Medical Quality Presentation 1998
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Medical Quality Presentation 1998

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Quality Medical Care presentation made to a major Pharm mfgr in 1998 at a national meeting. Purpose is to explain how pharm company could use gov mandates to add value to contracts with MCOs.

Quality Medical Care presentation made to a major Pharm mfgr in 1998 at a national meeting. Purpose is to explain how pharm company could use gov mandates to add value to contracts with MCOs.

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Medical Quality Presentation 1998 Presentation Transcript

  • 1. ENTERING INTO VALUE-ADDED PARTNERSHIPS WITH YOUR HMOs
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 2. The Cost and Cost Containment of Medical Care
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 3. The Cost = 18% of GNP $2.3 Trillion
  • 4. 16 15 14 13 12 11 10 9 8 7 6 1970 1975 1980 1985 1990 1995 2000 National Health expenditures as a percent 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 A PERCENT OF GROSS NATIONAL PRODUCT BY YEAR
  • 5. Cost of Medical Care
    • The issue is not the cost of
    • Coronary Surgery
    • The issue is the cost of
    • diagnosing and treating
    • Chest Pain
  • 6. Sample of Actual Medical Knowledge (Tested Knowledge) Knowledge Test Score Age (years) 100% 75% 50% 25% 20 40 60 80 100 0% 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
  • 7. 100% Efficient Health Care* A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System * Most cost efficient, medically necessary, effective and best expected result for the patient. TIME
  • 8. COMMUNITY HEALTH STATUS vs. UTILIZATION and EXPENDITURE RATE B C D A $/C H Conservative Style Elaborative Style Underservice Range of Acceptable Practice Overservice SERVICES and EXPENDITURES PER CAPITA Source: Booz, Allen and Hamilton Inc. HEALTH STATUS of the POPULATION
  • 9. EPIPHANY
    • A spiritual event
    • in which
    • the essence of a truth
    • appears to the subject
    • as in
    • a sudden flash of recognition
  • 10. A New Paradigm The 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
  • 11. TONS TIME Tons of Paper Printed in Medical Journals Not Shinola Shinola Growth of Medical Publishing Growth of Medical Knowledge
  • 12. Managed Care
    • Managed 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.
  • 13. 100% Efficient Health Care* B Judgment & Feedback A Judgment Alone Maximum quality attainable using memory based system Augmented memory based system + Other Feedback Quality of Care - Memory Base System Outcomes * Most cost efficient, medically necessary, effective and best expected result for the patient. TIME
  • 14. B C D A Q O PRESSURE TO SATISFY PATIENTS Q = QUANTITY OF MEDICAL SERVICES CONFLICTING PRESSURES ON THE HEALTH SERVICE DELIVERY SYSTEM O = CLINICAL OUTCOME PLATEAU OF COMPARABLE OUTCOMES PRESSURE TO CONTROL COST
  • 15. 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.
  • 16. Continuous Quality Improvement
    • The Application of CQI to the Medical Care Delivery System
    • Roger H. Strube, M.D.
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. An Introduction to Total Quality Management ( TQM ) and the Deming Philosophy
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 21. 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.
  • 22. Components of the Health Care Industry
    • Customers
    • Suppliers
    • Managers
    • Workers
    • Investors
    • Materials
    • Machines
  • 23. 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
  • 24. Corporate
    • Plan Management
    • Plan Supervisors
    • Workers
    • Customers
  • 25. - NEXT - - TOPIC -
  • 26. W. Edwards Deming Continuous Quality Improvement Management Theory for the TRANSFORMATION OF BUSINESS THROUGH APPLICATION OF THE FOURTEEN POINTS
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 27. 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
  • 28. 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
  • 29. 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.”
  • 30. 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
  • 31. 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.
  • 32. 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
  • 33. Practice Guidelines
    • Measurement
    • and
    • Feedback
    • You cannot manage
    • what you don’t measure
    • CLOSE THE LOOP
  • 34. 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? )
  • 35. POINT SIX
    • Institute training on the job
  • 36. 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
  • 37. POINT EIGHT Drive 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
  • 38. 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.
