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NAMI Submits Comments To NCQA On Accreditation Standards For Managed Care

Chris Marshall
For Immediate Release
30 Apr 99

NAMI submitted comments today to the NCQA (National Committee for Quality Assurance), which provides accreditation and performance measurement of health plans through a voluntary and market-based approach, on NCQA’s proposed accreditation standards for the year 2000. NAMI has been concerned that NCQA currently has stricter, more detailed accreditation standards for free standing MHBOs (Managed Behavioral Healthcare Organizations) and less meaningful standards for MCOs (Managed Care Organizations), which internally manage behavioral healthcare standards. The full text of the comments are below.

Although NAMI does not believe that NCQA, the foremost accrediting body for managed care, has sufficiently focused on the needs of people with serious brain disorders, it does provide an important measure of a health plan’s commitment to quality and minimum appropriateness. NAMI continues to advocate, both federally and on a state level, strong regulatory approaches to guarantee that necessary treatment is immediately delivered by all health plans in the nation, including the enactment of a Patient’s Bill of Rights (see NAMI E-News Vol. 99-107).

April 30, 1999

Shane Atkinson
Policy Department
National Committee for Quality Assurance
2000 L Street, NW, Suite 500
Washington, DC 20036

Dear Ms. Atkinson:

NAMI – the National Alliance for the Mentally Ill – a grassroots organization with 208,000 members who are predominantly family and consumer members, wishes to provide comments on "Accreditation 2000 – Draft Standards for Managed Care Organizations and Managed Behavioral Healthcare Organizations."

NAMI is also submitting comments as part of the Mental Health Liaison Group. NAMI helped to draft the MHLG comments and fully supports them. However, there were additional areas where the larger coalition of professional societies, providers, administrators, and advocates could not agree. This letter contains some of the comments contained in the MHLG letter as well as comments unique to family and consumers – the health plan enrollees.

Our comments follow:

MCO and MBHO Alignment

The standards still contain some areas where MBHOs must meet higher standards than MCOs. NAMI advocates that all organizations claiming to manage behavioral healthcare benefits, regardless of organizational sponsorship and structure, meet the same national standards.

Specifically, in 2000, MCOs and MBHOs should meet the same standards. This is currently not the proposed situation for behavioral health within QI and UM programs and evalutions (QI1, QI 10, UM 1), meaningful improvement demonstrated in behavioral health (QIAs, QI 7-10), member satisfaction and complaints related to behavioral health (QI4), clinical guidelines and preventive services for behavioral health (QI5), accessibility of behavioral health network (AR2), written criteria for behavioral health decision-making (UM5), and over-utilization and under-utilization of behavioral health (UM11).

6 New Areas of Significant Standards

NAMI commends NCQA for requiring the use of external entities for independent and binding decisions about clinical appeals, for requiring the same or similar specialist review of appeals, for requiring health plans to allow a 90 day continuity of care access to a discontinued practitioner, for revising the confidentiality and drug formulary standards, and for publishing within the standards themselves the surveyor guidelines. All of these are significant improvements over previous standards.

UM 10 Drug Formulary Use

The proposed standards would require formularies to be based on "sound clinical evidence" and be updated at least annually. This requirement must be expanded so that formularies "recognize the most recent advances in the treatment of illness through new medications as announced by the National Institutes of Health and other leading research entities." As an example, on February 12, 1998 the Health Care Financing Administration sent to all state Medicaid directors a National Institute of Mental Health letter announcing the evidence-base for using the newer atypical antipsychotics.

The proposed standards would provide consultation with and information to practitioners. This is good. However, nowhere are enrollees mentioned. Add: "Health plan enrollees must have access to all formulary information and summaries of formularies in a form easily understood by the enrollee."

QI 6.2.3 Evaluating The Use of Psychopharmacological Medications

NAMI supports MCO involvement in MBHO psychopharmacological evaluations so long as MBHOs are equally involved in MCO psychopharmacological evaluations.

