CMSA Today - Issue 5, 2011 - (Page 18)

ACCREDITATION AND REFORM Health Plan Accreditation BY CRIS WALTER, MS, RN-BC, CCM, CCP and Health Care Reform performance. “Quality health care means doing the right thing, at the right time, in the right way, for the right person—and having the best possible results.” Accreditation is generally based on evaluation against a few types of standards: • Organizational standards (policy and process best practices) – Does the health plan organize around provision of quality and structure and measure its operations to provide quality health care? • Clinical performance benchmarks – Quantitative measurement of whether members are receiving the treatment and achieving the outcomes they should. • Consumer ratings – What is members’ perspective on the quality of health care they receive? T he Patient Protection and Affordable Care Act (National Health Care Reform) will require all health plans to be accredited in order to participate in the state health exchanges coming in 2014. WHY IS HEALTH PLAN ACCREDITATION IMPORTANT? It is anticipated that health plans will be required to be accredited in order to participate in the state health exchanges (table stakes). Health plan accreditation provides assurance to the marketplace that the plan is providing quality health care for its members and allows plans to distinguish themselves from their competition based on their quality. — “Patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, — “As well as consumer access, utilization management, adequacy and access, and patient information programs by any entity recognized by the Secretary for the accreditation of health insurance issuers or plans (so long as any such entity has transparent and rigorous methodological and scoring criteria).” Secretary of Health and Human Services has currently not released a strict final date on the timeline for requiring health care plan accreditation. WHAT ARE THE OPTIONS FOR ACCREDITATION? There are two organizations that provide health plan accreditation that are the likely candidates to serve as standards of quality for participation on state exchanges and one organization that provides surveys and tools for patient centered care: • NCQA – National Committee for Quality Assurance • URAC – (originally stood for Utilization Review Accreditation Commission – now URAC) Due to The Patient Protection and Affordable Care Act (National Healthcare Reform), all health plans must seek health plan accreditation: • PPACA Section 1311 requires that all health plans offered through state insurance exchanges “Must be accredited with respect to local performance on: — “Clinical quality measures such as the Healthcare Effectiveness Data and Information Set (HEDIS) WHY PURSUE HEALTH PLAN ACCREDITATION? Accreditation is being mandated by National Health Care Reform. Accreditation will be table stakes to participate in the state health exchanges. • URAC is currently working with the government on the final regulations. • The required date for accreditation has not yet been set. Health plan accreditation provides assurance to the marketplace that the plan is providing quality health care for its members and allows plans to distinguish themselves from their competition based on their quality Member Experience Clinical Effectiveness Process, Policy & Operational Infrastructure EVALUATION STANDARDS 1. Process, Policy, and Operational Infrastructure The documented use of industry best practices, methods, structure, and processes in the operation of the health plan. 2. Clinical Effectiveness (e.g. HEDIS) Standardized, quantitative measurement of whether members are receiving appropriate treatment and achieving appropriate outcomes. 3. Member Experience (via CAHPS survey) The members’ perception of the quality of health care they receive. WHAT IS HEALTH PLAN ACCREDITATION? Health plan accreditation is evaluation of a health plan’s “quality” against national standards by an independent thirdparty and provision of credentials by the third-party about the health plan’s Due to The Patient Protection and Affordable Care Act (National Healthcare Reform), all health plans must seek health plan accreditation. 18 CMSA TODAY ISSUE 5 • 2011 • DIGITAL http://www.cmsa.org

Table of Contents for the Digital Edition of CMSA Today - Issue 5, 2011

President’s Letter
Case Managers are Critical to Decreasing Fragmented Care
A Caregiver’s Emotional Journey Helps in Development of Valuable Case Management Resource
A Managed Care Poem
Case Managers in the Spotlight: The Impact of Case Management on Nursing Leadership and Health Care
CMSA and NASW Launch the CMI Case Load Capacity Calculator
Health Plan Accreditation and Health Care Reform
Association News
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 5, 2011

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