  • 39. 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
  • 40. 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
  • 41. 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.
  • 42. 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
  • 43. POINT THIRTEEN
    • Institute a vigorous program of
    • education and self-improvement
    • for everyone
    • Educate everyone in the
    • new philosophy
  • 44. POINT FOURTEEN
    • Put 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
  • 45. - NEXT - - TOPIC -
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. 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)
  • 50. 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
  • 51. 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)
  • 52. Quality Improvement Roadblocks 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.
  • 53. The Realities of Clinical Practice are Changing
    • The physician must transition
    • from
    • Captain of the Ship
    • to
    • Quarterback of the Team
  • 54. Why Invest in Continuous 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
  • 55. - NEXT - - TOPIC -
  • 56. NCQA Accreditation The Plan’s Perspective A Walter Mitty* Story Fantasy vs Reality Roger H. Strube, M.D.
    • * “The Secret Life of Walter Mitty” -- James Thurber
  • 57. NCQA
    • An independent non-profit organization that assesses the quality of managed care plans
    • A partnership among purchasers, consumers, and health plans
  • 58. NCQA Board of Directors
    • NCQA president
    • Purchasers
    • Health plans
    • Union representative
    • Consumer advocate
    • Health lawyer
    • AMA
    • Quality expert
    • State legislator
  • 59. States Mandating NCQA Accreditation
    • Florida
    • Kansas
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Oklahoma
    • Pennsylvania
    • Vermont
  • 60. Employers Mandating NCQA Accreditation
    • AlliedSignal Pepsico
    • Ameritech UPS
    • CHAMPUS USAir
    • GTE Xerox
    • Mercantile IBM
    • Bristol-Myers Squibb General Electric
    • New York Ohio
  • 61. 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
  • 62. 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 )
  • 63. NCQA Accreditation Standards
    • Quality Management and Improvement
    • Utilization Management
    • Credentialing
    • Members’ Rights and Responsibilities
    • Preventive Health Services
    • Medical Records
  • 64. 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
  • 65. NCQA Quality Improvement Standards
    • Critical Tools
    • The Reviewer Guidelines
      • Explanatory back-up
      • Compliance guidelines
      • Scoring guidelines
    • HEDIS 3.0
  • 66. Practice Guideline Development
    • Applying
    • Continuous Quality Improvement
    • Principles
    • to
    • Medical Practice
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 67. 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
  • 68. Guideline Definition
    • Systematically developed
    • guides to assist providers and
    • patients in making appropriate
    • health care decisions in
    • specific clinical circumstances
  • 69. 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
  • 70. 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)
  • 71. 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
  • 72. 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.
  • 73. 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.
  • 74. Guideline Sources
    • Rand
    • USPHSTF *
    • ACP *
    • HAYES Medical Directory
    • Specialty Organizations
    • AMA
    • VHS
    • “ Home Grown”
    • Many New Sources
    • * Opportunity for access to medical director
  • 75. Practice Guidelines
    • Measurement
    • and
    • Feedback
    • You cannot manage
    • what you don’t measure
    • CLOSE THE LOOP
  • 76. “ The God’s honest truth is it’s not that simple”
    • Fruitcakes - Jimmy Buffett
  • 77. - NEXT - - TOPIC -
  • 78. NCQA Accreditation The Plan’s Perspective
    • Quality Improvement
    • Standards
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 79. 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.
  • 80. Quality Oversight Should Be:
    • Balanced -- quality of care, service
    • Comprehensive -- all aspects of the delivery system
    • Positive -- provide incentive to continuously improve
  • 81. 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.
  • 82. NCQA Review 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.
