Health Care Industry Gives Mixed Grades to 'Report Cards.' (Evaluations of Health Maintenance Organizations)(includes Information on Resolving Disputes with HMOs)

Article excerpt

Other than financially, it has been virtually impossible to compare health plans, judge the quality of their network of physicians and hospitals and rate how well they manage patient care. "We don't have the information we need," complains Maryann Napoli, associate director of the Center for Medical Consumers in New York City.

That's starting to change. "Measuring quality in health care is still a young science - some would say art - filled with a great many uncertainties," says Margaret O'Kane, president of the Washington-based National Committee for Quality Assurance, or NCQA. "Yet, despite its infancy, remarkable progress has been made in this field."

NCQA was founded in 1979 as an advocate for quality health care and began accrediting health maintenance organizations in 1991. Its team of reviewers spend two to four days evaluating plans based upon a checklist of 50 quality-control standards including how well the HMO investigates the credentialing of its physicians, follow-up procedures for abnormal tests and practices for ensuring prompt treatment. The findings are analyzed by a national oversight committee of doctors. A plan is granted one of four rankings: a full three-year accreditation, a one-year accreditation, a provisional seal of approval, or denial.

Failure to secure accreditation doesn't mean the HMO is a bad plan, experts insist; it means the company hasn't documented for NCQA how well it's performing - which employers are coming to expect. "We use accreditation to level the playing field because it's based on the standards of a third party," says Chris Moakley of Chernoff Diamond & Co., a benefits consultant in Albertson, N.Y "If one health plan passed and others did not, that indicates it was perhaps of a higher quality."

NCQA also is working on a broader "report card" that measures whether people actually are receiving good care. It looks at such things as the percentage of toddlers who have been immunized. Nearly two dozen major corporations, including First Union Bank, Federal Express, Federated Department Stores (the parent of Macy's and Bloomingdale's) and GTE Corp. demand such standardized information before signing a contract with a health plan. Separately, United HealthCare Corp. …