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A Comparison of the Audit and Accreditation Tools Used By The Health Care Financing Administration, The Texas Department of Insurance, and The National Committee on Quality Assurance: The Cost of Multi-Agency Oversight on Medicare+Choice Plans in Texas
Final rept. Jul 2000-Jul 2001
ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TX HEALTH CARE ADMINISTRATION
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On 1 January 2001, approximately 711,000 Medicare patients lost their MedicareChoice MC health maintenance organization HMO provider. The costly MC regulatory environment is one reason cited by health plans for their mass exodus from the program. In response, 37 states have passed laws accepting industry-based accreditation as satisfying all or part of state oversight requirements. Texas, however, has not passed such legislation and prepares to increase state oversight on HMO operations. This content analysis study examined the current oversight models used by federal and state government regulators and compared these auditing tools to an industry-based accreditation survey. Results suggest that significant differences do exist among the current models alpha .05 regarding the emphasis they place on the four oversight topics of finance, beneficiary protection and information, quality assessment and improvement, and plan management. By developing a MC supplement to its current accreditation survey process, the NCQA could eliminate the differences in the models. This initiative would result in lower costs for both regulators and health plans. By law, the health plans would be required to pass along approximately 400,000 dollars in additional benefits to over 361,000 Texans participating in the MC program.
APPROVED FOR PUBLIC RELEASE