Providers

This particular subsection (formerly Core 33(e)) provides:

The organization has a quality management committee that. . . (e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group); (Secondary)

This subsection applies to Health Plans and Health Networks.  The question comes up, "if we don't have a participating provider on the QMC itself, how do we make sure that the input from the participating provider committee is adequate?"

Our answer to this question is, "make sure that anything that is the responsibility of the QMC to receive reports about, or do, or issue reports on, gets to this physician group."  That can be a lot.  As our blog post on QMC responsibilities shows (click here), that may involve a lot of activity.

So, if your physician advisory group is not particularly active, either gear it up to meet the full range of the QMC's clinical responsibilities or play it safe and appoint a participating provider to your QMC.

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

The disease management program establishes and implements procedures for communicating with treating providers and their representatives in a collaborative manner regarding care of participating and/or eligible consumers that includes:
(Primary)

    (c) Information on rights and responsibilities of providers whose patients are participating in the disease management program. (Secondary)

As usual, the documentation begins with a P&P that describes the organization's approach to communication and collaboration with the treating provider.  This is true even if the primary communication is through the consumer -- the P&P still must describe this approach.  The P&P should describe in some detail how, when, and by what mechanisms information will be communicated to the provider.  This should include the mechanism for notifying the provider of a critical healthcare incident that the consumer might face.  A key test of the adequacy of the provider outreach is whether he/she is receiving enough information to identify the DM program and to access that program.

Document needed for the desktop review stage is simply a combination of the appropriate P&Ps and the staff training protocols.  The onsite review will focus on staff interviews and any documentation of provider outreach to verify implementation of this standard. 

DM 3, which carries a weight of 4, provides:

The disease management program develops and updates its scope of service, including clinical interventions, with the guidance of actively practicing providers and content experts with expertise in the relevant clinical condition(s). (Primary)

This standard complements the requirement of DM 2 to keep guidelines up-to-date with the help of clinical experts by requiring a similar effort regarding interventions. As is the case with DM 2, DM 3 requires the involvement of clinical experts appropriate to each of the DM programs.

The documentation required for the desktop review phase includes a list of clinical experts, along with their CVs, used in reviewing and updating its interventions. Documentation at this phase also should include minutes that indicate their attendance at appropriate meetings.

During the onsite phase, in addition to reviewing the documentation submitted during the desktop review phase, the URAC reviewer will talk to clinical leadership -- including the clinical experts that are the subject of this standard -- to confirm that the experts were indeed involved at the level they need to be involved to fulfill the intent of this standard.

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.

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. 

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).  

NM 8 provides:

The organization’s written agreements with participating providers do not include:
(a) Any clauses or language that could restrict participating providers from discussing matters relevant to consumers’ health care; nor
(b) A definition of “medical necessity” that emphasizes cost/resource issues above clinical effectiveness.

This is a mandatory standard, and all elements are primary.  It is the same for both Health Plan and Health Network accreditation programs.

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of the “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy discussed in another blog on this site (http://integralhs.com/doing-right-not-enough-having-policy-do-it-right-required-too).

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.