NCQA Aims to Ensure Quality in Managed Care, Says APA Rep

By Daniel Borenstein, M.D.

While APA members know that the National Committee for Quality Assurance (NCQA) may have an impact on patient care in some vague way, they may not know how this occurs. In this article, I hope to provide a more comprehensive understanding of the NCQAs structure and activities.

The NCQA is an employer-sponsored 501(c)3 nonprofit organization that began accrediting managed care organizations (MCOs) in 1991. Since that time it has gone through reorganizations in 1992, 1993, and 1997, growing from four employees to 240 at the end of 1997. Its current budget is about $20 million, and it has a $300,000 budget surplus. About 55 percent of the nation's HMOs participate in the NCQA accreditation process.

A22-member board of directors consisting of representatives of employers, health plans, consumers, and the AMA governs the NCQA. The current AMA representative, Tom Reardon, M.D., is president-elect of the AMA.

In 1997 the NCQA began accrediting managed behavioral health care organizations (MBHOs) and has expanded these activities to include accreditation of physician organizations and organizations that verify credentials. To date, one MBHO has been accredited, and six others have applied for accreditation and are being evaluated.

During its accreditation surveys, the NCQA reviews plans against more than 50 different standards. The standards fall into the following six categories: quality management and improvement (40 percent of a plan's score), credentialing and recre-dentialing (20 percent), members' rights and responsibilities (10 percent), preventive health services (15 percent), utilization management (10 percent), and medical records (5 percent).

The Accreditation Status List and Accreditation Summary Reports are available on all plans that have undergone a complete review since July 1, 1995. The reports may be obtained through the NCQAs Web site .

The NCQAs second major activity was the development of the Health Plan Employer Data and Information Set (HEDIS), a set of performance measures that can be used to compare health plans. The most recent set is HEDIS 3.0, which was released in January for implementation on July 1 and contains 71 performance measures.

Measurement advisory panels (MAPs) were established in 1997 to develop new HEDIS measures and fill gaps in the 3.0 set. There are MAPs for cardiovascular disease, asthma, behavioral health, diabetes, women's health, pediatrics, geriatrics, and oncology.

The behavioral health MAP was charged with developing the first of such measures by March 1998; it was to have six to eight such measures by fall 1998. It has proposed three measures: adequacy of duration of antidepressant medication for a new episode of depression, percentage of patients with substance abuse problems who enroll in addiction treatment, and measurement of patients' satisfaction with the care they received. Drafts of proposed MAP measures have been released for comment. The final 1999 MBHO standards are scheduled to be released in the next few months.

The Practicing Physicians Advisory Council (PPAC) is one of the NCQAs more recently created components. Its intent is to supply a formal channel through which physicians can participate in the NCQAs decision-making process. Its stated mission is also to help the NCQA identify areas of managed care in which quality can be improved and to educate physicians about activities of the NCQA.

Iserve as APA's representative to the PPAC with members from other specialty societies, the AMA, and the California Medical Association. During meetings, members are informed of the latest NCQA activities and are asked for input about perceived problems in these and other NCQA endeavors. Recent discussions included such topics as the need for increased clinical representation on NCQA committees, psychologists' desire for representation on the PPAC, and problems in coordination and continuity of care with behavioral health carveout companies. So far the PPAC seems to be having a positive influence on the NCQA and its activities.

The newest development planned by the NCQA is an integration of HEDIS and its accreditation procedures, in an effort to move the organization toward "performance-based accreditation." Initial efforts to conduct these integrated reviews were scheduled to begin this summer. This move was designed to eliminate inconsistencies between the two activities and to base assessments on a plan's "demonstration of capacity to deliver quality care through effective structures and processes, and on its actual performance against HEDIS measures." Evaluations will shift from "continuous quality improvement" (CQI) alone to improvement plus achievement, and a standardized audit process will be developed. The proposed modifications to the accreditation standards are intended to increase rigor in utilization review, to introduce information standards, and to integrate behavioral health requirements.

The NCQA has an agreement with the JCAHO to develop measures to assess practices regarding confidentiality of patient medical information. Two meetings on this topic were held in 1997. The only practicing physician among the 35 participants at the first meeting was Denise Nagel, M.D., chair of APA's Committee on Confidentiality. Former APA President Mary Jane England, M.D., joined Dr. Nagel at the second, larger meeting.

As you can see, the NCQA has gone through a number of evolutions and is in a continual state of development. Time will tell whether this organization, which is dominated by employers and managed care representatives, will lead to improved quality of patient care.

The NCQAs Web site is www.ncqa.org.

Dr. Borenstein is an APA vice president and is in private practice in Los Angeles.