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President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Strengthening the Market to Improve Quality

Chapter Nine
Promoting Accountability

While all participants in the health care system must be accountable for improving the quality of health care in the United States, employing the extensive knowledge and expertise of organizations that oversee health care quality across the Nation, States, and local communities -- in both the public and private sectors -- is essential to quality improvement. These Quality Oversight Organizations (QOOs) include State licensing bodies, private sector accrediting bodies, Medicare/Medicaid compliance determination bodies, the Department of Labor, and individual provider certification and credentialing organizations. They have a long-standing and strong track record of assessing, ensuring, and improving health care quality. Together with group purchasers, the proposed Advisory Council on Health Care Quality, and the Forum for Quality Measurement and Reporting, QOOs can promote greater accountability across the entire health care system, and thereby greater incentives for the improvement of quality.

Recommendations

Roles of Quality Oversight Organizations

Quality Oversight Organizations are organizations that assess the quality of health care delivered by health plans, facilities, and integrated delivery systems, as well as individual practitioners. These organizations include both private gateway.html organizations as well as Federal, State, and local government agencies. Although they vary widely in the scope of their reviews as well as the types of action they can take, they represent a concentration of expertise and knowledge that can be used to improve health care. They include:

Implementing the Consumer Bill of Rights and Responsibilities

The Consumer Bill of Rights and Responsibilities is a set of standards for certain aspects of health plan, group purchaser, health care provider, and health care facility operations and interactions with individual consumers. Although the Commission has not taken a position on the best way to achieve full implementation of the Consumer Bill of Rights (i.e., statutory or regulatory approaches versus more voluntary approaches), it did determine that because licensing, accreditation, and certification organizations have experience in setting and monitoring compliance with related standards for health care organizations and providers, it is reasonable to expect that they, in conjunction with the Advisory Council for Health Care Quality, the Forum for Health Care Quality Reporting, and group purchasers can develop an effective array of accountability mechanisms within the health care system to promote and monitor implementation of the Consumer Bill of Rights and Responsibilities.

The Bill of Rights and Responsibilities specifies the following rights to be ensured: information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect and nondiscrimination, confidentiality of health information, and complaints and appeals. Table 1 identifies potential roles of each of the above four entities in ensuring the implementation of these rights, as well as in promoting consumer responsibilities. The Commission encourages all health plans, providers, and facilities to move rapidly to implement the provisions of the Consumer Bill of Rights and Responsibilities through existing policies and practices. Group purchasers and quality oversight organizations can provide strong mechanisms for holding health plans, providers, and facilities accountable for doing so. Their efforts will be aided by the creation of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting.

The Advisory Council has the responsibility for tracking implementation of the Bill of Rights and Responsibilities, identifying barriers and obstacles to its implementation, and reporting on the progress made in its annual report. The Commission recommends that the Advisory Council annually assess the extent to which quality oversight organizations and group purchasers have incorporated the provisions of the Consumer Bill of Rights and Responsibilities into contractual and oversight requirements. Three years after the promulgation of the Bill of Rights and Responsibilities, the Council should issue a comprehensive report assessing the extent to which the Bill of Rights provisions have been adopted through legislative, regulatory, or voluntary measures, and if necessary, make recommendations for enhancing compliance.

The Advisory Council will need to perform its analysis of progress in implementing the Bill of Rights and Responsibilities by examining data and information from two sources. From quality oversight organizations, it will need to obtain copies of the standards and reviewer guidelines utilized by the public and private sector licensing, accreditation and certification entities. These can inform the Advisory Council of the extent to which quality oversight organizations have adopted the Bill of Rights and Responsibilities. The QOOs would then be asked to provide to the Council summary (i.e., aggregate) information on the extent to which the entities that have been reviewed against these standards are in compliance with them. To determine the extent to which group purchasers have adopted and adhered to the provisions of the Consumers Bill of Rights and Responsibilities, the Advisory Council may wish to conduct a survey of a sample of group purchasers.

Participation in the Council and Forum

Quality Oversight Organizations have a critical role to play in advancing a national quality improvement agenda. In addition to continuing with their established activities in order to safeguard and improve health care quality, Quality Oversight Organizations will need to continue to strengthen their accreditation, certification, quality measurement, and other quality-related activities in order to provide a mechanism for enacting the work of the Advisory Council on Health Care Quality and the Forum for Quality Measurement and Reporting.

