Founded in 1990, the National Committee for Quality Assurance (NCQA) is an independent organization that evaluates the quality of services provided by managed care organizations (MCOs). The standards set by the NCQA allow purchasers and consumers to compare plans based on quality and make more informed health care purchasing decisions (1). Employers and government officials recognize the NCQA as the nation’s leading independent reviewer of MCOs. NCQA efforts are organized around accreditation and performance measurement in areas such as member satisfaction, quality of care, access, and service (2). The NCQA uses a team of independent physicians and managed care experts to evaluate MCOs against more than 60 quality related standards (1). A national oversight committee reviews the team’s findings, and an accreditation level is assigned based on how an MCO measures up against these standards, which fall into five categories: access and services, qualified providers, staying healthy, getting better and living with illness (1).
There are five levels of NCQA health plan accreditation: Excellent, Commendable, Accredited, Provisional, and Interim (3). The Accredited, Provisional, and Interim designations encourage an organization to identify opportunities for quality improvement. A Commendable rating signifies that a plan operates continuous quality improvement programs and meets NCQA’s rigorous standards. An Excellent rating is given to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve Health Plan Employer Data and Information Set (HEDIS) (3). HEDIS is used to measure the clinical quality performance of health plans. This is accomplished through the collection and analysis of data documenting the clinical care received by individual plan members from providers, influenced through activities and programs delivered by the health plans. The data is aggregated and reported collectively to reflect the ‘collective’ or population-based care received by the plan’s membership (4). Over 190 million Americans are enrolled in health plans that report quality results using HEDIS (5).
At the center of the NCQA’s tools is the Patient-Centered Medical Home (PCMH) Recognition program, which is the most widely adopted PCMH evaluation program in the country. Approximately 13,000 practices (with 67,000 clinicians) are recognized by NCQA. Additionally, more than 100 payers support NCQA Recognition through financial incentives or coaching (6). The objective of the PCMH model is to have a centralized setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner (7).
Evidence shows that PCMHs improve quality and the patient experience, and increase staff satisfaction—while reducing health care costs. According to a study conducted in 2012 involving 190,000 Medicare beneficiaries, it was found that NCQA PCMH enrollment resulted in $1,099
lower average per-patient total Medicare spending (8). Practices that earn NCQA recognition have made a commitment to continuous quality improvement and a patient-centered approach to care (6). Moving forward, the NCQA will need to continue developing new standards, tools, and measures for providers to evaluate the effectiveness and quality of their care.
- National Committee for Quality Assurance (NCQA). (n.d.). Retrieved from http://www.aetna.com/data/ncqa_99.pdf
- National Committee for Quality Assurance (NCQA) Overview. (n.d.). Retrieved from https://www.niddk.nih.gov/health-information/communication-programs/ndep/health-professionals/practice-transformation-physicians-health-care-teams/team-based-care/patient-centered-medical-home/national-committee-quality-assurance-overview
- Health Plan Accreditation. (n.d.). Retrieved from https://www.ncqa.org/wp-content/uploads/2018/08/20180804_HPA_Advertising_and_Marketing_Guidelines.pdf
- Maurer, J. (2017, March 15). What is HEDIS and What Does it Mean to You? Retrieved from https://magellanhealthinsights.com/2017/03/15/what-is-hedis-and-what-does-it-mean-to-you/
- HEDIS. (n.d.). Retrieved from https://www.ncqa.org/hedis/
- Patient-Centered Medical Home (PCMH). (n.d.). Retrieved from https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/\
- What is the Patient-Centered Medical Home? (n.d.). Retrieved from https://www.acponline.org/practice-resources/business-resources/payment/delivery-and-payment-models/patient-centered-medical-home/understanding-the-patient-centered-medical-home/what-is-the-patient-centered-medical-home
- Benefits of NCQA Patient-Centered Medical Home Recognition. (2017, October). Retrieved from https://www.ncqa.org/wp-content/uploads/2018/08/20171017_PCMH_Evidence_Report.pdf