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NCQA sets managed care standards


Pharmaceutical Representative

One standard against which many providers are measuring their performance is the National Committee for Quality Assurance.

As some industry experts have stated, health care providers can't just be good anymore; they have to be able to prove that they're good. One standard against which many providers are measuring their performance is the National Committee for Quality Assurance.

The NCQA was created in 1979 as a non-profit, private organization by two trade associations: the Group Health Association of America and the Managed Care Review Association. The associations recognized that the collection, standardization and analyses of data could help managed care organizations provide quality health care.

The NCQA's purpose, according to its mission statement, is to provide information to purchasers and consumers of managed care so that they can judge plans based on quality and value rather than price and provider network. In order to do so, NCQA offers accreditation and performance measurement programs.

Although NCQA accreditation and performance measurement are voluntary, many large employers, when making their health care purchasing choices, are demanding that managed care organizations present NCQA information.

Meeting NCQA standards, therefore, is growing more important as competition among managed care organizations heats up.

As of December 1997, the NCQA had reviewed 285 of 630 managed care plans. According to NCQA data, more than 75% of all Americans covered by health maintenance organizations are in HMOs that have been reviewed by the NCQA.


What does NCQA accreditation mean? In order for an organization to achieve accreditation, it must undergo a survey that evaluates its quality of care and service. It must also meet established standards of clinical and administrative systems.

The standards against which the plans are measured are lumped into six main categories: quality improvement, physician credentials, members' rights and responsibilities, preventive health services, utilization management and medical records.

Quality improvement accounts for 40% of a plan's score. It evaluates how well the plan coordinates its delivery system, how the plan examines its quality of care, what steps it takes to ensure that members have access to care in a reasonable amount of time and what improvements in care and service the plan can demonstrate.

Physician credentials, which make up 20% of the plan's score, look at how the plan investigates the training and experience of the physicians in its network, how it researches history of malpractice or fraud and whether or not the plan keeps track of and periodically evaluates physician performance.

Members rights and responsibilities, worth 10%, examines how the plan communicates to members about health services, how to choose a physician and how to make a complaint. It also measures how responsive the plan is to members' complaints.

Utilization management, worth 10%, evaluates whether the plan uses a reasonable and consistent process when deciding what health services are appropriate for individuals' needs. It also considers a plan's claims denial process and how a plan protects itself against under-utilization.

Medical records, worth 5% of the plan's score, includes how consistently medical records are kept by the plans' physicians and whether or not they meet NCQA standards.

The surveys are conducted by a team of physicians and managed care experts.

A national oversight committee of physicians analyzes the survey's results and assigns one of four possible accreditation levels: full, one-year, provisional or denial.

Performance Measurement

The NCQA measures performance of managed care organizations with the Health Plan Employer Data and Information Set,® also known as HEDIS. The principal performance measurement tool for managed care, HEDIS is a set of 71 performance measures used to evaluate and compare health plans based on actual achievement.

The NCQA has released three versions of HEDIS since the committees' inception. A version specifically geared toward evaluating plans that serve populations dense with Medicaid patients was also released in 1996.

The next update to HEDIS is scheduled for release in 1998.

With each revision of HEDIS, the NCQA presents more specific expectations and requirements, according to Jack Fincham, dean of the school of pharmacy at the University of Kansas. "Whether you're a hospital or health care provider, HEDIS is a guiding document of performance measures and methodology."

And with the increasing importance that the industry is placing on outcomes measurement, future HEDIS results may have a heavier impact on enrollment and profitability for managed care plans than they do already.

"The whole emphasis on therapies and outcomes is crucial right now to all of us in the health care industry - payers, providers or purchasers," Fincham said. "We used to look at the point of care as the end of the process, but that has changed. Now you're looking at assessing the worth of that care well past the point of care."

Raising the bar

Some health care payers and consumers receive HEDIS data in the form of health plan "report cards." The data creates at least the perception that the plans will be held accountable for their quality of service. Their value will be questioned and compared.

Consequently, health care providers and plan administrators need assistance in meeting and maintaining NCQA standards. The challenge for pharmaceutical companies and pharmaceutical sales representatives is to learn how to provide that assistance. PR

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