Kristine Thurston Toppe is vice president of state affairs at the National Committee for Quality Assurance (NCQA), a leading healthcare accreditation organization. She recently spoke with Healthcare Innovation about her team’s work with health plans and state Medicaid agencies to use accreditations from NCQA to help address health equity issues.
Healthcare Innovation: Could you just talk a little bit about your role there at NCQA? What types of things do you and your team engage with states on?
Toppe: Our team is really the conduit for NCQA out to the states for all issues related to what we do as an accreditor and as a measure developer and also as a thought leader in the healthcare quality space. My team is responsible for messaging out to states as well as being that lane back into NCQA for the priorities that states have related to what we do to drive quality.
HCI: Does a lot of that have to do with Medicaid programs?
Toppe: Medicaid is probably the major influencer in terms of the one that is most focused typically on quality. They tend to be a major stakeholder for us. And because of how they can execute that through contract requirements, it becomes a natural intersection for us, but it's not the only stakeholder we engage. We also work with state [insurance] exchanges. We have engagement with public employee benefit programs as well.
HCI: Are more state governments putting requirements on Medicaid managed care organizations related to health equity? Is that part of the need for health equity accreditation on the plans’ part?
Toppe: Over the last several years, not surprisingly, given the pandemic and the awareness of inequities and the disparities that come about as a result of those inequities, there's been an increased prioritization of how to address equity. NCQA accreditation is really a roadmap for organizations to address that. States look at that as a tool in the toolbox, if you will. The majority of state Medicaid programs actually require our health plan accreditation, so there's a lot of familiarity with us, the rigor of our process, all of that. That has given states a comfort level with who we are, what we do, and our prioritization of health equity through this program, and the application of health equity across our programs.
To directly answer your question, yes, states are adding this in as a requirement. At this point, there are 13 state Medicaid programs that have put it into formal requirements via contract. The timelines for implementation vary depending on RFPs and contract start dates, but the idea is that they are setting a bar for in-market plans, and they're setting a bar for any potential new entrants, which, I think, is really important.
HCI: You mentioned some activity on the health insurance exchange side as well.
Toppe: Yes, California and Maryland have specifically put it into their requirements. Washington, D.C., has made it a recommendation from their board and they're working through how that would play out. I don't want to overstate where they are in the process, but we're seeing a desire for a population-level approach. My team is very much encouraging what I call public sector multi-payer alignment. It’s not rocket science; it's pretty obvious, but it doesn't always play out. We are seeing that kind of synergy at a very top level of state leadership around the leverage, frankly, that a state has when it has Medicaid, if they run a state-based exchange, and then with the public employee benefit program, they have a lot of purchasing power, right?
We're talking about multi-payer alignment, but in the public sector, that is a newer idea, because there tend to be silos within states. But that theme is resonating with states because of the population focus that they have. They don't want to see certain populations not be able to access care, or have worse outcomes because of where they live or because of their racial and ethnic backgrounds. A big focus of my team has been to carry the water on that message. California has been the most out in front in that regard. They have actually required the health equity accreditation for Medicaid and in Covered California, the marketplace, as well as CalPERS. Given how big CalPERS is, that is a significant statement, but they have aligned as agencies.
HCI: If you look across those 13 states that have put health equity requirements in Medicaid managed care contracts, are they all asking for similar things? Are they aligned with each other as far as what they're asking health plans to do and report on?
Toppe: I think it's pretty early for some states. This is the first bar that a number of them are creating. They're looking for that pathway so they can get to better data down the road. And that's really what this does. It says okay, these are the state's expectations of the plans and we're looking to this NCQA evaluation to help make sure you do it. The state can then start to see some of the benefits of that in terms of the data, because one of the other critical facets of the work in health equity as a whole that we are supporting is the stratification of certain clinical measures. That means the HEDIS measures are being stratified. There's a bucket of HEDIS measures — I think we're at 13 as of this measurement year — that we're applying that stratification methodology to. Those are going to be really critical tools for plans, for states and for policymakers to be able to look in a validated and consistent way at how populations are faring on a variety of healthcare conditions.
