Strengthening the Market to Improve Quality

Chapter Nine
Promoting Accountability

While all participants in the health care system must be accountable for improving the quality of health care in the United States, employing the extensive knowledge and expertise of organizations that oversee health care quality across the Nation, States, and local communities -- in both the public and private sectors -- is essential to quality improvement. These Quality Oversight Organizations (QOOs) include State licensing bodies, private sector accrediting bodies, Medicare/Medicaid compliance determination bodies, the Department of Labor, and individual provider certification and credentialing organizations. They have a long-standing and strong track record of assessing, ensuring, and improving health care quality. Together with group purchasers, the proposed Advisory Council on Health Care Quality, and the Forum for Quality Measurement and Reporting, QOOs can promote greater accountability across the entire health care system, and thereby greater incentives for the improvement of quality.

Recommendations

Public and private sector Quality Oversight Organizations and group purchasers should incorporate the provisions of the Consumer Bill of Rights and Responsibilities into their contractual and oversight requirements. The Advisory Council on Health Care Quality should annually report on the extent to which public and private quality oversight organizations and group purchasers have incorporated the provisions of the Consumer Bill of Rights and Responsibilities into contractual and oversight requirements, issue a comprehensive evaluation in the year 2000 on the extent of compliance with the Consumer Bill of Rights and Responsibilities, and, if necessary, make recommendations for enhancing compliance.

Quality Oversight Organizations should make a commitment to participate in the work of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting. The Forum is a voluntary, private sector approach intended to produce an efficient and comprehensive approach to quality measurement and reporting by promoting collaboration across existing QOOs. The Council, in its annual reports, should evaluate the success of this approach in obtaining the cooperation of QOOs.

Quality Oversight Organizations should take steps to increase public confidence in their oversight processes. QOOs can accomplish this by expanding the representation of consumers on governing boards and committees that establish oversight standards and make determinations; providing for public review of and deliberation on existing and proposed standards; making standards and survey protocols used to reach licensing, certification, and accreditation decisions (as well as results of oversight processes) available to the public at little or no cost; and fully disclosing all funding sources. Alternative funding mechanisms for accreditation processes should be explored to further minimize conflicts of interest and equitably spread the costs of oversight across all health care organizations. QOOs also should ensure adequate input from health care workers into their oversight processes and enhance mechanisms to assess the care of vulnerable populations.

Quality Oversight Organizations should take steps to move to a common set of quality standards for each sector of the health care industry (i.e., health plans, facilities, and other health care entities). These standards should be strongly oriented to quality improvement and should be required of all entities within each sector of the industry.

Quality Oversight Organizations should coordinate their quality oversight processes within the health care industry. Once common standards are agreed upon, use of one oversight organization's findings to satisfy another oversight organization's need for assurance on the same standard(s) (i.e., "deeming") should be pursued so long as standards to ensure public confidence in, and the integrity of, oversight processes and accountability to the public are in place.

Roles of Quality Oversight Organizations

Quality Oversight Organizations are organizations that assess the quality of health care delivered by health plans, facilities, and integrated delivery systems, as well as individual practitioners. These organizations include both private gateway.html organizations as well as Federal, State, and local government agencies. Although they vary widely in the scope of their reviews as well as the types of action they can take, they represent a concentration of expertise and knowledge that can be used to improve health care. They include:

State Licensing Bodies

States, typically through their health departments, have long regulated health care delivery through the licensure of health care institutions such as hospitals, long-term care facilities, and home health agencies, as well as individual health care practitioners such as physicians and nurses. States also license, through their insurance and health departments, financial "risk-bearing entities," including both indemnity insurance products and those managed care products that perform the dual function of bearing risk (like an insurer) and arranging for or delivering health care services (like health care-providing entities).

Private Sector Accrediting Bodies

Accrediting bodies set standards for health care organizations and assess compliance with those standards. They also focus on the operation and effectiveness of internal quality improvement systems. In some areas, State and Federal governments rely on or recognize private accreditation for purposes of ensuring compliance with licensure or regulatory requirements. Existing accreditation efforts include:

