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Supporting National Standards of Accountability for Access and Quality in Managed Health Care
Policy Date: 1/1/1995
Policy Number: 9615(PP)
I. Statement of the Problem
With enrollment of 130 million,1 managed care is now the predominant mode of health care delivery and financing for privately insured populations in the United States, and many states are shifting Medicaid beneficiaries into managed care programs.2-13 A small but increasing number of Medicare beneficiaries are enrolled in managed care. Diverse models of managed care have emerged.7,14,15 Depending on how it is implemented, managed care may either enhance or diminish the appropriateness, quality, and affordability of care for the population as a whole, and in particular ways for physically, mentally, geographically, and financially vulnerable populations.16-24
Managed care holds out the promise of redirecting the US health care system toward preventive and primary care, enhancing quality while controlling costs. These are elements of the group practices and consumer-controlled health care cooperatives that served as models for early health maintenance organizations (HMOs). They are also the key features of international systems with better health outcomes and lower health care expenditures than the United States.25
The distinguishing feature of the current generation of managed care plans is that they rely fundamentally on financial incentives to control health care utilization and charges, through capitated or discounted payments to a defined panel of providers. Providers may be organized through closed panels or looser networks. The health plan assumes the financial risk for the cost of enrollees' health care. This arrangement reverses the incentives of the fee-for-service system, which rewarded health care providers, insurance companies, and the health care industry as a whole for providing each additional service, too often in the most expensive acute care settings.
In the current market-based health care system, managed care organizations compete primarily on the basis of price and secondarily on the basis of quality. For major purchasers, price is the main determinant in selecting health plans.26 Incentives in the marketplace for managed care plans to focus on access and quality have been weak if not absent.22 As the enrollment in managed care has grown and as government becomes a larger purchaser of these services, the demand for quality and access is growing. The growth of for-profit health plans and conversions of previously nonprofit providers, in the absence of adequate regulation, create distorted incentives. Nonprofit managed care organizations, while distinct in many respects, respond to the same market forces of price competition; if for-profit plans are able to lower their prices by reducing services, nonprofits come under pressure to follow suit or lose enrollment.
In this context, the trend toward managed care raises issues of concern for public health:
1. Denial of necessary care. The financial incentives to control costs are also incentives to underserve plan enrollees.9,27 Without systems of accountability, enrollees may be denied necessary health services, or reimbursement for services already provided. Instances of inappropriate denials of service and delays in treatment of managed care enrollees have been documented.28-31 Further, use of both positive and negative financial incentives to providers to limit or reduce the volume of services delivered can subject providers to a conflict of interest.
(a) Incentives to deny care may be felt most acutely by enrollees who need expensive services, including hospital care, referral to specialists, and emergency services.32
People in poor health have reported significantly more difficulty in managed care plans than in fee-for-service in getting appropriate treatment and needed diagnostic tests.23
(b) The Health Care Financing Administration (HCFA) has contracted with the Center for Dispute Resolution (CDR) to hear automatic appeals from Medicare beneficiaries who are enrolled in managed care plans and who do not prevail in plan-level grievances for denial of insurance claims or authorization for referral. From 1989 to 1993, as Medicare enrollment in managed care increased, the volume of grievances increased faster than enrollment, leveling off in 1994 and 1995. In 1995, beneficiaries prevailed in 41.9% of reconsiderations (first-level HCFA hearings) and 41.7% of appeals (second level). CDR estimates that from 1989 to 1993, over $13 million in HMO claim denials were deemed inappropriate and that without the appeals program, nearly 2,500 enrollees would have faced inappropriate claim liability, averaging about $2,500.33
Most private sector plans do not have this kind of independent review procedure, nor are grievances open for inspection. However, anecdotal evidence in the media and recent court decisions penalizing health plans for systematic denial of needed referrals, including DeMeurers and Christie cases in California, suggest continuing problems at some level.
Other measures of quality, including access, continuity, coordination, and interpersonal accountability, show mixed results.6,9,14,15,34-40
2. Underfunding of public health. Public health services that have been directly financed or indirectly subsidized in the past by public and private insurers risk reductions in funding, and the uninsured and other vulnerable populations stand to lose access to care as a result. Managed care plans contract with and pay only a limited selection of providers, which may not include public health providers. Insurance subsidies for population-based health services are lost when managed care plans drive down premiums to cover only their own enrollee base.