  • 83. NCQA Review of Delegation
    • RED FLAGS
    • Carve Outs Hospitals
      • Mental Health
      • Physical Therapy Home Health Agencies
      • Vision Care
      • Chiropractic Skilled Nursing Facilities
    • Multispecialty Groups
    • IPAs Ancillary Services
    • Single Specialty Networks
  • 84. NCQA Review of Delegation
    • Functions Frequently Delegated
    • Quality Improvement
      • Data Collection
      • Audits
    • Standard / Criteria Development
      • Access
      • Clinical Guidelines
      • Preventive Health Guidelines
  • 85. NCQA Review of Delegation
    • Functions Frequently Delegated
    • Utilization Management
      • Benefits Determination
      • Referral Management
      • Concurrent Review
      • Discharge Planning
      • Complex Case Management
      • First Level Appeals
  • 86. NCQA Review of Delegation
    • Functions Frequently Delegated
    • Credentialing
      • Data Collection
      • Primary Source Verification
      • Credentialing / Recredentialing Decision
    • Member Services
      • Complaint & Grievance First Level Review
      • Member Satisfaction Surveys
  • 87. NCQA Review 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
  • 88. NCQA Review 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
  • 89. 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.
  • 90. 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 PRIOR 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.
  • 91. Quality Improvement Roadblocks 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.
  • 92. 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.
  • 93. Utilization Management Roadblocks 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
  • 94. NCQA Accreditation The Plan’s Perspective
    • Credentialing
    • Roger H. Strube, M.D.
    • Medical Director of Quality Improvement
    • PHP Companies, Inc.
  • 95. Cr 1.0 Credentialing Policies 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
  • 96. 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
  • 97. Initial Credentialing
    • CR 3.0 At the time of credentialing, the managed
    • care organization verifies information from
    • primary sources
      • CR 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
  • 98. 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
  • 99. Initial Credentialing
    • CR 5.0 Evidence the MCO requests information on the practitioner from recognized monitoring organizations, that the information has been received PRIOR 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
  • 100. 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
  • 101. 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.
  • 102. 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; and
      • CR 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.
  • 103. 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 PRIOR 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
  • 104. 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
  • 105. 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
  • 106. 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.
  • 107. 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.
  • 108. 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.
  • 109. 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.
  • 110. 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 the managed care organization evaluates the delegated agency’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 delegated agency does not fulfill its obligations.
  • 111. 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 PRIOR 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.
  • 112. 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
  • 113. 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?
  • 114. 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.
  • 115. 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”
  • 116. 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)
  • 117. 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
  • 118. 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
  • 119. Quality Improvement Roadblocks 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
  • 120. Why Invest in Continuous Quality Improvement?
    • “ You do not have to do this;
    • Survival is not compulsory.”
    • - W. Edwards Deming
  • 121. The Light at the End of the Tunnel is not a Train Coming the Other Way
    • or
    • Is There Indemnity
    • After Managed Care
    • After Indemnity?
  • 122. Participatory Work Group Session
    • Determine Tactics to use in
    • Strategically Applying
    • CQI and NCQA Principles
    • to the Schubert’s
    • “ Unfinished Symphony”
  • 123. - NEXT - - TOPIC -
  • 124. NCQA and The Evolving Role of Information Technology
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 125. NCQA Accreditation The Plan’s Perspective
    • Medical Records
    • Roger H. Strube, M.D.
    • Managed Care Consultant
  • 126. 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.
  • 127. 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.
  • 128. Medical Records The 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.
  • 129. Medical Records The 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.
  • 130. Medical Records The 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?
  • 131. Medical Records Roadblocks & 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
  • 132. 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
  • 133. NCQA Value Added Partnering
    • Do not allow your business
    • entity to suffer because the
    • MCO staff lacks the
    • knowledge or budget to
    • survive an NCQA review.
  • 134. NCQA Value 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.
  • 135. NCQA Value 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.
  • 136. NCQA Value 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.
  • 137. 100% Efficient Health Care* A Judgment Alone Maximum quality attainable using memory based system Quality of Care - Memory Base System * Most cost efficient, medically necessary, effective and best expected result for the patient. TIME
  • 138. 100% Efficient Health Care* B Judgment & Feedback A Judgment Alone Maximum quality attainable using memory based system Augmented memory based system + Other Feedback Quality of Care - Memory Base System Outcomes * Most cost efficient, medically necessary, effective and best expected result for the patient. TIME
  • 139. 100% Efficient Health Care* C Judgment & Computer B Judgment & Feedback A Judgment Alone Maximum quality attainable using memory based system Augmented memory based system Physician Judgment + Computer decision support 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