• For managed care plans: The National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and the American Accreditation Health Care Commission/Utilization Review Accreditation Commission (AAHCC/URAC).
• For hospitals: JCAHO, the American Osteopathic Association (for osteopathic hospitals), and the Rehabilitation Accreditation Commission (for rehabilitation hospitals).
• Behavioral health organizations: JCAHO (for institutions and behavioral health organizations) and NCQA (for managed behavioral health organizations).
• Long-term care facilities: JCAHO.
• Home care organizations: JCAHO and the Community Health Accreditation Program of the National League of Nursing.
• Ambulatory care organizations: JCAHO and the Accreditation Association for Ambulatory Health Care (AAAHC).
• Clinical laboratories: JCAHO and the College of American Pathologists.
• Physicians: The American Medical Association recently launched a voluntary accreditation program (the American Medical Accreditation Program) to measure and evaluate individual physicians against national standards. In addition, medical specialty certifying boards already have established methods to evaluate cognitive knowledge in board certification and recertification. Some of these organizations also have begun approaches to proficiency testing for specific clinical skills and performance measures.

Medicare, Medicaid Compliance

In order for a health care entity to receive Medicare or Medicaid reimbursement, the entity must meet certain federally specified "Conditions of Participation" (COPs) or other standards. The U.S. Health Care Financing Administration (HCFA) promulgates COPs for hospitals, home health agencies, nursing facilities, hospices, ambulatory surgical centers, renal dialysis centers, rural health clinics, outpatient physical and occupation therapy, and rehabilitation facilities. HCFA also establishes standards for the participation of managed care organizations contracting under the Medicare program.

Department of Labor

Oversight of certain aspects of employer-provided health plans is performed by the U.S. Department of Labor. The Employee Retirement Income Security Act of 1974 sets minimum Federal standards for group health plans maintained by private sector employers, unions, or jointly by employers and unions. The Department oversees plan compliance with the following legal requirements of plan administration: reporting and disclosure of plan features and operations, fiduciary obligations for management of the plan and its assets, handling benefit claims, continuation coverage for workers who lose group health coverage, limitations on exclusions for pre-existing conditions, prohibitions on discrimination-based on health status, renewability of group health coverage for employers, minimum hospital stays for childbirth, and parity of limits on mental health benefits.

Individual Certification and Credentialing Organizations

The American Board of Medical Specialties (an umbrella for 24 specialty boards), and the American Osteopathic Association have certification programs that designate certain medical providers as having completed specific training in a specialty and having passed examinations testing knowledge of that specialty. The Accreditation Council for Graduate Medical Education, sponsored by the American Medical Association and four other organizations, accredits nearly 7,700 residency programs in 1,600 medical institutions across the country. For nursing, the American Board of Nursing Specialties sets standards for the certification of nursing specialties. The largest numbers of nurses, both in generalist and specialist practice, are certified by the American Nurses Credentialling Center, based on practice standards established by the American Nurses Association.

Implementing the Consumer Bill of Rights and Responsibilities

The Consumer Bill of Rights and Responsibilities is a set of standards for certain aspects of health plan, group purchaser, health care provider, and health care facility operations and interactions with individual consumers. Although the Commission has not taken a position on the best way to achieve full implementation of the Consumer Bill of Rights (i.e., statutory or regulatory approaches versus more voluntary approaches), it did determine that because licensing, accreditation, and certification organizations have experience in setting and monitoring compliance with related standards for health care organizations and providers, it is reasonable to expect that they, in conjunction with the Advisory Council for Health Care Quality, the Forum for Health Care Quality Reporting, and group purchasers can develop an effective array of accountability mechanisms within the health care system to promote and monitor implementation of the Consumer Bill of Rights and Responsibilities.

The Bill of Rights and Responsibilities specifies the following rights to be ensured: information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect and nondiscrimination, confidentiality of health information, and complaints and appeals. Table 1 identifies potential roles of each of the above four entities in ensuring the implementation of these rights, as well as in promoting consumer responsibilities. The Commission encourages all health plans, providers, and facilities to move rapidly to implement the provisions of the Consumer Bill of Rights and Responsibilities through existing policies and practices. Group purchasers and quality oversight organizations can provide strong mechanisms for holding health plans, providers, and facilities accountable for doing so. Their efforts will be aided by the creation of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting.

The Advisory Council has the responsibility for tracking implementation of the Bill of Rights and Responsibilities, identifying barriers and obstacles to its implementation, and reporting on the progress made in its annual report. The Commission recommends that the Advisory Council annually assess the extent to which quality oversight organizations and group purchasers have incorporated the provisions of the Consumer Bill of Rights and Responsibilities into contractual and oversight requirements. Three years after the promulgation of the Bill of Rights and Responsibilities, the Council should issue a comprehensive report assessing the extent to which the Bill of Rights provisions have been adopted through legislative, regulatory, or voluntary measures, and if necessary, make recommendations for enhancing compliance.

