PPO

As I described elsewhere, URAC has a new category of standard in its new scoring system: Leading Indicator, which it defines as a "non-weighted, optional element highlighting effective practices not yet widely adopted in health care."  HCP 8 is just such a standard:

Data for physicians and other providers is collected and aggregated. [L]

I am not really sure what URAC is trying to accomplish with this standard that it has not already addressed in the other standards.  Hopefully, a member of the Standards Committee will read this and comment, clearing it up for all of us.

The HCP proposed standard that is of least interest to URAC, at least if you look at the weight it would be assigned, is HCP 7, which reads:

Organizations have a written plan to aggregate data from various sources using an appropriate methodology for the purposes of health care performance reporting on physicians and other providers. [1]

Even the interpretive information that URAC provides is sparse:

Collecting and aggregating data, including data collected across various payers, helps to achieve a more representative and valid sample.

There is little reason to think that an organization would need to do more than to submit such a written plan at the AccreditNet phase of the process.  It seems unlikely that this would be the subject of any activity during the onsite review. 

Of all the new standards proposed for the revised Health Plan/Health Network v. 5.1 standards, this is the most significant, if only for its length and therefore for the relative weight in the new scoring system.  It reads:

If the organization creates programs for physician or other provider performance measurement, reporting and tiering (including rating, ranking or measurement designations): [--]
(a) Accurate, reliable, and valid measures must be used, and [--]
(i) Endorsed by the National Quality Forum where available; and [3]
(ii) If not available, then the Ambulatory Quality Alliance, the AMA-convened PCPI, or national accreditor-endorsed measures are used; and [3]
(iii) If none of the above are available, then measures based upon nationally recognized practice guidelines are used. [3]
(b) Measures used must be: [--]
(i) Clearly delineated; and [3]
(ii) Appropriately risk adjusted to account for characteristics of the physician’s or other provider’s patient population such as case mix, severity of patient’s condition, comorbidities, and outlier populations. [4]
(c) Categories of measurement cannot exclusively include cost efficiency, but must also include quality of performance. [M]
(i) Both types of measures are calculated and reported separately; and [M]
(ii) If combined, the individual component scores and their proportion of the combined score must be disclosed separately. [M]
(d) When comparing or ranking physicians and other providers: [--]
(i) The relative weight of each measure and each type of measure must be publicly available; [4]
(ii) Cost efficiency measures must compare physicians and other providers by specialty area or peer group and geography. [4]
(e) Data: [--]
(i) Must describe statistical basis for number of patients (data) used; and [3]
(ii) Must use current data consistent with the proper timeframe to attain adequate sample sizes. [3]

As you can see, it has 3 mandatory subsections and 30 other "scoring points", making this about as consequential a standard as you'll find anywhere in the revised standards.  

This standard does five basic things:

1. Establishes a minimum threshold for the source of the measures to be used the performance measurement system;
2. Requires risk adjustment;
3. Insists on the inclusion of quality measures and thereby prohibits cost-efficiency-only performance measurement;
4. Creates standards of fairness in the use of performance measures to compare providers; and
5. Establishes minimum requirements -- albeit vague ones -- for the statistical validity of the measures being used, with particular attention on sampling methodology.

One can assume that the documentation for this standard will need to be extensive.  Most of it, I'm imagining, will be submitted during the AccreditNet phase of the application process -- extensive P&Ps, program descriptions, and documentation supporting the choices made about measurement selection and sampling methodology.  The onsite review, I'm guessing, will hold few surprises, assuming the initial documentation submission is sufficient to get past the desktop review.

The proposed new standard, HCP 5, establishes minimum requirements for the due process that must be allowed to providers who choose to appeal an organization's performance measurement.  It reads:

If the physician or other provider makes an appeal within 30 days of receiving notice from the organization, then no change will be made to the information or ranking and it will remain unpublished until such time as the dispute is resolved. [4]

By requiring the health plan or health network to resolve a timely-filed provider appeal before it can implement a performance measurement publication or use in tiering, this standard places a premium on handling appeals promptly.  Think of it this way -- if you publish or use in network tiering a new or newly revised performance measurement system when there is an outstanding appeal that was timely filed, you have violated this standard.

