As health plans and other organizations prepare for Health Reform – including meeting Health Exchange requirements and preparing and competing for the expansion in government program business – there is a renewed focus on meeting accreditation and quality measurement requirements.  These requirements are promulgated by organizations such as CMS and state regulators and administered by the National Committee on Quality Assurance (NCQA), URAC and other auditors that are certified by these government agencies.

For experienced health plans with generously staffed Quality Management departments this is old hat to them. To others – newer health plans, provider-sponsored health plans and community-based organizations – the language of the requirements can be foreign and the work required to meet them can seem ominous.

There tends to be theme songs to some of the key quality regulations and requirements. What data do you have that shows your knowledge of the population? How do you use the data to identify opportunities in the population? And how do you measure that your initiatives have had any impact?

Tools like MedInsight, with its clinical analytic and the risk scoring capabilities can be very effective in addressing the needs of some of these requirements. Most organizations are using these tools to identify preventive care gaps and address those gaps but many are missing opportunities to address other critical accreditation and quality improvement areas.

Some of these opportunities include:

• NCQA Health Plan Quality Improvement Standard 7 – requires the ability to identify members with complex illnesses and comorbidities, establish identification methods and conduct an annual population evaluation to determine the continued validity of those methods.
• NCQA Health Plan Quality Improvement Standard 8 – requires the ability to identify condition populations for disease management and implement a stratification approach for selective intervention.
• CMS Special Needs Plan (SNP) Model of Care (MOC)- requires the ability to define the needs of the population, identify frail and high need members and provide interventions based on analysis of population needs.

MedInsight and the Milliman Advanced Risk Adjuster (MARA) provide the ability to efficiently and consistently identify candidates for case and disease management, identify comorbidities and stratify members for targeted intervention. As quality managers and care management leaders gain access to this information these teams will find strong evidence of their ability to meet these accreditation requirements and a solid source of qualified members who will benefit from their programs.