URAC HCP 1 -- Proposed v. 2.1 Revision -- NEW STANDARD -- Health Care Performance

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.