This suggests what will be useful information for reviewers.  Certainly, at the AccreditNet phase you'll need to submit a P&P that mirrors the standard.  The onsite review likely will look like a two-fold request -- one for the a list of the dates of any launch or revision to your performance measurement system and the other for a list of provider appeals.  The reviewer will then cross check the two lists, looking for publication before appeal resolution.

This new standard provides:

At least 45 days prior to releasing performance data to the public, the organization must disclose to physicians and other providers an explanation of and provide access to: [--]
(a) How physician and other provider perspectives were incorporated in the development of the health care performance reporting program; [4]
(b) Data used for physician and other provider ratings; [4]
(c) The methodology and measures used to assess physicians and other providers, including attribution; [4]
(d) How the data will be utilized; [4]
(e) The physician’s and other provider’s right to make corrections; and [4]
(f) The physician’s and other provider’s right to: [--]
(i) A reconsideration with the organization; and [4]
(ii) To make an appeal to the organization; [4]

This standard offers a blend of transparency and due process, requiring the plan or network to notify affected providers of  a variety of elements of the program to use provider performance data.  Much is suggested by this standard, not the least of which is a process to assure that there is effective notification 45 days prior to use or publication.  I predict that this will be a sticking point for some organizations who fail to plan ahead and find market pressures to get a tiered network to market pushing up against this requirement to do so in a way that encourages provider input.

Again, URAC has not yet developed (or at least published) its review process information, but my guess is that the desktop reviewer will want to see a full policy and procedure describing this process, and that the onsite reviewer will ask for documentation of launch dates of tiered networks or published performance data, then look for documentation of full notice to providers 45 days prior. 

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. 

This standard provides:

The organization establishes provider selection criteria that address: (Primary)
    (a) Quality of care; (Primary)
    (b) Quality of service; and (Primary)
    (c) The business needs of the organization. (Secondary)

Subsections (a) and (b) are relatively straightforward.  For (a), most URAC applicants submit their credentialing requirements, such as valid, unrestricted license in the applicable state, current DEA certificate (if applicable), appropriate education and training for specialty, board certification in specialty, proof of liability insurance or self insurance, good standing with Medicaid and Medicare, etc.  For (b), we usually see requirements regarding responsiveness of the provider’s office staff, cleanliness of the provider’s office, hours of operation, and the like.  

Subsection (c) is a bit trickier for some.  As URAC's interpretive comments note:

NM 3(c) is intended to allow the organization flexibility in not accepting providers that otherwise meet the criteria for quality and service.  For example, if the organization already has enough qualified primary care providers, it might not accept another qualified primary care provider based on business needs.

Make sure your documentation gives you the flexibility to say "no" if your network is full in that specialty or some other business reason has you want to restrict a network (except, of course, if you operate in a state with an "Any Willing Provider" law).  

In amending this standard, which describes an aspect of the provider dispute resolution process for clinical and quality disputes, URAC simply clarifies that its use is limited to participating providers. It does so by amending subsection (b) to read, “Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information.” The new language is simply the word “participating”.

The standard now reads:

The dispute resolution mechanism required under Standard NM 16: (Primary)
(a) Specifies that all disputes are referred to first-level panels consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute; (Primary)
(b) Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information; and (Primary)
(c) Provides for consideration to a secondlevel panel consisting of at least three individuals that comply with Standard NM 17(a) and that were not involved with the first-level panel. (Primary)

For a more complete discussion of URAC's provider dispute resolution standards, see my earlier blog.

In what some will call a Band-Aid for a serious wound, URAC merely renamed the standard which, in both the Health Plan and Health Network accreditation standards describes the requirements for participating provider dispute resolution where the dispute is merely administrative (and neither clinical nor quality-related). The old title for the standard is “Participating Provider Dispute Resolution Process: Type A”, while the new one adds “ – Administrative” at the tail end of the title.

