Minimum Qualification for Teachers in Medical Institutions Regulations,1998 ()
Medical Quality Presentation 1998
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Transcript of Medical Quality Presentation 1998
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 of
diagnosing 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 truth
appears to the subject as in
a sudden flash of recognition
A New ParadigmThe Hypotheses is
an Iconoclasm
It is impossible for physicians to make
appropriate medical decisions using the
present memory-based system
The information is too great and the medical
knowledge 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 the
physician’s problems, it is a response to the
cost and quality issues resulting from the
failure of the memory based medical decision
making process. Managed care is not simply
another iteration of insurance or administration.
It is the major catalyst and driving force behind
the most significant, positive changes in the
American medical delivery system in this
century. It is the agent of change which will
fundamentally 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 of
people in the and reports evaluated treatments monitored
proper positions by the right people or recommendations
with the appropriate and are appropriate followed up and
authority 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 system
applied by the people in an organization which leads to a
cycle of continuous improvement of the quality of the
processes and and resulting outputs (outcomes) of the
entity.
A tool for organizational learning - the way an
organization re-engineers their business to meet
customer 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 of
education and self-improvement
for everyone
Educate everyone in the
new 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 Pepsico
Ameritech UPS
CHAMPUS USAir
GTE Xerox
Mercantile IBM
Bristol-Myers Squibb General Electric
New 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
Applying
Continuous Quality Improvement
Principles
to
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 developed
guides to assist providers and
patients in making appropriate
health care decisions in
specific 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 Directory
Specialty Organizations
AMA
VHS
“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 Improvement
Standards
Roger H. Strube, M.D.Managed Care Consultant
NCQA Definitions
Oversight
The monitoring and direction of
a set of activities by individuals
responsible for the execution of
the activities, resulting in the
achievement 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 as
credentialing, utilization management, and quality
improvement. Although a managed care organization
can 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 FLAGSRED FLAGS
Carve Outs Hospitals Mental Health
Physical Therapy Home Health AgenciesVision Care
Chiropractic Skilled Nursing Facilities
Multispecialty Groups
IPAs Ancillary Services
Single 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 is
evidence 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; and
QI 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 is
evidence 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 PRIORPRIOR 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; and
QI 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 believe
that Utilization Management is one of their core
competencies. The function is only delegated
as a last resort to gain access to a provider
network or sell the plan to a specific purchaser.
In reality, many plans require complex, difficult
utilization processes and the contract / benefit
decision 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 sourcesCR 3.1 Current valid license to practice
CR 3.2 Clinical privileges at a network hospital
CR 3.3 Valid DEA or CDS certificate
CR 3.4 Graduation from medical (dental, podiatric, chiropractic) school and completion of a residency or board certification
CR 3.5 Board certification if the practitioner states he/she is
board certified on the application
CR 3.6 Work history
CR 3.7 Current, adequate malpractice insurance according
to the MCO policy
CR 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 position
CR 4.2 Lack of present illegal drug use
CR 4.3 History of loss of license and/or
felony convictions
CR 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 PRIORPRIOR to making the credentialing decision
CR 5.1 National Practitioner Data Bank
CR 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 of
credentials (recredentialing, reappointment, or
recertification) that is ongoing, up-to-date and
occurs every two years, minimally.
The process includes the same primary source
verification 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 PRIORPRIOR to making the recredentialing decision.
CR 8.1 National Practitioner Data Bank
CR 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; and
CR 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; and
CR 12.2 The MCO confirms accrediting body approval; or
CR 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 any
credentialing and recredentialing activities, there is
evidence 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 PRIORPRIOR 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 YOU
DO 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 Indemnity
After 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 for
conformance, and institutes corrective action
when standards are not met. Documentation of
items on the NCQA Medical Record Review
Summary Sheet demonstrates that medical
records are in conformity with good
professional medical practice and appropriate
health management.
Medical RecordsThe State of the Art
The vast majority of physicians world wide use recording
tools and techniques which are hundreds, if not
thousands of years old. Whether using a feather quill
pen, a Mont Blanc fountain pen or a lap top computer, the
format has not changed much in several hundred years.
The power of the new tools (the computer) has not been
tapped and the computer has not significantly changed
the way we work. The present applications have merely
provided us with chaos at light speed and a more
efficient way to detect human error.
Medical RecordsThe State of the Art
The knowledge base of medicine is so large no human
can master the knowledge needed to make proper
medical decisions. Physicians seldom take the time to
gather and record the needed information from the
patient even if they could integrate that information with
the medical knowledge base so that a proper decision
regarding the care of the patient could be made. The
literature suggests that half of medical care delivered in
the 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 21st
century by demanding ever more complex CQI statistical
analysis of the system as the first step. Most of the
payor industry is not capable of providing sound data.
The medical record keeping of most physicians would
have been state of the art 100 years ago. To satisfy the
needs of NCQA, an army of record reviewers is needed to
collect the data. The data is needed, the reports will be
generated and the system will evolve, but...to what? and
at 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 business
entity to suffer because the
MCO staff lacks the
knowledge or budget to
survive an NCQA review.
NCQAValue Added Partnering
Do not wait to be asked by your
MCO 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