The Advisory Council will need to perform its analysis of progress in implementing the Bill of Rights and Responsibilities by examining data and information from two sources. From quality oversight organizations, it will need to obtain copies of the standards and reviewer guidelines utilized by the public and private sector licensing, accreditation and certification entities. These can inform the Advisory Council of the extent to which quality oversight organizations have adopted the Bill of Rights and Responsibilities. The QOOs would then be asked to provide to the Council summary (i.e., aggregate) information on the extent to which the entities that have been reviewed against these standards are in compliance with them. To determine the extent to which group purchasers have adopted and adhered to the provisions of the Consumers Bill of Rights and Responsibilities, the Advisory Council may wish to conduct a survey of a sample of group purchasers.

Participation in the Council and Forum

Quality Oversight Organizations have a critical role to play in advancing a national quality improvement agenda. In addition to continuing with their established activities in order to safeguard and improve health care quality, Quality Oversight Organizations will need to continue to strengthen their accreditation, certification, quality measurement, and other quality-related activities in order to provide a mechanism for enacting the work of the Advisory Council on Health Care Quality and the Forum for Quality Measurement and Reporting.

QOOs will need to participate in and support the work of the Council in several ways:

• Participate in developing a comprehensive quality measurement strategy to address the national aims for quality improvement.
• Provide the Council with information on compliance with the Consumer Bill of Rights and Responsibilities to assist the Council in assessing its implementation.
• Provide the Council with information on the extent to which health care plans, facilities, and other entities are reporting core sets of quality measures.
• Produce comparative quality reports on the entities they oversee for the public at large.
• Recommend strategies for achieving greater improvements in health care quality.
• Identify issues pertaining to quality improvement requiring attention by the Council.
• Participate in the development of a research and development agenda for quality improvement.
• Implement public education and communication initiatives consistent with a strategy developed with the Council.

Participation of QOOs in the Forum for Quality Measurement and Reporting is even more critical. Because QOOs have been the national leaders in the measurement and reporting of quality for public accountability, and because the mission of the Forum is to translate the national aims into specific quality measures and ensure the implementation of standardized core measurement sets, the active participation and support of QOOs are important ingredients to achieving widespread compliance with the measurement and reporting strategy advanced by the Forum.

While a number of QOOs already have exercised leadership nationally in the development of core quality measurement sets, by bringing together the strongest possible group of stakeholders committed to quality measurement, the Forum can bring to bear greater expertise, resources, and support for the activities of existing QOOs. QOOs that may not have had the resources or the authority to advance the practice of quality measurement as fast as they may have liked would now have the commitment and influence of the Forum to assist them in their efforts to develop the strongest possible quality measurement data sets. Because of this, the Forum and QOOs will need to create a strong partnership that builds on the quality measurement and oversight expertise that the QOOs already have and aids them in taking the next steps to implement even stronger measures of quality for all sectors of the health care industry.

Enhancing Public Confidence

Public confidence in the assurances offered by quality oversight organizations is not always high. This may stem in part from some aspects of the process used to oversee quality, limitations in public participation and openness of their processes, and the appearance of conflict of interests. QOOs can increase public confidence in their oversight processes by addressing these issues.

Countering Conflicts of Interest

Conflicts of interest can arise from multiple sources. For example, private sector accrediting bodies have as one of their customers the entities that the organization accredits. The organizations to be accredited sometimes are the same organizations that created or fostered the creation of the accrediting entity and often are necessarily involved in identifying the standards to which they will be held accountable.

An accrediting organization can be faced with the contradictory pressures of setting standards high enough to be credible but not so high that a large number of entities will not meet the standards. This is particularly true when accreditation is voluntary and paid for by the entity seeking review. These customers understandably are upset when the entity that is supposed to serve their needs and that they chose to be reviewed by, for which they will incur large costs not incurred by entities not willing to be reviewed, treats them in a punitive fashion, such as when accreditation is denied or other sanctions are taken (Brennan and Berwick, 1996) or when they believe the standards are inappropriately high.

Quality oversight organizations also have a second set of customers -- health care consumers -- who depend on the work of these organizations to make comparative judgments about the quality of certain types of health care organizations. This is particularly true when public regulators use accreditation as a means of meeting public standards (e.g., when JCAHO-accredited hospitals are deemed to have met Medicare Conditions of Participation). Consumer advocacy organizations become concerned when the accrediting organization seems overly solicitous of the views of the industry or when very few organizations have their accreditation denied (Scholsberg and Jackson, 1996; Dame and Wolfe, 1996).