For the sake of context, this is the standard that was added in v. 5.0 to bring some order to the mess created by the drafting of the comparable standard in v. 4.0. As I outlined long ago in a blog to describe the long and unhappy history of these standards, the v. 5.0 standards only compounded the problem, and renaming this one seems like less than a half-measure.

The best way to understand this whole series of standards dealing with participating provider dispute resolution is still to read an explanatory note that was posted on the URAC website a few months after I posted my initial blog on the issue. You can read that note in my blog.

One can only hope that the clarity expressed in that Web site note will be replicated in v. 6.0, whenever URAC issues that version.

'Tis the season for retrospectives, and I am not immune from the temptation to muse about recent developments in healthcare. So, this is the first in an irregular series that will appear here for the next month in which I look at what seem like important developments, as opposed to fads, in healthcare. I'll focus on finance, delivery, and management issues, and leave clinical developments to other sites.

Not as flashy as electronic health records (EHRs), the trend away from HMOs and insured PPOs toward self-insurance combined with non-risk-bearing PPOs seemed to accelerate in 2005 and 2006:

• After reaching a peak of 1.640 million enrollees in 2001, most HMOs have seen their enrollment decline. As of June 2006, there were 1.293 million HMO members in the state. National companies like Compcare, Humana and UnitedHealthcare (once the largest HMO in the state) have encouraged employers to move into PPOs and to self-insure their benefits.

“Wisconsin HMOs at a Glance”, by Allen Baumgarten
http://www.AllanBaumgarten.com

Allen Baumgarten has nearly identical language in his reports of the health industries in every one of his state surveys:

• Minnesota (“Commercial HMO enrollment has declined from more than 1 million in 1996 to 510,000 in 2005”)
• Colorado (“Enrollment in Colorado HMOs reached a peak of 1.637 million enrollees in 2000, but has dropped every year since then”)
• Michigan (“health plans and employers alike are moving away from the HMO model to benefit plans that allow more consumer cost-sharing”)
• Ohio (“there are 225,000 fewer Ohioans in HMOs now than at the end of 2003”)
• Illinois (“Since [2000, HMO] enrollment has decreased steadily and in all three lines of business - commercial, Medicare and Medicaid”)
• Florida (“Enrollment in Florida HMOs dropped by 431,000 members or 15.8% in the 18 months from January 2004 to June 2005. That was the fifth straight year of declining enrollment.”)
• Texas (“As of June 2005, HMO enrollment in Texas has fallen to 2.337 million, down from a peak of nearly 4 million members in 2000.”)
• California (“Medical groups, which built their systems around receiving monthly capitated payments, face a continued decline in HMO enrollment”)

The HMO industry’s loss of market share to PPOs is not news – indeed, reports of the decline of HMO enrollment can be found well back into the 1990s. Yet, much of that migration from HMO to PPO in the late 1990s and the early part of this decade was from HMOs to insured PPOs, often in the same Blue Cross Blue Shield plans that offered the HMOs. What seems to this observer to be the story is not the shift to PPOs, then, but the shift to self-insurance.

Self-insurance was very popular in the late 1980s and, in some parts of the country, early 1990s until insured HMOs offered better cost-control options to employers. So, we saw a rapid migration from self-insured plans (usually not involving managed care principles other than utilization management) to HMOs. The reign of the HMOs, however, was relatively brief and not all that geographically widespread. By the turn of the century, as we've seen, the benefit flexibility that self-insurance offers started to lure employers back to their comfort zone of self-insurance.

That this migration has picked up steam over the last two years is, in my view, among the little-understood but most important developments in healthcare finance and delivery. As we'll see in succeeding essays, trend is serving as a platform for many other developments that are receiving much more ink in the "end of the year" articles about healthcare, such as EHR and consumer-directed healthcare.

The reader is well-advised to remember this platform as you think about the policy and management implications of these higher-profile developments.