3. Accountability. There is no public authority or other mechanism for holding managed care plans accountable to their enrollees or to the public at large. Most managed care organizations are not accredited, though many are moving in that direction. About 34% of the approximately 600 HMOs are currently accredited by any agency; only 1% of the 500 integrated delivery systems, and 12% of the estimated 1,050 patient provider organizations (PPOs) are accredited.41
Every state in the union has passed consumer protection legislation in one or more area, including due process through grievance and appeals procedures, fair and honest marketing and enrollment procedures, access and benefits, information and disclosure, governance, and plan solvency.
Further, state laws do not apply to self-insured health plans, which account for the vast majority of employer-sponsored health plans, and cover over 70 million Americans, over two thirds of the total US work force. The federal Employee Retirement Income Security Act (ERISA) preempts states from regulating benefits provided directly by employers and reserves that right to the federal government. Self-insurance has been growing over the last 10 years at the rate of 3% to 5% a year in firms of 1 to 500 employees, and at 1% to 3% a year in firms with 500 or more employees. In 1994, 91% of large employers were self-insured, and these firms employ the vast majority of American workers.42
On the federal level, the HMO Act of 1973 sets standards for health plans, but plan participation in programs under the Act is voluntary.
4. Choice. Loss of choice of health care provider poses special problems for several populations.
Among populations with chronic and/or multiple health problems, both physical and mental, people who have established relationships with caregivers providing fine-tuned, effective treatment could be placed at great risk if obliged to enroll in a managed care plan that requires them to change providers.
Recent commercial attempts to create local delivery systems in rural communities through contracting with selected rural providers are threatening the existing health infrastructure by diminishing the ability of other traditional providers to continue in practice.
Other geographic and ethnic/racial communities already experiencing shortages of health professionals are similarly finding that managed care plans often are not contracting with a sufficient number of providers to maintain services in the community.
Women risk losing access to the reproductive services of their choice, if their network providers do not offer these services. As large health plans come to dominate or monopolize some urban areas, these services may not be available even outside the individual's network.24
5. Access, discrimination. Some plans discriminate against high-risk patients and communities, and the providers who serve them, thus limiting access to care. These patients are likely to demand more services and reduce capitation income. A survey in New York City revealed that 95% of managed care plans were unable to refer callers to a primary care physician experienced in treating persons with HIV (human immunodeficiency virus).43
6. Information, disclosure, and data. Information about health plans is not adequately collected, or disclosed to the public. This creates problems for plan enrollees attempting to identify and choose a suitable health plan; providers considering contracting with plans; health plans attempting to monitor their own performance internally; researchers interested in a wide range of medical and health care issues; and advocates attempting to gauge health plan quality and enforce standards.
(a) Most strikingly, this major transformation of the financing and delivery system is occurring so rapidly that very little is reliably known about how managed care plans are actually operating. Even less is known about the impact of these plans on the population as a whole.44,45
(b) In the current health care system, specifically in state Medicaid systems, detailed information exists in the form of administrative data sets that are maintained for fee-for-service reimbursement programs. The evaluation of clinical care has been possible through the use of this information. For example, descriptive studies have reported on the quality, patterns of use, and costs of clinical services46,47 and of related drug therapies48 and on the characteristics of recipients of care. This general area goes by various names, including clinical health services research and, for pharmacy claims, pharmacoepidemiology.49 The availability of these relatively inexpensive, accessible data sources will be thwarted by managed care, capitated programs unless state health systems mandate the provision of automated clinical services information at the same level of detail as exists currently. In doing so, population-based health services can be described and evaluated by independent public sector scientists-a crucial aspect for the assurance of quality of care under a competitive managed care rubric. Data sources for the epidemiologic evaluation of clinical services, including pharmaceuticals, will be assured only if patient-level data are collected and available for all members of the insurance system receiving managed care services.
