Quality Ratings

Quality Ratings

Champions of managed health care plans claim that these cost-conscious organizations deliver the highest quality health care in the United States. They point proudly to the promises of preventive medicine and coordinated health care. While these assertions may be true, there is little reliable information to back them up. Despite recent efforts by the managed care industry to rank HMOs, Colorado Springs personal injury lawyer Glendale Green says Americans who shop for health coverage are still at a loss in making effective comparisons on the basis of quality.

Consumers face a number of challenges that make assessing and comparing these plans very difficult. First, managed care plans differ sharply in structure, ranging from loosely-knit networks to tightly organized HMOs. Second, even similarly organized health plans offer divergent benefits packages. Third, little reliable information is available on the quality of individual physicians and hospitals. Therefore, even the most persistent consumers will find it very difficult, if not impossible, to make judgements based on their own research.

Former President Obama, as well as some Republican and Democratic members of Congress, proposed establishing easy-to-understand “report cards” for rating health plans during last year’s debate over national health reform. Even though Congress and the Obama administration failed to act, the managed care industry has made some progress in establishing quality standards and “report cards” for HMOs.

Several initiatives of the National Committee for Quality Assurance (NCQA), an HMO accrediting organization, hold some promise. The NCQA has established a preliminary set of standards for reviewing and accrediting HMOs, and it has begun doing just that. The NCQA has reviewed 181 of the nation’s 574 HMOs, accredited 153 and denied accreditation to 24. The NCQA says it will review one-half of the nation’s HMOs. The NCQA is making every effort to ensure that its seal of approval will become the nationally recognized symbol of quality for HMOs.

The NCQA launched an HMO “report card” project last year, which rated 21 HMOs on a wide array of services, including their effectiveness in providing preventive care. The NCQA’s ratings were based in part on interviews with 10,762 members of these HMOs.

Organizations representing health consumers welcome the NCQA’s efforts, but they point out some possible deficiencies:

1) The NCQA receives substantial financial support from the managed care industry, and it is not truly independent.

2) Both the accrediting process and the “report card” project are in the rudimentary stages of development and can only provide consumers with the most preliminary guidance.

3) The NCQA’s programs are voluntary, and fewer than one-half of all HMOs have participated in them. Therefore, the NCQA is still unable to assess the entire HMO industry.

4) The NCQA’s reviews are not backed up by any laws or regulations.

5) The NCQA’s “report card” program makes no special effort to measure the level of satisfaction among HMO members who suffer from severe and chronic illnesses. For that reason, the NCQA’s ratings probably overstate levels of satisfaction.

Despite these concerns, the NCQA has clearly begun to establish national standards. To date, consumers have had to navigate their way through a confusing morass of rules, regulations and standards. The states establish their own standards for commercial HMOs, the federal government does the same for Medicare HMOs, and both the federal and state governments govern Medicaid HMOs. The growing number of employer-sponsored health plans are regulated under a special federal law and are not subject to state laws.

John Norwood
John Norwood is best known as a technology journalist, currently at Ziddu where he focuses on tech startups, companies, and products.