2006-2007
Consumer's Guide to Michigan Health Plans
Consumer Health Information
Health plans should provide health programs and
information to encourage consumers to adopt health habits, understand the
medical care available to them and understand how doctors and hospitals perform
on standardized, clinical procedures. these programs and tools should be
widely and routinely available through health plan websites and customer service
centers. the table below illustrates how well several health plans
surveyed provide health programs and information to consumers for selected
preventive health and computer support tools.
How well does the health plan improve
the health of its members who have chronic health conditions?
High blood pressure and high cholesterol are risk
factors that can lead to heart disease. Through coronary artery disease
management programs, health plans help people improve and control these risk
factors. The following charts illustrate the percent of members with
coronary artery disease within each health plan who have had their blood
pressure tested and members who have had a recent heart attack who have
controlled blood cholesterol.
Regular testing of blood glucose levels can reduce the risk of having long-term complications from diabetes. Since having diabetes already puts people at risk for heart disease, it's especially important to keep cholesterol levels down. These charts illustrate the percent of members with diabetes within each health plan who have had their blood glucose levels tested and who have controlled blood cholesterol.
HEALTH PLAN ACCREDITATION
Purchasers expect that health plans have external
review and oversight of operations by one or more of the following
organizations: the Joint Commission on Accreditation of Healthcare
organizations (JCAHO), the National Committee for Quality Assurance (NCQA),
and/or URAC. Participation in external accreditation ensures that health
plans are reviewed against nationally accepted standards of care and
service. The table below describes accreditation achieved by the health
plans reviewed in this guide.
Source: NCQA and URAC websites. Accreditation
status is accurate as of June 30, 2006.
Description of Accreditation Status:
HMO and Point-of-Service (POS) Plan Accreditation
HMO and POS plans undergoing accreditation are
reviewed against more than 60 different standards designed to evaluate the
health plan's clinical and administrative systems related to such issues as
consumer protection, confidentiality and customer service. These plans must also
report on their clinical performance, using a measurement tool known as HEDIS,
the Health Plan Employer Data and Information Set.
NCQA assigns HMOs and POS one of five possible
accreditation levels based on the plan's performance:
Excellent - NCQA's highest accreditation
outcome is granted only to those plans that demonstrate levels of service and
clinical quality that meet or exceed NCAQ's rigorous requirements for consumer
protection and quality improvement. Plans earning this accreditation level
must also achieve HEDIS results that are in the highest range of national or
regional performance.
Commendable - This accreditation outcome is
awarded to plans that demonstrate levels of service and clinical quality that
meet or exceed NCQA's rigorous requirements for consumer protection and quality
improvement.
Accredited - Health plans that earn the
Accredited outcome must meet most of NCQA's basic requirement for consumer
protection and quality improvement.
Provisional - Provisional accreditation
indicates that a health plan's service and clinical quality meet some, but not
all of NCQA's basic requirements for consumer protection and quality
improvement.
Denied - Denied is an indication that a
health plan did not meet NCQA's requirements during its review.
PPO Plan Accreditation
NCQA's PPO Accreditation program focuses on two of the areas addressed by the
HMO/POS Accreditation program described above. PPOs don't generally manage
health care the same way HMOs do, so the requirements applied to HMOs in the Staying
Healthy, Getting Better and Living with Illness categories donot
apply to PPOs. PPO standards fall into two categories: Access
and Service and Qualified Providers.
NCQA assigns PPOs one of four accreditation
outcomes:
Full - NCQA's highest accreditation outcome for
PPOs is granted to those plans that have excellent programs for quality
improvement and consumer protection and that meet or exceed NCQA's
standards. Full accreditation is effective for a three year period.
One Year - The
PPO has well-established programs for quality improvement and consumer
protection and meets most NCQA standards. NCQA has given the PPO plan a
list of recommendations and will review the organization again after a year to
determine if it qualifies for Full Accreditations.
Provisional -
Provisional accreditation indicates that a PPO's service and clinical quality
meet some, but not all of NCQA's basic requirements for consumer protection and
quality improvement.
Denied - Denied
is an indication that a PPO did not meet NCQA's requirements during its review.
URAC also accredits PPO plans. PPO plans accredited by URAC undergo a
rigorous, comprehensive review against national standards for quality health
care. URAC review health plans under sixteen different programs such as
Health Call Center, Utilization Management, Health Network, Disease Management
and many others.
OTHER SOURCES OF INFORMATION
Patient Safety is a priority in Michigan. The Michigan Health and Safety Coalition is a collaborative quality improvement effort focused on improving patient safety in Michigan. Its mission is to improve health care quality through cost-effective improvements in patient safety, including medical errors, accross all health care settings. All heath plans featured in this guide actively participate in the Michigan Health and Safety Coalition. For more information, visit www.mihealthandsafety.org.
Another important foundation for hospital quality and safety improvement is the Leapfrog Group. valuable information about patient safety can be found at www.leapfroggroup.org.
For information on hospital performance in southeastern Michigan, go to www.savelivessavedollars.org to view the Save Live Save Dollars Health Care Performance Report. This public report provides comparative information on how well local hospitals follow established standards of care.
Additional information can be obtained from the following organizations:
Agency for Healthcare Research and Quality- www.ahrq.gov
Centers for Disease Control and Prevention - www.cdc.gov
Centers for Medicare and Medicaid Services - www.cms.hhs.gov
National Committee for Quality Assurance - www.ncqa.org
National Quality Forum - www.qualityforum.org
URAC - www.urac.org
PARTICIPATING PURCHASERS
Alliance for Health and the West
Michigan Business Group on Health represents over 700,000
beneficiaries. The Alliance for Health is a broad-based coalition
encouraging high quality health care services at the best cost. The
Alliance identifies and prioritizes community health care issues, acts as a
catalyst, convenes diverse groups and presents recommendations to solve health
care challenges.
The Greater Detroit Area Health Council (GDAHC) is a multi-stakeholder coalition of more than 75 business, health care provider, physician, labor, government, education and community organizations dedicated to improving health care quality, access and cost with an end goal of improving community health status. GDAHC plans and implements region-wide programs in initiatives in Southeast Michigan. Its Save Lives Save Dollars initiative, which is poised to become a national model, aligns stakeholders to drive improvements in quality and derive cost savings through compliance with evidence-based guidelines. employers who participate in value-based initiatives reported in this guide include: AFL-CIO Employer Purchasing Coalition, The Auto Club Group, Daimler Chrysler, Ford Motor Company, Gallagher Benefit Services and General Motors. www.gdahc.org
Michigan Purchasers Health Alliance (MICHPHA) includes 55 employers in Jackson, Washtenaw, Livingston and Lenawee Counties representing more than 150,000 beneficiaries. MICHPHA is governed by purchasers with the mission of enacting strategies that improve the quality and efficiency of the local health system. www.michpha.org
The information on this
webpage may not be reproduced without the express permission of the Greater
Detroit Area Health Council,
the Alliance for Health and the Michigan
Purchasers Health Alliance.