NASW Comments on NCQA's draft Accreditation '99

Phyllis Torda
Vice-President of Policy and Products Development
National Committee for Quality Assurance
2000 L Street, Suite 500
Washington, DC 20036

Dear Ms. Torda,

The National Association of Social Workers, representing over 155,000 social workers in the U.S. and abroad, would like thank you for the opportunity to comment on the draft Accreditation ’99: Standards for Managed Care Organizations. Since social workers practice in many different settings--including health, mental health, substance abuse, schools and child welfare--we are involved in many different practice settings affected by managed care systems. As members of the Health Care Practitioner Advisory Committee, we have gained a better understanding of the context of NCQA products. There is much to applaud in the proposed revisions although we do have suggestions that we think would create further improvements. The rating scale is attached.

The draft Accreditation ’99 includes new areas that NASW is pleased to notice:

• Development of information systems standards is extremely critical for the protection and appropriate utilization of clinical and administrative data in integrated managed care systems.
• New ER standards tie payment to "prudent laymen" judgment. Clearly, this has been an issue in managed care organizational (MCO) practices, as now the majority of states have passed state regulations requiring this criterion. Likewise, the new drug formularies standard is raising attention to an area where managed care organizations have suffered criticism. Hopefully, the greater decision processing and communication requirements will help assure that patients get the best prescription of drugs for their condition--regardless of cost.
• Continuity of care revision lift up the need to integrate behavioral health care with primary care. NASW believes strongly that integrating primary and behavioral health care is one of the greatest challenges to managed care systems. Indeed, we would urge even greater emphasis of this standard, both in process and outcome measures, to help answer such important questions as whether to "carve out" or "carve in" behavioral health in administrative and/or clinical arrangements.

Further, NASW suggest the following improvements to the revisions:

• NASW supports the movement of NCQA to greater use of outcome measures by including HEDIS standards in MCO accreditation. Nonetheless, we would like to see greater inclusion of mental health and some inclusion of substance abuse as outcome measures. As you know, studies demonstrate that depression and substance abuse are very common and can have serious consequences in health status, yet continue to be neglected by primary care practitioners.
• In UM 6, NASW applauds greater delineation of the need to give the provider clear reasons for denials. But we would suggest in UM 6.1, the second use of "physicians" be replaced with practitioner, so that behavioral health care providers who are not physicians but are the primary clinicians have the same access to discuss the utilization management decisions as do physicians.
• In UM 3, it states that "appropriate licensed professionals supervise all the review decisions". This would seem allow peer review of cases, as NASW supports, so that in behavioral health licensed social worker would make the UM decision in cases where social workers provide the care. Yet UM 3.2 places the physician as the ultimate authority in all cases of medical appropriateness. Assuming this includes medical necessity decisions of treatment appropriateness, this excludes non-physicians from all treatment necessity decisions. NASW would prefer peer review as the best mechanism of practice review.
• NASW has received complaints from members that managed care companies request full record submission without the ability of the practitioner to expunge identifying information. We have been told this happens when the company is preparing for an NCQA review, even though the identifying information is expunged for the actual NCQA review. So it would be helpful in RR 7, on member confidentiality, if RR 7.5 include practitioners and that MCOs allow practitioners to expunge identifying information in full chart review.
• The development of a patient satisfaction instrument may greatly help the field develop a standardized measure in this very diverse measure. Under Item #8, it would be helpful to have a question that would explore what was the source of the problem in getting a referral to a specialist. This would be helpful information to begin to fix the problems integrating specialty care with primary care.

Again, NASW appreciates the opportunity to comment. If you have questions, please contact me at 202/336-8218.

Sincerely,

Rita Vandivort, ACSW
Senior Staff Associate and Member, NCQA Health Care Practitioner Advisory Committee

For more information, contact Rita Vandivort at rvandivo@naswdc.org or call 800-638-8799, ext 218