Strengthening the methods used by quality oversight organizations and operating in a stronger climate of public participation and disclosure can reduce real or apparent conflicts of interest. This can be accomplished by (1) expanding the representation of health care consumers, public purchasers, and regulators on governing boards and the committees that establish standards and make accreditation decisions; (2) expanding public input into the standard-setting process through public review and deliberation on existing and proposed standards; (3) making standards and survey protocols used to reach accreditation decisions, as well as detailed information from the accreditation surveys, available to the public at low or no cost; (4) using unannounced inspections for some elements of the survey process; (5) making full disclosure of funding sources; and (6) creating alternative funding mechanisms that reduce potential conflicts of interest.

Involving Workers in Quality Oversight

At the present time, there are no quality oversight organizations that have procedures for incorporating the views of a representative sample of health care workers into the accreditation process. The establishment of such procedures would ensure that quality oversight organizations would obtain a more complete picture of the organizations that they oversee. QOOs that accredit health plans, facilities, and networks often interview a number of individuals in key management positions. While these individuals may have a firm grasp of the management processes that govern their organizations, they may not always be aware of problems that are obvious to those who work with patients on a daily basis. A related problem is that frontline health care workers who are aware of quality problems at a plan or facility may not come forward because they fear being disciplined or even terminated (go to Chapter 13).

Addressing the Needs of Vulnerable Populations

Many of the standards used by QOOs to assess and improve the quality of care for the general population are not as effective for populations with special needs. These populations include individuals who are economically vulnerable and therefore may encounter financial barriers to care; those who are vulnerable because of health status, such as the mentally or physically disabled and the chronically ill; and those who are vulnerable because of communication barriers, such as language.

One of the key challenges in this area is the development of accreditation standards that can assess whether health plans, facilities, integrated delivery systems, and other providers have the structures in place to care for different vulnerable populations. Although accreditation and licensure standards often address areas such as the availability of interpreter services for patients who speak languages other than English and physical accessibility, greater attention should be focused on assessing the adequacy of care management processes and specialized delivery programs (e.g., whether a health plan has appropriate services for members with a particular disabling or chronic condition).

Efficiency of Oversight and Accountability Processes

As the number of quality oversight organizations has grown, and as their requirements have expanded, many entities on the receiving end of quality oversight have voiced concern about the problems of multiple and overlapping standards and levels of accountability. A managed care health plan, for example, may be held to a wide range of standards, including State licensing requirements, Medicare and Medicaid contracting requirements, NCQA accreditation standards for managed care organizations, JCAHO network accreditation standards, and URAC network accreditation standards. This can result not just in increasing administrative burden to the plans, facilities, and providers who must comply with these different standards, but can divert resources away from quality improvement initiatives or other areas of the health care system needing resources (e.g., expanding coverage). Two ways that greater efficiency can be introduced into quality oversight are to move to a common set of standards and to coordinate the review of health care entities.

Common Sets of Standards

In some sectors of the health care system, different QOOs are moving to reduce inconsistency among their standards for health care entities. The Federal Government in the past year began an initiative to develop common standards for Medicare and Medicaid contracting health plans. The National Association of Insurance Commissioners tries to achieve consistent standards across States by promulgating "Model Acts" for use by States. The NCQA, in its third version of HEDIS, achieved consistency across performance measures for Medicaid, Medicare, and commercial populations. In spite of these achievements, there still is room for reducing inconsistency.

For example, the standards used by States for licensing HMOs are not always the same as those used by private accrediting organizations or those used by Medicare or Medicaid. Across private accrediting organizations, managed care plans can be accredited against very different sets of standards. While it may be healthy to have different entities developing standards (in the same way that it may be desirable to have different entities develop stronger performance measures), more collaboration and coordination of quality standards used by quality oversight organizations could result in greater efficiency in the health care system. A process for jointly testing and implementing new standards could allow the development of stronger standards while reducing unnecessary inconsistency.

Coordinated Quality Oversight

Once common standards are more widely adopted, QOOs should begin to design and test ways to reduce duplicative reviews. For example, if a health plan has been found to meet quality standards for State Medicaid contracts and these are identical to standards for Medicare contracting (if the process for determining compliance has integrity), should a health plan undergo a separate, duplicative review for Medicare contracting? Such a situation was addressed by the Balanced Budget Act of 1997, which permits, at the option of a State, a health plan that is engaged in Medicare to be exempt from certain Medicaid quality reviews under certain circumstances. Precedent for such coordinated quality reviews was created in the Medicare program. Hospitals accredited by JCAHO or the American Osteopathic Association are deemed to have met conditions of participation for Medicare. Accepting one QOO's determination to satisfy another's has gone by the name of "deeming."

