Managed Care Quality Agency NQCA Expands into Key Areas Around Population Health

Jan. 1, 2019
Last month, NCQA, which has been measuring and validating health plan quality for nearly three decades, announced the creation of two programs around population health, and pop health IT capabilities

Last month, the Washington, D.C.-based NCQA (National Committee for Quality Assurance), which since 1990 has been the main organization tasked with measuring and validating the quality of care management delivered by U.S.-based managed health plans, announced that it was expanding its mission, by launching two new programs. In a December 10 press release, the organization stated that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.” Both programs, particularly the Population Health Management Prevalidation program, could have a meaningful impact on how provider-based organizations move forward around population health management efforts, particularly on how they leverage data and information technology to facilitate population health management initiatives.

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” Margaret E. O’Kane, NCQA’s president, said in the December 10 press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs.” The program will evaluate organizations around the following areas of competency: data integration; population assessment; population segmentation; targeted interventions; practitioner support; and measurement and quality improvement. Accreditation in that area is intended to “improve person-centered care,” and to help the leaders of organizations providing population health management capabilities to “improve individualized, person-centered care.”

Meanwhile, as the press release noted, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. That program evaluates the solutions that organizations use, in up to four areas: data integration, population assessment, segmentation, and case management systems.”

The press release indicates that “Organizations using health IT solutions that meet NCQA requirements can earn automatic credit toward their NCQA surveys, saving time and easing the administrative burden of providing supporting documentation.” They can also “gain a competitive edge” be advertising “direct alignment of health IT functionality with NCQA requirements”; “access industry resources,” as they “enjoy an ongoing collaborative relationship with NCQA and learn frontline details about planned policy changes and enhancements to program requirements”; and “receive marketing support,” since “NCQA lists prevalidated vendors on its website.”

Shortly after NCQA made the announcement of the two new programs, two of its leaders spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the implications of the program for organizations providing care management and population health management, in their managed care contracting. Raena Akin-Deko is NCQA’s assistant vice president for product strategy and development, and Natalie Mueller is the organization’s manager of product development. Below are excerpts from that interview.

What was the strategic origin of NCQA’s decision to expand into this area?

Raena Akin-Deko: This is the way that providers and plans are beginning to organize around treating conditions in a value-based environment. In the past, health plans and providers created and operated disease management programs. There have been some questions about whether that type of management was really effective; what emerged from that is the thought that we needed to think about how to treat the whole person. And as we move into value-based care delivery and management, the question is, how do we understand a population and address the needs of plan members and patients, in an evidence-based way? So this set of programs has emerged out of our efforts to help facilitate how the leaders of organizations think about how to do population health in a holistic way, and in a way that’s evidence-based. We want to make sure that organizations work using the best methods.

Can you share a bit about the mechanics of how the programs have been developed?

NCQA is a consensus-driven organization. The Committee is very strong. We have internal experts who do baseline research into frameworks that are evidence-based. What we do is that we move forward and look at frameworks to determine what the important areas of function are around those frameworks. And the committee agreed, and voted on the requirements for PHM. David Nash of Jefferson Health, sat on our committee, for example, and was one of the folks who identified the important functions and voted on them. So it’s really a matter of bringing what’s evidence-based, in front of a committee, and to have the members of that committee determine what standards should be set.

Can you explain a bit about the two different programs, and how they work?

The accreditation program is really aimed at organizations that are performing population health management services—a health plan, a provider with specific programs targeted at an audience. So, health plans, physician groups, clinically integrated networks, ACOs. The prevalidation program focuses on a smaller set of requirements aimed at those helper organizations. In doing the research, we recognized that many organizations are getting support from HIT organizations. The requirements in the prevalidation reflect those that are most common. Segmenting, that’s something that’s really common. So it’s an opportunity to take a look at the systems involved.

Is it the IT department’s work that will be prevalidated? Or the vendor’s?

If an organization is using a homegrown  system, yes; but in most cases, it will be the IT vendor whose solution will be validated. Data integration, risk stratification or segmentation, assessment tools, and case management systems, will all be evaluated. So vendors with specific platforms or tools, would be prevalidated. They could be homegrown or third-party vendors.

Natalie Mueller: Organizations that could be prevalidated are analytics vendors, such as Medecision, Z Omega, and Alta Vista Health.

Will this function in any way similar to how vendor solutions were accredited under the meaningful use program, for providers?

This is a little bit different from those certifying bodies. Currently, we are looking at it for whether or not they meet the requirements for the PHP organizations. For instance, we require that a PHP organization, the CIN, be able to produce certain reports about their certification. So we’d be checking to see whether that particular software is capable of producing reports that do the segmenting.

How many organizations might be the universe that could be certified for the two different programs?

That’s an interesting number, because it includes not just organizations that traditionally do PHM or DM, but also provider-based organizations using the services. And when we looked at the number of HIT entities, it was around 200 that I had identified, Natalie says. I’m sure there are more.

What might be the universe of accreditation?

Akin-Deko: That’s a harder number to count, but in terms of just ACOs [accountable care organizations, they’re of a magnitude of at least 1,000-plus.

What do you hope will ultimately happen, as these two programs evolve forward?

Because we have both health plans and provider organizations in mind as we were developing this, within our HP accreditation product, we include population health management requirements, so health plans are required to meet very similar requirements. So part of what we wanted to do was to align expectations; we saw that moving into VB care, some plans were delegating activities to providers, so a framework for how they might approach this and be aligned, was needed. We want them to be playing from the same playbook.

Do you see things moving forward quickly overall, in the shift into value-based care delivery and care management models?

I see a lot of experimentation, with the ACO model, population health efforts, etc.; we see a lot of experimentation. And we’re still trying to figure out how to make VBC work, and how to have a positive impact. There are a lot of good models being tested. I think we’ll be in an environment where there’s going to be lots of experimentation for a long time.

What is the effective date for organizations to apply to both of these?

Mueller: They can apply now, they can submit a query, and someone from NCQA will reach out to them to begin the application process.