Quality in Nursing Center Care

A blog for and about The Joint Commission’s Nursing Care Center Accreditation Program.

The Evolving Relationship Between Health Care Payors and Accreditors

07/23/2020

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By Kimberly Clawson, MSHA, senior associate director, Payor Relations

The Joint Commission recently presented health care insurance plans with new ways to use  accreditation and certification, including:

  • Centers of Excellence (CoEs)
  • value-based incentive and credentialing programs
  • on-site evaluations

Our goal is to help enhance quality and safety for health plan members and reduce the insurer’s administrative burden. 

Centers of Excellence    
CoEs, or a limited group of providers that achieve improved outcomes, are increasingly popular with major health care insurance plans and are making their way to other health care insurers, state Medicaid plans and employer groups. 

To attain this designation, providers are selected to participate in a narrower referral network. Depending upon the individual CoE program’s process, providers are either invited to participate in a CoE or may voluntarily elect to join. In either instance, the provider is only recognized or designated as a CoE participant if its organization meets specific criteria above and beyond standard credentialing. Requirements often include demonstrating higher levels of performance, cost savings or organizational efficiency. 

Recently, several major health care insurance plans recognized Joint Commission certification within their CoE programs for hip and knee replacement:

  • Blue Cross Blue Shield Association’s (BCBSA) Blue Distinction Centers for Specialty Care
    Under the Blue Distinction Centers for Knee and Hip Replacement program, hospitals and ambulatory surgery centers (ASCs) performing total knee and total hip replacement procedures must be accredited by one of several national accreditation organizations (which include The Joint Commission) identified in the program’s selection criteria. In 2019, BCBSA refreshed the program so that ASCs doing total knee and total hip replacements must also possess an advanced orthopaedic certification. Joint Commission accreditation and Joint Commission Advanced Total Hip and Knee Replacement Certification (THKR) is one of several advanced orthopaedic certification programs recognized within the Blue Distinction program selection criteria.
  • Aetna’s Institutes of Quality (IOQ)
    Aetna’s IOQ is a network of high-performing health care organizations that offer specialized care. Aetna’s IOQ for orthopedic care requires Joint Commission Advanced THKR Certification as a mandatory requirement for both hospitals and ASCs. The Advanced THKR Certification requirement was launched in 2019.

The Joint Commission’s collaboration with American Academy of Orthopaedic Surgeons (AAOS) and the American Joint Replacement Registry (AJRR) – the nation’s largest orthopaedic registry – establishes its Advanced THKR Certification as the highest certification available. All providers that achieve Advanced THKR Certification must also participate in the AJRR. This participation allows providers to benchmark their outcomes against others and offers comprehensive data to health care insurance plans on both clinical and patient-reported outcomes. 

Humana’s and State Medicaid’s Value-Based Incentive Programs (VBIPs)
VBIPs offer health care providers incentive payments for achieving a higher quality of care while reaching specific performance measures or achievements. VBIPs are designed for health care insurance plans to create strong provider incentives for overall performance improvement. 

The Joint Commission is recognized within several VBIPs, including Humana’s Hospital Incentive Program (HIP). Humana’s HIP aims to:

  •  better integrate care
  • reduce duplicative services
  • reduce hospital readmissions
  • reduce complication rates in acute care inpatient admissions.

The program provides provider compensation based on quality improvement and performance. Humana’s HIP metrics recognize two certification programs developed by The Joint Commission: Integrated Care Coordination (ICC) and Hospital-Based Palliative Care Coordination. 

State Medicaid authorities also are experimenting with VBIP to reward organizations for providing high-quality care. In Florida, a new prospective payment system for nursing homes was introduced in 2016 and included a quality incentive payment to providers that scored points on a quality matrix or scorecard.

Measures include:

  • staffing
  • overall five-star rating performance on the Centers for Medicare & Medicaid Services (CMS) quality measures as well as specified awards
  • designations such as Joint Commission Nursing Care Center accreditation

Credentialing and On-site Evaluations
Health care insurance plans often seek to comply with accreditation requirements by performing an on-site assessment. Many health care insurance plans also accept a proxy for on-site evaluation and The Joint Commission accreditation is often accepted. The Joint Commission performs on-site performance assessments of health care organizations at select intervals, typically every two to three years, depending on the accreditation or certification program of the health care organization. On-site survey processes are data-driven, focused on patient safety and quality, and evaluate actual care processes and technology. 

Health care insurance plans that utilize Joint Commission accreditation as a validation survey free up resources to direct to other areas of plan administration. 
For more information, please contactvia email.

Kimberly Clawson, MSHA, is senior associate director, Payor Relations. Prior to this role, she worked as the associate director of business development for the Joint Commission’s Nursing Care Center Accreditation Program where she was instrumental in garnering recognition for The Joint Commission in state Medicaid, value-based programs. Prior to joining The Joint Commission, Ms. Clawson worked on the provider side where she developed strategic business units and services lines including an insurance network of post-acute providers. She served on the faculty of several universities in the Chicagoland area, teaching courses in health care marketing and administration.