UM 12 Referral and Triage for Behavioral Health Care
UM 4.1 Timelines for UM Decision Making

We are pleased to see that "an emergency is an immediate and serious condition that threatens an individual’s life or limb. For example, a patient who presents with threats of suicidal or homicidal behavior would be assessed as an emergency…" (UM 4.1, page 179) In the actual timelines standards for "urgent" and "nonurgent" care, this rationale statement for emergency does not apply. It should be contained in the standards themselves.

UM 4 should explicitly recognize that some managed care plans, such as some Medicaid plans, do not require precertification. Therefore, the initial certification actually is concurrent.

Further, in UM 12 – Referral and Triage for Behavioral Health Care – a standard must be included: "Suicide attempts and the possibility of suicides are always treated as medical emergencies and are immediately referred to facilities specializing in the treatment of medical emergencies and suicides." Crisis bed programs would meet the intent of this proposed standard.

UM 12’s requirement for level of care and appropriateness of setting decisions be based on protocols is helpful. Further, these protocols must be publicly available including being immediately available to health plan enrollees.

UM 12 Referral and Triage for Behavioral Health Care
UM 3.2 Practitioner Review of Denials

NAMI endorses the high threshold proposed by NCQA for those authorized to approve and deny care. There are over 600,000 mental health professionals within the United States. Clearly the existence of a qualified mental health professional as recognized by state law and practice is not an adequate professional standard for whom may authorize and deny payment for services.

Thus, NAMI endorses proposed standards UM 12.6.1 and UM 12.6.2: namely, that inpatient referral and triage decisions are overseen by a board-certified psychiatrist with appropriate qualified experience and that outpatient referral and triage decisions be made by either a psychiatrist or a doctoral level clinical psychologist. We would expand this requirement to UM 12.5 – only doctoral level practitioners should be authorized to supervise clinical referral and triage staff.

We further endorse proposed UM 3.2 that "denials for behavioral health care should contain documentation that an appropriate behavioral health practitioner (i.e., psychiatrist, doctoral level clinical psychologist, or certified addiction medicine specialist) has reviewed all denial decisions on the basis of clinical appropriateness." All such clinical appropriateness criteria must be available to the public, particularly immediately available to health plan enrollees.

RR3 Procedures for Complaints and Appeals

We strongly endorse the use of independent, third party, and binding clinical appeals entities. We suggest two additions:

1. If a state has established such third party independent entities, NCQA accredited entities must comply with these state law entities.

2. If there are two or more NCQA accredited entities within a state, enrollees should have the choice of entity.

Further, we ask that NCQA place in the standards themselves the actual criteria to be used by NCQA for accrediting independent third party clinical review entities.

NAMI strongly endorses the NCQA proposed standard that the health plan enrollee incur no cost in seeking appeals, including appeals to third party independent entities. Cost must not be a barrier to accessing appropriate and necessary care, including accessing services through appeal.

Denials Must Be Part of NCQA’s Accreditation Survey and Assessment

NAMI is totally opposed to NCQA’s decisions that "in evaluating UM2 NCQA will not, in 2000, include a review of cases to determine applicability of UM criteria" (page 3) and "NCQA surveyers will evaluate procedures but will not include drug denials in the sample of UM denials for 2000" (page 53). Review of health plan denials is an appropriate role of an accrediting organization seeking to determine the quality of utilization management and formulary access. We strongly encourage NCQA to reverse these decisions.

Examples of Acceptable Methods For Assessing Provider Performance

NAMI concurs with the MHLG comments related to the examples cited on page 16 that in conducting site-visits to assess provider performance, audits should be conducted on "blinded records." NAMI endorses strict provider accountability based on clinical and patient rights performance. However, concerns for privacy and confidentiality should allow the use of blinded record review for quality assurance purposes.

We thank NCQA for the opportunity to comment and hope that NCQA will make revisions in the best interest of health plan enrollees.


E. Clarke Ross, D.P.A.
Deputy Executive Director for Public Policy