Healthcare Accreditation

This standard has two mandatory subsections and a third subsection that is a "leading indicator":

The wellness organization selects and designs defined interventions that are: (---)
(a) Consistent with and supported by evidence-based practices; (M)
(b) Approved by a committee designated by the wellness organization to have authority over the clinical aspects of the wellness program; and (M)
(c) Within three years of initial accreditation, provides level of evidence supporting interventions to health benefits purchasers proactively and to consumers upon request. (L)

Subsection (a) echoes from earlier standards URAC's insistence on basing the fundamental components of a wellness program on evidence.  So, like the health risk assessment tool, the interventions must be evidence-based. Affirmative documentation demonstrating that the intervention was based on current clinical research will be an essential part of the submission to AccreditNet.  Additionally, however, URAC is almost sure to require that the program have a policy and procedure that requires the basing of the design of interventions on clinical evidence. 

Subsection (b) is written in a curious way, particularly when read together with the Interpretive Information.  The standard is unambiguous in requiring that the interventions be approved by a committee.  The interpretive guide, however, suggests that this could be something other than a standing committee, that is, the senior clinical officer could approve it in consultation with other providers, not necessarily a standing committee.   While I find it curious that the standard itself doesn't say that a committee is not required; on the contrary, it explicitly requires committee review.  That being said, applicants can take URAC at its word, at least for the initial version of the standard, and, if they choose, may submit evidence of approval by the senior clinical officer.  However, those that take the individual approval route rather than the committee approval route almost surely will require evidence that the senior clinician, in fact, did consult with others in the design and selection of interventions.  Absent such evidence, the applicant runs the risk of violating this mandatory subsection.

The leading indicator subsection (c) places a responsibility on the organization to provide the evidence it used in designing the intervention to the employer -- without the requirement of a request by the employer for that evidence.  Additionally, the program will have to provide such evidence to participants upon request.  Again, not only will there need to be documentation that this evidence was provided, but that the program has a policy and procedure requiring that it submit such documentation to employers and participants in a manner that complies with this subsection.

The onsite review for this standard is likely to be a combination of interviews with relevant personnel and documentation to be submitted onsite upon selection of employers from a list of employers.  Furthermore, the applicant would do well to maintain a log of participant requests for such evidence, from which the reviewer will select files to determine how responsive to those requests the program has been.

Subsec

This standard, which bears a scoring weight of 4, provides:

The disease management program establishes and implements policies and procedures to promote consumer decision-making that specify: (Secondary)

(e) Circumstances under which a family member/legal guardian may be asked to give consent or provide to/receive information from the disease management program. (Secondary)

This standard has a wide reach, covering such decision support tools as educational videos and brochures, Web sites, and information delivered in-person. The communication suggested by this standard, it should be noted, is a collaborative one, not a one-way flow from the DM organization to the consumer, as reflected in subsections (c) and (d). Further, because nothing happens in URAC-land unless it is documented, it is incumbent on the organization to have a mechanism to record the process of collaborating with consumers to establish and monitor the consumer's health goals.

It would be important to make sure that any changes in consumer-directed decision support tools, such as the addition of a new brochure, or Web-based education campaign, be reflected in the DM program documentation. Therefore, any process of periodic review of that documentation should include an assessment of whether it is up-to-date regarding such decision tools.

Subsection (e), as the interpretive information makes clear, is for minors or other consumers without the legal or clinical capacity to make decisions regarding their health care without assistance. The DM program documentation must foresee this possibility and provide a mechanism in anticipation of that eventuality. This documentation should be consistent with the program's HIPAA guidelines, and therefore should be coordinated with the compliance department.

For the most part, the proposed changes to Health Plan and Health Network in v. 5.1 are modest -- too modest for my taste in the case of provider dispute resolution as I discussed in an earlier post.  However, what ought to get the attention of HMOs and PPOs that publicly report physician or other provider performance and/or establish tiered networks or differentiating physicians based upon quality and cost data is that URAC proposes eight new standards called "Health Care Performance."  I will devote this and the next several posts to explaining these standards, which are the first significant modification to the Health Plan and Health Network Standards since the late-1990s and v. 2.0.

The proposed HCP 1, which would be in both Health Plan and Health Network accreditation programs, would read as follows:

If the organization creates programs for physician or other provider performance measurement, reporting and tiering (including rating, ranking or measurement designations), the organization will display prominently in its communications to consumers: [--]
(a) Where its physician or other provider performance ratings are found; [4]
(b) A statement that performance ratings are only a guide to choosing a physician or other provider and such ratings have a risk of error and should not be the sole basis for selecting a physician or other provider; [4]
(c) Information explaining the rating system; [4]
(d) Any limitations of the data the organization uses; [4]
(e) How physicians or other providers are selected for inclusion or exclusion in a tier; [4]
(f) Details on the factors and criteria used in the organization’s rating systems; [4]
(g) How consumer and purchasers’ perspectives were incorporated in the development of the physician or provider reporting program; and [4]
(h) How a consumer may register a complaint or comment on the ranking or quality information of a physician or other provider to the organization. [4]

What jumps out with this standard is that it has eight subsections, each weighted 4, for a total of 32 weight-points for this one standard.  None of the subsections is mandatory, but you get a sense of how important transparency to consumers is to URAC from these choices about scoring.

URAC has not fleshed out its interpretive information completely (still no statement about what kind of documentation would be required).  However, one comment that URAC does provide are worth repeating here:

The unit of measure for performance measures may be an individual physician, a group practice or practice location, as well as other types of health care practitioners and delivery systems (e.g., clinics, IPA, PHO, etc.).

As we'll see in subsequent posts, these new HCP standards are not only about transparency.  They also provide due process for aggrieved providers and specific requirements regarding what kind of measures may be used in these reporting or tiering systems.