The Role of Accreditation in Utilization Management
Over the last 30 years, accreditation organizations have assumed an increasingly important role in filling regulatory gaps by establishing quality standards before similar provisions are adopted by states and federal governments. Supporters of private sector accreditation programs note that these nonprofits can work more efficiently create quality standards that fill important gaps in the health care delivery system. They also are known for moving the ball forward in ensuring meaningful compliance by the industry.
The rise of accreditation programs, usually voluntary in nature and sponsored by a non-governmental organization, have been found to have a positive impact on the quality of health care services.[i]General accreditation programs have been shown to improve clinical outcomes, and the structure and process of care.[ii]
These programs help reduce the burden of state oversight, as states can choose to focus limited resources on specific issues.[iii] In addition, accreditation can be used to supplement state regulations. The federal government has called for the use of accreditation to help ensure quality in managed care settings, and specific provisions within the Affordable Care Act (ACA) call for the use of accreditation programs in the areas of medical homes, case management and disease management, wellness programs, medication therapy management services, pharmacy benefit management and utilization review.[iv]
However, critics of the accreditation model, relating to UM oversight, have expressed concerns about the price of accreditation, which has increased exponentially over time, and the regulatory “deemer” status that is often given to the accreditation agencies by state and federal regulatory agencies. Regarding the former, some believe the cost to pay for an accreditation application and the administrative costs associated with carrying out the review far exceed the value. In reference to the latter, some policy experts believe that the government is inappropriately delegating regulatory oversight responsibilities to private entities. Some also comment that even though most accreditation agencies are non-profits, they excel at generating revenue and creating quality-assessment monopolies.
Critics also express concerns that UM standards do not go far enough in holding health plans and other organizations accountable in today’s value-based purchasing environment. Going forward, the challenge is to transition from “process” and “structure” metrics to a more outcomes-based approach to assessing quality, clinical efficacy, and financial performance. The move toward a value-based purchasing approach provides a dynamic to assess the return on investment (ROI) associated with UM programs, in addition to creating incentives to advance more cutting-edge care management and population health programs.
[i] Alkhenizan, Abdullah, & Shaw, Charles. (2011). Impact of Accreditation on the Quality of Healthcare Services: a Systematic Review of the Literature. Annals of Saudi Medicine, v.31(4). [Abstract]. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156520/
[iii] NCSL. (2011). Accreditation to Approve Health Plans and Providers. Retrieved fromhttp://www.ncsl.org/documents/health/HRHealthPlans.pdf