Ensuring Quality Health Care

Licensure, Accreditation, & Systems Standards

This session examined State governments' efforts to ensure quality in health care through their licensure activities. Specifically, discussed were State licensure requirements for managed care organizations, including a description of what is involved in the licensure of these entities, and an explanation of upon what aspects of health care quality these requirements focused.

Following a discussion of the strengths and weaknesses of States' approaches to the licensing of managed care organizations—which are often based on frameworks that are 10 to 20 years old and no longer reflect today's marketplace—options for developing more appropriate regulation of new care models were described. These options included:

• The expansion of current health maintenance organization (HMO) regulations.
• The creation of new licensure categories.
• A more sweeping overhaul of a State's health insurance/managed care regulatory structure.

In this context, model regulations and statutes being developed by the National Association of Insurance Commissioners (NAIC), and the issues associated with linking public licensure and private accreditation efforts, were also discussed.

References

A Report to the Governor on State Regulation of Health Maintenance Organizations, Aspen Systems Corporation, 1993.

Berger, D. Playing the Accreditation Game: Strategies for Networks. Health Care Innovations, March/April 1996, 828.

Health Care Professional Credentialing Verification Model Act, NAIC 1996, 70-1 70-6.

Quality Assessment and Improvement Model Act, NAIC 1996, 71-1 71-8.

States' Roles in Monitoring Quality is Evolving, NCQA, Winter 1995-96, Vol. II, No. 3.

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