pharm mfgr advise1998
DESCRIPTION
Power Point Presentation made to a major pharmaceutical manufacturer in 1998. Identifies cause of Medical Crisis and how Pharm mfgrs can use regulations to add value to their contracts with MCOs.TRANSCRIPT
ENTERING INTO VALUE-ADDED
PARTNERSHIPS WITH YOUR HMOs
Roger H. Strube, M.D.Managed Care Consultant
The Cost and Cost Containment of Medical Care
Roger H. Strube, M.D.Managed Care Consultant
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.
100% Efficient Health Care*
B Judgment & Feedback
A Judgment AloneMaximumqualityattainableusingmemorybasedsystem
Augmentedmemorybasedsystem
+ Other Feedback
Quality of Care - Memory Base System
Outcomes
* Most cost efficient, medically necessary, effective and best expected result for the patient.
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
Roger H. Strube, M.D.Managed Care Consultant
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
Roger H. Strube, M.D.Managed Care Consultant
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
Roger H. Strube, M.D.Managed Care Consultant
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
Roger H. Strube, M.D.Managed Care Consultant
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.
NCQAReview of Delegation
RED FLAGSCarve Outs Hospitals
Mental Health
Physical Therapy Home Health AgenciesVision Care
Chiropractic Skilled Nursing Facilities Multispecialty Groups IPAs Ancillary ServicesSingle Specialty Networks
NCQAReview of Delegation
Functions Frequently Delegated
· Quality Improvement· Data Collection· Audits
· Standard / Criteria Development· Access· Clinical Guidelines· Preventive Health Guidelines
NCQAReview of Delegation
Functions Frequently Delegated
· Utilization Management· Benefits Determination· Referral Management· Concurrent Review· Discharge Planning· Complex Case Management· First Level Appeals
NCQAReview of Delegation
Functions Frequently Delegated
· Credentialing· Data Collection· Primary Source Verification· Credentialing / Recredentialing Decision
· Member Services· Complaint & Grievance First Level Review· Member Satisfaction Surveys
NCQAReview of Delegation
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
NCQAReview of Delegation
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.
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.
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
Initial Credentialing
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
Initial Credentialing
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
Initial Credentialing
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 Recredentialing Standards
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 Recredentialing Standards
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
CR 9 Recredentialing Standards
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
CR 10 Recredentialing Standards
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 Rights & Responsibilities Roadblocks & Challenges
· 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)
Member Rights & Responsibilities Roadblocks & Challenges
· 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
Quality ImprovementRoadblocks and Challenges
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
Roger H. Strube, M.D.Managed Care Consultant
NCQA Accreditation The Plan’s Perspective
Medical Records
Roger H. Strube, M.D.Managed Care Consultant
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.
Medical RecordsThe State of the Art
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.
Medical RecordsThe State of the Art
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.
NCQAValue Added Partnering
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.
NCQAValue Added Partnering
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.
NCQAValue Added Partnering
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.
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
100% Efficient Health Care*
B Judgment & Feedback
A Judgment AloneMaximumqualityattainableusingmemorybasedsystem
Augmentedmemorybasedsystem
+ Other Feedback
Quality of Care - Memory Base System
Outcomes
* Most cost efficient, medically necessary, effective and best expected result for the patient.
TIME
100% Efficient Health Care*
C Judgment & Computer
B Judgment & Feedback
A Judgment AloneMaximumqualityattainableusingmemorybasedsystem
Augmentedmemorybasedsystem
PhysicianJudgment +Computerdecisionsupport
Computer
Assisted Physician Judgment
+ Other Feedback
Quality of Care - Memory Base System
Outcomes
* Most cost efficient, medically necessary, effective and best expected result for the patient.
TIME