Benchmarking Health Plan Convenience

A starting point, in the journey to simplify health care, would start with trying to understand, measure, compare and evaluate the choices we have in place today. Health plan coverage is a central point in which most American consumers interact with the health care system. So how are health plans measured, compared and evaluated?

NCQA, the National Committee for Quality Assurance (www.ncqa.org) is the most recognized entity that performs this function. Here’s how NCQA describes itself: “NCQA is a private, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. We are governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, policy makers, and representatives from organized medicine. NCQA’s mission is to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health care purchasing decisions. This encourages plans to compete based on quality and value, rather than on price and provider network. Our efforts are organized around two activities, accreditation and performance measurement, which are complementary strategies for producing information to guide choice.”

NCQA thus accredits and rates participating health plans, and employers and consumers often look to these findings when evaluating their health plan choices. NCQA can have a major impact on how health plans operate, in that plans will typically adjust their processes to conform with NCQA standards.

So, how much does NCQA measure issues that impact health care simplification, and how does NCQA try to influence plans in this regard?

NCQA measures performance for five categories when evaluating health plans:
1, Access and Service
2. Qualified Providers
3. Staying Healthy
4. Getting Better
5. Living with Illness

The Access and Service category touches on simplification issues, in addition to other issues. NCQA states that in regard to this category they evaluate “how well the health plan provides its members with access to needed care and with good customer service.” They list 31 requirements they evaluate in this regard. The following are those requirements that have some relationship with simplification issues:

1) a well-defined process that the health plan uses to make decisions about covering medical treatments and services for plan members.

2) policies that define the rights and responsibilities of plan members.

3) effective communications that make plan members aware of their rights and responsibilities.

4) information that clearly informs plan members about services, benefits and how the plan works.

5) processes that protect the confidentiality of information and medical records of plan members.

6) accurate and thorough information about the health plan to prospective members.

7) clear communications from the health plan to members and doctors about reasons for denying medical treatments or services and about the process for appealing plan decisions to deny treatment or services.

8) processes to resolve member complaints and appeals of health plan decisions.

9) evidence of fair and prompt handling of complaints and appeals from plan members.

10) members’ and doctors’ satisfaction with how the health plan makes decisions about coverage of medical treatments and services for plan members.

11) evidence of improving members’ satisfaction with the health plan.

12) health plan members’ reports about how difficult it is for them to get needed care; specifically, how much of a problem did members have getting a personal doctor they are happy with, a referral to a specialist, care they thought was necessary and approvals for care.

13) health plan members’ reports about how often they received care quickly; specifically, how often did members get advice as needed, timely appointments for routine care, prompt care for illness or injury and short waits at the doctor’s office.

14) health plan members’ opinions about how difficult it was for them to good customer service; specifically, how much of a problem did members have finding or understanding written information, getting help from customer service or completing paperwork from the health plan.

15) health plan members’ reports about how often their health plan paid claims in a reasonable time and correctly.

NCQA provides a rating for how health plans perform in each category, including Access and Service. Ratings are given in the form of stars, from zero to four, with four meaning excellent. You can view how NCQA has rated participating health plans at the NCQA web site.

The questions are:

A) is NCQA looking at the right information and issues in regard to simplifying health care?
B) Is NCQA giving the proper weight to simplification when evaluating plans, compared to the quality and access issues they must also consider?

What do you think?