THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Tuesday, February 27, 1996 TAG: 9602270288
SECTION: BUSINESS PAGE: D1 EDITION: FINAL
SOURCE: BY MARIE JOYCE, STAFF WRITER
LENGTH: Long : 107 lines
As health maintenance organizations become more common, consumers choosing among health plans must venture into new territory.
Now, a national organization wants to give them a road map.
The National Committee for Quality Assurance has been conducting voluntary inspections of HMOs for the past five years, using the information to help companies select health plans. This summer, for the first time, it will start providing answers for individual consumers, too.
The accreditation summaries will be released in June for the 50 HMOs inspected most recently by the NCQA, a private group that is fast becoming the gold standard for health maintenance organizations.
The reports don't have all the answers.
None of the Hampton Roads-based HMOs will be included, at least not right away.
Detailed results of NCQA inspections are not available to the public. And some health care experts question how well the standards actually measure quality.
But for now, NCQA accreditation is probably the best tool a consumer has, said William K. Ginnow, associate dean for health affairs at Norfolk's Eastern Virginia Medical School. ``There isn't any other marker to use,'' he said.
Sentara Health System has the only locally owned HMOs to obtain NCQA accreditation, but Sentara's summary won't be available before fall.
A few larger companies that do business in Hampton Roads, including Aetna and CIGNA, will be among the 50 available this summer, an NCQA spokesman said.
The two-page summaries show general information and compare plans to the national average in the six areas NCQA evaluates.
NCQA, started by an HMO trade organization, has been independent since 1990 and accrediting HMOs since 1991. Its budget is paid mostly by fees from the insurers undergoing inspection.
NCQA has no enforcement power, but is influential because of pressure from large companies looking for health insurance. National companies that are trying to find plans for employees throughout the United States want some standard comparisons, and many have accepted NCQA as the standard-bearer.
``A year or two ago they (were) asking. Now they're demanding,'' said Dr. David C. Gundlach, medical director of Sentara Alternative Delivery Systems.
Starting this summer, Medicaid will require accreditation for any company that wants to participate in a Hampton Roads test programto create HMOs for the poor. The federal government has altered its Medicare requirements to take into account NCQA approval.
In Hampton Roads, small companies don't ask for it, possibly because this area is still a relatively young market for HMOs. Roughly 25 percent of Hampton Roads residents are in some type of managed-care plan, by some estimates. Nationally, a recent survey showed 71 percent of Americans who get their health benefits through work are now in managed care, The Associated Press reported.
``The owner of a 10-person company - he probably doesn't know what NCQA means,'' said Dr. Louis Hochheiser, vice president for Medical Management for Tidewater Health Care, the Virginia Beach-based company that owns Priority Health Care.
But eventually, Hochheiser believes, the NCQA stamp of approval will become necessary to survive, just as accreditation by another private, national agency has become a de facto requirement for hospitals.
``You're not going to want to go into a health plan that's not accredited,'' he said.
The process for HMOs is rigorous, taking at least a year of documentation before the HMO can even apply. Hochheiser estimates that Priority, which will submit its application by July 1, probably spent about a quarter of a million dollars on it.
Officials at HMOs who have gone through the process think their companies have improved as a result.
Officials at Trigon Blue Cross Blue Shield know just how difficult the process can be. The Richmond-based insurer, which does a lot of business in Hampton Roads, was turned down by NCQA last spring. The company has improved and will reapply in April, said Dr. Richardson Grinnan, Trigon's senior vice president for Health Care Management.
Grinnan wouldn't estimate how much the two attempts have cost the company. He said the denial raised questions by employers looking at Trigon's HMOs, although the company's managed-care business has expanded over the past year.
``I can't say it hasn't created some concerns in the minds of certain people,'' Grinnan said.
Trigon was turned down, he said, largely because of problems in documentation, ``dotting the i's, crossing the t's, having the paperwork in the right file folder. . . . We weren't doing them exactly in the manner they wanted them done.''
Despite its thoroughness, the NCQA process may offer more promise than anything else.
``While it's got some real value down the line, right now it's not mature enough,'' Hochheiser said.
The reviews are based on paperwork and procedures. It's a lot harder to evaluate whether patients are getting what they need.
``What they're not doing, obviously, is measuring the quality of care,'' said Ginnow, of Eastern Virginia Medical School. ``They're measuring the quality of the system.'' ILLUSTRATION: Graphic by John Earle
...More information about HMO grades is available from the National
Committee for Quality Assurance at 202-955-3510.
Or you can visit the group's site on the World Wide Web at:
http://www.ncqa.org/
[For complete text, see microfilm]<
KEYWORDS: HMO ACCREDITATION by CNB