy with the HMO’s reimbursement rate. So, disenrollment numbers by themselves are often an inadequate way to measure quality. They are best used in conjunction with other measures listed here.
  
  
• Member Satisfaction: Each HMO is required to submit member satisfaction survey data to the NC Department of Insurance. HMOs must collect this data using similar methods so that the results should be comparable.This information is also available from the NC Department of Insurance.
  
  In general, most HMOs have relatively high member satisfaction levels. But these numbers may not be good indicators of the experiences of people with special health care needs. Most HMO members, and consequently, most of the people who respond to the member satisfaction surveys, are relatively healthy. A member who is healthy and rarely uses health services will have fewer interactions with the HMO, and thus are likely to have fewer problems within the system. A better way to assess the plan would be to survey the members who have greater health care needs. However, this information is not currently collected.
  
  
• Utilization Review and Appeal: The NC Department of Insurance collects information about the number of utilization reviews conducted by each health plan. Utilization review is a mechanism HMOs use to evaluate the appropriateness of certain procedures, providers or tests. Utilization review can include precertifications, concurrent reviews or retrospective reviews. precertification systems require members to obtain prior approval or preauthorization from the plan before being admitted to the hospital or obtaining certain health care services. Concurrent reviews are usually done when the members are in the hospital. This is the method used to review the proposed length of stay or prescribed course of treatment for appropriateness. Retrospective reviews occur after services are provided, and is used to assess whether the services that were provided were appropriate.
  
  The Department of Insurance also collects information on the number of requests for coverage of services or treatment that were denied. HMOs must also report the number of noncertification appeals filed with a plan and whether the member won or loss the appeal.
  
  North Carolina began collecting information about the types of services examined by utilization review in March 1999. These include inpatient hospitalizations, outpatient procedures, referrals to specialists, prescriptions, inpatient mental health or substance abuse admissions, outpatient mental health and substance abuse services. The data also include the number of noncertifications, whether these noncertifications were appealed, and the results of the appeal. Utilization review and appeal information is available in the NC Department of Insurance’s 1999 Managed Care Handbook which is available from the Department or its web site.
  
  Consumers should look at more than the numbers of reviews, noncertification decisions and appeals because again, some health plans have more members than others. Consequently, large plans usually have more reviews and more noncertfications. In addition, plans differ in their policies about when prior authorization is required. A better approach is to look at the review, noncertification and appeal rates, such as the number of reviews divided by the average number of HMO members. As previously stated, this information cannot be used in isolation. Review and noncertification rates may demonstrate how stringent a plan’s review systems is; however, this information may not apply to your particular medical needs.
  
  
• Grievance Reports: HMOs are required to report information about all written correspondence from members expressing dissatisfaction with the plan. Grievances include:
  
  
  • Problems with the insurer’s policies or actions related to delivery, quality or availability of health care services;
  • Problems with claims payments or reimbursement for services;
  • Issues related to the contractual relationship between the member and the insurer, including questions about covered benefits;
  • Requests to further review the decisions of first level noncertification appeals.
    
    The data include the number of grievances filed by reason, and the outcomes of these grievances. Again, look at grievance rates, that is, the number of grievances divided by the average number of members, before comparing plans. These data, used with the utilization review or disenrollment numbers, may be useful in identifying plans with more problems. Grievance and appeal information are available in the NC Department of Insurance’s 1999 Managed Care Handbook. This publication is available from the Department or its web site.
    
    
• Department of Insurance Market Practice Examination Reports: The NC Department of Insurance inspects each HMO at least once every three years. The Department’s review covers 11 areas: company overview, management and control, general administration, delivery system and provider relations, utilization management, quality management, claims administration, member services, sales and marketing, premium rate setting and underwriting, and services which the HMO delegates to another organization. This report is often the best source of information about a health plan’s internal operations. However, these reports are not always current. They are generally released about six months after the inspections have been conducted. The Department conducts follow-up inspections when necessary. These inspections are called compliance examinations and are conducted one year after the initial inspection to determine if the health plan has corrected the problems. These compliance reports also take about six months to be released to the public. You may obtain a copy of the report from the NC Department of Insurance.
  

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