7. Marketing abuses. Marketing abuses reflect the efforts of some health plans to enroll members selectively.
Deceptive marketing practices have led to the enrollment of misinformed persons in managed care plans ill suited to their needs. Medicaid managed care plans have been particularly susceptible to abuses in marketing and enrollment. The state of Florida disqualified 21 of 29 Medicaid managed care organizations in 1995 for deceptive marketing practices.31
Increasingly, middle-income people covered by private insurance and Medicare are beginning to face common barriers to access to high-quality care similar to those experienced by low-income populations.16,21 This community of interests provides an important basis for an alliance to hold health plans accountable.
Managed care may have the potential to enhance efficiency and effectiveness in the delivery of care, although the magnitude of savings, if any, is far from clear at this time.27,50,51 Yet the transformation to managed care continues to be driven largely by the desire of payers simply to contain near-term costs and by capital markets' sensing of new opportunities for profitable investment.9,27,52-55 The prevalence of the kinds of malfunctions and abuses described above is, for the most part, a problem still waiting to be addressed effectively.9,28,56,57 It indicates a need for a range of remedies, including more effective regulation.17,58,59
II. Purpose and Objectives
Long-standing principles of the American Public Health Association establish a commitment to the right of all people to attain and maintain good health, through population-based public health services and through access to personal health care services that are of high quality, accessible, affordable, comprehensive, efficient and effective, and inclusive of input from consumers and providers. Further, it is the responsibility of society at large, and the public health system in particular, to safeguard the public interest in achieving these principles.
Managed care is influencing all aspects of public health, including the way most Americans receive and pay for health care services. In its various forms, it presents distinct opportunities as well as challenges to the public's health. At this formative stage, it is incumbent on the Association both to address the threats to health and to define principles for acceptable operation by managed care health plans.
In keeping with APHA principles, managed care organizations should meet the following standards:
1. Accountability to consumers, providers, and the public, through adherence to uniform standards, and through reporting, oversight, and accreditation. While major strides in accountability and quality assurance have occurred through development of and adherence to such standards as those promulgated by the National Council on Quality Assurance (NCQA), and such reporting systems as Healthplan Employer Data Information Set (HEDIS), the development of a major comprehensive accountability framework truly able to anticipate and reflect the impact of managed care on the public's health is required. Public health dimensions of accountability apply epidemiologic analysis to issues concerning populations covered and not covered by the area's managed care entities, and to conditions covered and not covered by the plan.
2. Access within each plan to a sufficient range of services and providers, that are geographically accessible and culturally appropriate. Plans should give particular attention to enrollees with special health needs, including special needs children and people with mental illnesses and addictive conditions, and to adequate coverage for emergency services where the prudent-layperson criterion is met. Choice of providers should be available through an affordable point-of-service option as a safeguard to encourage plan compliance.
3. Due process. Timely grievance procedure when claims are denied or delayed, including both internal and independent external review.
4. Governance. Meaningful involvement in plan governance by plan enrollees and by plan providers who are not substantial owners or directors of the plan.
5. Data. Maintain patient-level and systemwide data regarding plan practices, performance, and finances, and make these available to the public at a sufficient level of detail to effectively monitor and assess quality of care.
6. Quality-improvement programs involving consumers and providers:
(a) Ongoing quality-improvement programs to establish guidelines for care and the enforcement of quality and to replace individual case-by-case reviews that are administratively cumbersome and that may not reflect the highest standards of quality.
(b) Assurance that clinical decisions are made on the basis of informed professional judgment in consultation with consumers, unencumbered by either financial conflicts of interest on the part of plan providers or the profit objectives of managed care organization investors.
7. Fair and honest marketing, enrollment, and contracting practices, including:
(a) Nondiscrimination against high-risk individuals and communities and their traditional caregivers.
(b) Provision of essential plan information to all prospective enrollees, in an understandable and culturally appropriate form, including a current and accurate list of providers available through the plan, premiums and other charges, the range of services covered, how to access those services, mechanisms for enrollment and disenrollment, and procedures for complaint and appeal. If such information is shown to be inaccurate, the enrollee shall have the option to disenroll without penalty.
8. Openness in provider-patient relationship to ban the use of gag rules in provider contracts that may compromise patient care.
