National Committee for Quality Assurance unveils connectivity standards for health plans

The quality standards are in four areas covering insurers' use of technology to better serve their members.

By Tyler Chin — Posted Sept. 6, 2004

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The National Committee for Quality Assurance has drafted standards to measure the level of electronic connectivity between health plans and their members.

The proposed standards, which were released for public comment in August, will assess how insurers use technology tools to deliver information and services to their members in four areas, said Margaret E. O'Kane, president of NCQA, a Washington, D.C., nonprofit organization that accredits health plans. Those areas are:

  • Support and information. This category will examine whether health plan members can electronically access services and information, including being able to change physicians, order enrollment cards, look up the cost of a given procedure or therapy, and provide feedback.
  • Claims. NCQA will be looking at whether plans enable members to submit and track claims electronically and if claims are processed accurately and in a timely manner.
  • Pharmacy benefits. NCQA will look at whether members can access information about their pharmacy benefits; medication costs; information about drug-to-drug interaction and generic substitutions; and order refills online.
  • Self-management. This category examines if plans offer interactive tools and evidence-based information that members can use to help them stop smoking, lose weight or otherwise improve their health status.

NCQA could not quantify how many plans are offering interactive tools to communicate with their members and vice versa. Still, more and more health plans are starting to move in that direction, particularly as they increasingly offer consumer-directed products requiring their members to pay higher costs out of pocket and keep better track of their co-pays and deductibles, O'Kane said.

Although the voluntary standards don't directly affect physicians, doctors nonetheless stand to benefit from them by making the prescription process more efficient, she said.

"I think this could be very helpful to physicians if [patients] know what's covered and what's paid out of pocket," she said. "That's a constant irritation when physicians write a prescription that's not on the formulary, and there's always a little fracas at the pharmacy."

The standards also can potentially help streamline patient-physician encounters, added Barry Scholl, a NCQA spokesman. "Knowing that the health plan will only be promulgating evidence-based information for members probably is sort of helpful to physicians too who ... are frustrated when members or patients come in with all kinds of wacky stuff they find on the Internet."

The standards are scheduled to be finalized and rolled out in March 2005. At that time, NCQA also will release two other sets of standards of interest to physicians. One set looks at plans' physician and hospital incentives, and how they measure and report on the performance of network physicians and hospitals. The other set measures plans' management of chronic conditions and health assessment strategies for their members.

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