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tatives indicated that there was a need for standards for utilization review and an independent accreditation organization. URAC currently accredits the utilization and quality management systems of 150 managed care programs that provide services for more than 120 million individuals. URAC also works closely with state regulators to address managed care regulatory issues, and nine states deem URAC accreditation in lieu of licensure. URAC has implemented a Network Accreditation Program and will be implementing a Workers' Compensation Utilization Management Accreditation program.

Changing Environment of Accreditation

There has been a proliferation and growth of accreditation organizations to match the structural changes in the industry. As described above, new accreditation organizations form to review any structure devised in managed care. Some organizations are unique, whereas others overlap in their accreditation domains but have a slightly different focus. For example, JCAHO and NCQA both accredit HMOs. JCAHO's accreditation process focuses on a staff model delivery system, whereas NCQA's process is focused on the HMO structure. Also, NCQA standards tend to focus at the highest level of an organization, whereas JCAHO, CARF, and COA are geared more toward particular programs or facilities that may be a division of a larger organization or may be free-standing or independent.

Currently, major purchasers of care may require accreditation for a health care delivery system to be eligible for contracts. In addition, many state insurance boards and employer groups have mandated that HMOs have NCQA or URAC accreditation to operate in their state or to be offered to employees, respectively. However, because of the complexities of health care structures, mandatory accreditation can impose a tremendous burden. Accreditation requirements often overlap in national managed care companies or health care delivery systems that perform multiple functions (e.g., a staff model HMO that is also a provider network). Many times, organizations must obtain more than one type of accreditation to satisfy employers, states, and other stakeholders. A behavioral health care carve-out company, for example, may operate in a state that requires URAC accreditation, whereas a multi-state employer group operating within that state may require NCQA accreditation.

The costs of achieving accreditation are also burdensome. The actual cost of the accreditation survey is only part of the burden. The personnel costs and time involved in preparing for accreditation also can also be extensive, and may be prohibitive for smaller organizations. For community-based organizations, the cost of COA accreditation is done on a sliding scale, with a graduated scale based on total agency revenue (COA, 1996a, b).

Cost certainly makes accreditation prohibitive for many small organizations; it also makes the issue of multiple accreditations unrealistic, despite the demands of states and employer groups. Thus, questions are raised about the utility and



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