QOOs will need to participate in and support the work of the Council in several ways:

Participation of QOOs in the Forum for Quality Measurement and Reporting is even more critical. Because QOOs have been the national leaders in the measurement and reporting of quality for public accountability, and because the mission of the Forum is to translate the national aims into specific quality measures and ensure the implementation of standardized core measurement sets, the active participation and support of QOOs are important ingredients to achieving widespread compliance with the measurement and reporting strategy advanced by the Forum.

Consumer Right
Table 1
Promoting Implementation of the
Consumer Bill of Rights:
Key Organizations and Their Activities

Council Forum Group Purchasers Quality Oversight Organizations
Information on health plans, facilities, and professionals Specify aims for improvement and goals for measuring and reporting performance information on health plans, facilities, and individual providers Implement a quality measurement and reporting strategy to make information on quality available on all sectors of the industry to the public at large Require reporting of information as part of their contracting requirements; participate in and support the work of the Forum Work collaboratively with the Forum and each other to implement quality reporting requirements; assess compliance of health care organizations with reporting requirements
Choice of health care providers Track implementation and report progress in its annual report Offer health plans that provide adequate choice of providers Encourage and assess compliance through standards and review processes
Access to emergency services Track implementation and report progress in its annual report Require adherence to this standard in their health plan contracts Encourage and assess compliance through standards and review processes
Participation in treatment decisions Track implementation and report progress in its annual report Require adherence to this standard in their health plan and provider contracts Encourage and assess compliance through standards and review processes
Respect and nondiscrimina- tion Track implementation and report progress in its annual report Require adherence to this standard in their health plan and provider contracts Encourage and assess compliance through standards and review processes
Confidentiality of health information Track implementation and report progress in its annual report Require adherence to this standard in their health plan and provider contracts Encourage and assess compliance through standards and review processes
Complaints and appeals Track implementation and report progress in its annual report Require adherence to this standard in their health plan and provider contracts Encourage and assess compliance through standards and review processes
Patient responsibilities Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities Assist in educating employees regarding their rights and responsibilities Encourage and assess compliance through standards and review processes

While a number of QOOs already have exercised leadership nationally in the development of core quality measurement sets, by bringing together the strongest possible group of stakeholders committed to quality measurement, the Forum can bring to bear greater expertise, resources, and support for the activities of existing QOOs. QOOs that may not have had the resources or the authority to advance the practice of quality measurement as fast as they may have liked would now have the commitment and influence of the Forum to assist them in their efforts to develop the strongest possible quality measurement data sets. Because of this, the Forum and QOOs will need to create a strong partnership that builds on the quality measurement and oversight expertise that the QOOs already have and aids them in taking the next steps to implement even stronger measures of quality for all sectors of the health care industry.

Enhancing Public Confidence

Public confidence in the assurances offered by quality oversight organizations is not always high. This may stem in part from some aspects of the process used to oversee quality, limitations in public participation and openness of their processes, and the appearance of conflict of interests. QOOs can increase public confidence in their oversight processes by addressing these issues.

Efficiency of Oversight and Accountability Processes

As the number of quality oversight organizations has grown, and as their requirements have expanded, many entities on the receiving end of quality oversight have voiced concern about the problems of multiple and overlapping standards and levels of accountability. A managed care health plan, for example, may be held to a wide range of standards, including State licensing requirements, Medicare and Medicaid contracting requirements, NCQA accreditation standards for managed care organizations, JCAHO network accreditation standards, and URAC network accreditation standards. This can result not just in increasing administrative burden to the plans, facilities, and providers who must comply with these different standards, but can divert resources away from quality improvement initiatives or other areas of the health care system needing resources (e.g., expanding coverage). Two ways that greater efficiency can be introduced into quality oversight are to move to a common set of standards and to coordinate the review of health care entities.

References

Brennan, Troy A., and Donald M. Berwick, New Rules: Regulation, Markets and the Quality of American Health Care (San Francisco: Jossey-Bass, 1996).

Dame, Lauren and Sidney Wolfe, The Failure of Private Hopsital Regulation (Washington, DC: Public Citizen, 1996).

Schlosberg, Claudia, Privatizing Government Regulation of Publicly Funded Health Plans: The Limits of Private Accreditation (Washington, DC: National Health Law Program, Inc., July 7, 1997).

Schlosberg, Claudia, and Shelly Jackson, "Assuring Quality: The Debate Over Private Accreditation and Public Certification of Health Care Facilities," Clearinghouse Review 30(7):699-719, November 1996.

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Last Revised: Sunday, July 19, 1998