Discussions of deeming often are contentious. Many consumer advocates, for example, are concerned about the use of private accreditation as a replacement for government regulation (Scholsberg and Jackson, 1996; Scholsberg, 1997; Dame and Wolfe, 1996). Some of their concerns include (1) the lack of independence of private accrediting bodies; (2) decreased accountability to the public when the raw data from the accreditation process are not as available to the public as the findings of licensing or Medicare and Medicaid reviews; (3) reduced public participation in the development of private standards, as compared to the public's role in establishing government standards; and (4) diminished access to standards and the results of accreditation surveys. Accrediting bodies generally charge the public for their standards, while government agencies provide them free of charge.

Addressing these concerns while pursuing ways to increase the coordination of quality oversight activities is a worthy goal. Federal and State governments may want to use demonstration projects to test new approaches to deeming that can address these questions. The Health Care Financing Administration currently is pursuing a modified approach to the deeming of Medicare managed care plans through an initiative known as "Enhanced Review." Under this approach, HCFA plans to use select results from private accreditation surveys to supplement its own work. If HCFA determines that the methodology used in a private accreditation survey is equal or superior to its own, HCFA has the option of using that information instead of doing its own review. Health plans will participate on a voluntary basis. Plans that choose not to participate or have not received an accreditation from an organization participating in this project will continue to have complete reviews of their operations by HCFA.

In addition to such coordination between public and private oversight entities, private accrediting bodies could also make use of deeming to simplify their own work. An organization that accredits health plans, for example, could make use of accreditation decisions or survey results from the organizations that accredited the hospitals, clinics, and medical groups affiliated with that health plan.

Holding Entities Accountable

Although licensing, accreditation, and certification standards are abundant, they cannot offer the public assurances about the quality of health care overall. Indeed, many of the problems cited in Chapter 1 have occurred in entities that meet licensing, accrediting, and certification standards. Recognizing this, most quality oversight organizations are moving to incorporate quality improvement as a major focus of their standards. However, even focusing to a greater degree on quality improvement will not offer uniform assurances about quality, as long as some entities do not choose to meet applicable quality standards.

Accreditation of health plans or facilities (e.g., long-term care facilities) often is voluntary, although less so to the extent that a given marketplace requires accreditation as a condition for receiving contracts. In addition, as newer types of health care delivery organizations are created (e.g., provider-sponsored organizations), and as different types of entities are held accountable for care delivery (e.g., medical groups), it is difficult for licensing, accrediting, and certification entities to keep up with the evolution of new health care delivery models and entities in the marketplace. In order for greater uniformity of assurance to be offered to the marketplace, all types of health care plans and care delivery organizations should comply with common standards for quality.

Compliance with such standards can be achieved in a variety of ways. Many health care entities choose to meet quality standards to live up to their own internal commitment to pursue excellence, as well as to distinguish themselves in the marketplace, as entities offering high-quality health care. In instances in which a health care entity may not perceive the need to adhere to external quality standards, group purchasers can require compliance with quality standards as a condition of doing business with any given health care entity. Licensure and other regulatory approaches can also be utilized. While the Commission hopes that quality standards will be embraced voluntarily, there is a need to monitor the achievement of compliance through voluntary and marketplace incentives. For this reason, it is recommended that the Advisory Council on Health Care Quality be established and charged with monitoring the Nation's progress in improving care and recommending when approaches are needed to stimulate additional mechanisms for quality improvement (go to Chapter 5).

References

Brennan, Troy A., and Donald M. Berwick, New Rules: Regulation, Markets and the Quality of American Health Care (San Francisco: Jossey-Bass, 1996).

Dame, Lauren and Sidney Wolfe, The Failure of Private Hopsital Regulation (Washington, DC: Public Citizen, 1996).

Schlosberg, Claudia, Privatizing Government Regulation of Publicly Funded Health Plans: The Limits of Private Accreditation (Washington, DC: National Health Law Program, Inc., July 7, 1997).

Schlosberg, Claudia, and Shelly Jackson, "Assuring Quality: The Debate Over Private Accreditation and Public Certification of Health Care Facilities," Clearinghouse Review 30(7):699-719, November 1996.

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