9. Disclosure. Recognizing the concern that excessive administrative costs and profit margins diminish the quality of health care, managed care shall publicly disclose the proportion of health plan premiums spent on direct services, including public health and preventive services.
10. Solvency. Plans should adhere to sufficient solvency standards to avoid the financial burdens and loss of services to enrollees and providers that have ensued from plan failures.
11. Confidentiality. Patient confidentiality must be protected, particularly in view of system-wide internal data systems that are accessible to a wide range of health plan personnel.
12. Provider termination should not occur without an explicit written statement of the sound reason for termination.
13. Ongoing local, state, and federal public health programs remain public obligations; these programs include protection of the air, water, and food supply; programs that serve vulnerable populations such as AIDS (acquired immunodeficiency syndrome) centers, school-based clinics, community health centers, rural health centers, homeless programs, WIC (Women, Infants, and Children) programs, and other safety-net community providers; financial support for the uninsured and underinsured; regional health planning; and health provider education. Managed care plans should be required to collaborate with state and local public health agencies in assuring that programs are provided to communities.
14. Responsible distribution of funds accumulated without payment of taxes when nonprofit plans and providers convert to for-profit status, including, where appropriate, the establishment of foundations responsive to the public's health concerns.
It is the responsibility of the public sector to hold health plans accountable for meeting the above standards and to assure that the public health functions listed below are carried out. Fulfillment of these responsibilities by local public health departments is desirable but not uniformly possible without additional appropriations for this purpose. Local health departments are willing leaders and participants in the assurance of quality access and public health status improvements, but, for these functions, require dedicated resources that do not divert attention from present programs and services. These functions are the following:
1. Institute oversight and surveillance routines to monitor service accessibility, quality, and outcomes, including measures of population-based health status and outcomes, as well as enrollee satisfaction.
2. Provide for periodic publication of (a) comparative performance data with respect to enrollee access, satisfaction, and outcome issues, including enrollment and disenrollment, and independently audited information on outcomes and (b) financial performance, including loss ratios and plan solvency. Collect and publish data across states so that national studies will be possible and population-based studies will be fostered.
3. Managed care plans should not invoke ERISA legislation to avoid their legal obligations to patients established by state laws.
4. Require plans to invest in the communities they serve through programs designed to address specific community problems with strategies directed at disease prevention, health promotion, and protection.
5. Require that plans work with public health agencies in partnership to collect data and provide information to communities, to assist in health-planning efforts and health policy development, to help mobilize community health efforts, to assure availability of quality health services, to build capacity to address problems, and to develop local plans for addressing problems such as outbreaks of environmental, chronic, and infectious disease.
6. Assure that the above standards are met in requests for proposals and contracts administered by local, state, and federal government agencies.
III. Actions Desired and Methods
1. That APHA and its affiliates support legislation at the federal, state, and local level that moves in the direction of the principles and objectives stated in Section II. This includes comprehensive legislation such as HR 2400, introduced in the US Congress in 1995, and similar bills. This also includes support to those groups and agencies reviewing for-profit conversions of not-for-profit providers and insurers to assure that appropriate funds are placed in public trust for the support of indigent care and public health programs.
2. That the HCFA establish regulations for federally sponsored managed care plans consistent with HR 2400 and with the items listed above in Section II.
3. That APHA continue to consider broader questions raised by managed care, including:
(a) Ways to assess and address the impact on public health of competition among health plans based on price as opposed to quality, including mandating equitable community-rated premiums.
(b) The implications of the conversion of many health plans and health care providers from nonprofit to for-profit status, including the creation of foundations responsive to the public health of the community.
(c) The obligation of managed care plans to contribute a portion of premiums, profits, or retained earnings for public health purposes.
(d) Establishing limits on the profits or retained earnings of health plans.
(e) The impact of market-driven mergers and acquisitions among health plans and providers on delivery system innovations that may or may not benefit the public.
4. That APHA continues to encourage managed care organizations to participate in an accreditation process such as those administered by the National Council on Quality Assurance (NCQA), the Joint Commission for the Accreditation of Health Organizations (JCAHO), and other organizations.
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