qotd: NCQA at 25 years: Lessons for us

Kaiser Health News
January 8, 2016
Health Plan Watchdog Still Seeks Progress After 25 Years
By Phil Galewitz

The nation's oldest private arbiter of what defines high-quality health
plans turned 25 last year. The National Committee for Quality Assurance
(NCQA) started soon after HMOs became popular in the 1980s, measuring
the effectiveness of the first managed care plans as millions of
consumers flocked to join them.

Today, NCQA accredits health plans in every state, covering 109 million
Americans or about 70 percent of all Americans enrolled in private coverage.

Founding and current president Margaret "Peggy" O'Kane discussed her
organization's past and future recently with KHN's Phil Galewitz.

Phil Galewitz: What do you see as NCQA's biggest achievement after 25
years?

Margaret O'Kane: Just getting the measurements out there in a
systematic way. We are now finally at a stage where the delivery system
is getting it and trying to reorganize itself with primary care medical
homes and accountable care organizations.

Galewitz: Is the United States doing a better job for consumers in
measuring health plans' quality of care?

O'Kane: Maybe the glass is half full on measurement, or less than that.
I think our strategy was to always walk behind the evidence. We have
good measures where there is good evidence on preventive services and
chronic diseases like hypertension and diabetes. What we are missing is
often in areas where the science is unclear. These also tend to be
high-stakes areas of care, like cancer or other complex illnesses.

Galewitz: Are health plans receptive to being evaluated by NCQA?

O'Kane: It's less than voluntary, I would say. It's in the health law
for exchange plans (to be accredited by NCQA or another accrediting
group) and has been driven by employers traditionally. Some plans really
question whether it matters what (their) quality is. You see narrow
networks emerging and if they are chosen just based on price, that isn't
going to go well among consumers.

Galewitz: How much has NCQA's work improved the quality of health care
that Americans receive?

O'Kane: In the areas we have measured, you can point to real
improvements. My main gripe now is what I see as contradictory
strategies of high deductibles versus a delivery system reform promoting
primary care. If you have to spend out of your own pocket $2,000 or
$5,000 before you get to see your primary care physician (for free),
many Americans don't have that money. We are reforming the delivery
system and then people can't afford to see their primary care doctor.
That makes no sense.

http://khn.org/news/a-health-care-watchdog-for-consumers-turns-25/

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Comment by Don McCanne

As our health care system is being refined to supposedly replace
quantity with quality in the delivery of health care services, we should
learn from the experience of the National Committee for Quality
Assurance (NCQA) - one of the more credible and experienced
organizations attempting to improve quality in health care. Their
founder and president, Margaret "Peggy" O'Kane, has a few lessons for us.

How are we doing on quality measurements? The glass is "half full… or
less." We are not doing well on "high-stakes areas of care, like cancer
or other complex illnesses." How can you ignore the quantity of care
that is required for these complex cases and pretend that you are going
to make payments based instead on quality that you can't measure?

And the reception by the exchange health plans of the ACA requirement
that they be accredited for quality? O'Kane says that the involvement of
the plans is "less than voluntary." She says, "Some plans really
question whether it matters what (their) quality is." Wow! Plans are
setting up narrow networks that are based on price (while ignoring
quality - DMc).

Her most important message: "My main gripe now is what I see as
contradictory strategies of high deductibles versus a delivery system
reform promoting primary care. If you have to spend out of your own
pocket $2,000 or $5,000 before you get to see your primary care
physician (for free), many Americans don't have that money. We are
reforming the delivery system and then people can't afford to see their
primary care doctor. That makes no sense."

As the policy and political communities divert their efforts to
structural reforms that have not been demonstrated to have more than a
negligible impact on quality, the private insurance industry has moved
forward with changes that are making health care unaffordable and
inaccessible for far too many Americans. When what we need is a strong
primary care infrastructure, our health care leaders are allowing the
insurers to erect intolerable financial barriers to care. As O'Kane
says, "That makes no sense."

It's great that we have dedicated organizations such as NCQA and AHRQ to
help ferret out and correct quality problems. But we cannot let that
distract us from what we really need to do: enact a well designed single
payer national health program that will bring us the structural reforms
that we desperately need, so all of us can have affordable, accessible,
high quality health care.