HCI: Could we go back and just talk about when the health equity accreditation program was launched and how it was created? How did NCQA decide what things were going to be included and how things would be measured?
Toppe: It was launched in 2021. But we actually had a previous accreditation program that was called Multicultural Health Care Distinction, which was established in 2010. It had some adoption. It was all voluntary, no mandates. It was really for organizations that were focused on language and culture as the primary areas of focus. The state of Pennsylvania’s Medicaid program, interestingly enough, had several plans that voluntarily adopted that program. When the state looked at the results of the plans that had that accreditation, versus those that did not, they were seeing better outcomes. So they said, we really want to prioritize this. Around that same time, we were examining, how we could modernize this program and make it reflective of the current state. That's the point at which we said, Okay, we have a responsibility and an opportunity to update the program and share that with our state and federal partners.
It goes beyond that earlier program and adds in a really critical component, which is organizational readiness. Does my organization have the right types of internal structures to make sure we're supporting our members in the right way? It speaks to availability of language, practitioner network responsiveness and addressing healthcare disparities, as well as the biggest issue, which is looking at race, ethnicity, language, gender identity and sexual orientation data that really had not been there before. It has really taken off. It's the only program that I've seen really get this quickly adopted, because I think the states and plans that are looking to show that they're addressing this want to be able to say ‘Okay, this is our roadmap.’ And on the state Medicaid side, they're required to have a state quality and equity strategy.
HCI: I saw on your website that NCQA also piloted a Health Equity Plus Accreditation program that included a couple of health systems: Hennepin Health and Novant. Is that a big change to have an accreditation for health systems as well as health plans?
Toppe: I appreciate you bringing that up because Health Equity Plus is the next level of health equity accreditation. Both programs are actually moving beyond just health plans. Both programs are applicable to health systems. We're seeing interest in how it can be applied to provider groups and practices. It could be applicable to hospitals. There are some variances in in how standards apply to different parts of the system, but both programs can support that wider application. I think that is a definitely a big innovation. The Health Equity Plus program actually gets into collection of community and individual-level data that is above and beyond race, ethnicity and language. It is really about what else is going on in the community that the plan or the organization needs to understand as part of their efforts to address disparities.
Some of the other facets of that program include data management and interoperability — being able to exchange data that you're collecting from those various endpoints and then channel that back into the work that the plan needs to do to figure out what to do at the population level.
HCI: What are some of the challenges that health plans have faced in terms of race and ethnicity data collection and some of the opportunities for improvement there?
Toppe: One of the big points is always around direct data collection versus imputed. The challenge around getting direct data from members is figuring out who's supposed to collect it. One of the biggest challenges is getting practitioners comfortable with the idea of asking those questions. Asking questions, especially around SOGI [sexual orientation and gender identity] data, can get really sticky. There's a lot of nuance and complexities to what you collect when, from whom, how you do it, the right way of doing it. There's activity around training front-line staff in how you ask those questions in a sensitive and appropriate way.
HCI: Anything else that you would like to mention about this work taking place at the state level?
Toppe: Secretary Mark Ghaly of the California Health and Human Services Agency did a fireside chat with us in fall of 2021. He's really been a huge supporter of this idea of a rising tide raises all boats. That is certainly not an uncommon phrase, but I think it was really very appropriate that he used it given how he and the state agencies that are under him have come together to address the population as a whole in that public sector multi-payer alignment. They have really done that beautifully. To me, that that is an important message for states to hear, because they have the power. They don't have to wait for the private sector. Medicare gets to do it at the federal level. Medicaid can do it at the state level. And depending on the state, the public employee benefit program can be a huge additional partner in that, especially for the states that have big enrollment in those plans. They have the ability to drive quality in a way that's very powerful. That's the thing that I would say is the greatest opportunity when it comes to addressing equity.
People change health coverage. If they fall off of Medicaid, hopefully they can go on to the exchange, or maybe they can go on to employer-based coverage. The more state- level policy supports you have across those different payment lanes, the more likely you're going to see effective efforts to address equity.
