What is NCQA?

National Committee for Quality Assurance (NCQA)
The Standards, HEDIS and Why it's Important!

Objectives

  • Understand the purpose of the National Committee for Quality Assurance (NCQA).
  • Understand the concept and significance of Healthcare Effectiveness Data and Information Set (HEDIS)

What is NCQA?

  • A not for profit organization.  Primary activities: assessing and reporting the quality of the nation's health care plans.  Goal: provide information to purchasers and consumers to help them choose health plans based on quality.

NCQA Components

  • Accreditation Survey on Quality System and Process standards.
  • Consumer Satisfaction Survey

Accreditation

  • Voluntary and rigorous
  • Began in 1991
  • Many employer groups require NCQA accreditation

Accreditation: The Process

  • Off site document review
  • On site file review

Accreditation: The Standards

During a survey, plans are reviewed against approximately 60 different standards, each of which focuses on an important aspect of the health plan.  These standards fall into five broad categories:

  • Access and Service
  • Qualified Providers
  • Staying Healthy
  • Getting Better
  • Living with Illness

HEDIS

  • Set of standardized measures and member satisfaction survey
  • Requires compliance audit
  • Complementary to but different from NCQA accreditation

Accreditation vs. HEDIS

  • Accreditation: assessment of a health plan's quality systems and processes.
  • HEDIS: evaluates the results of key areas of care and service.
  • Accreditation score is a combination of both processes.

Accreditation Score

  • Can achieve a top limit of 100 points.
  • Need at least 80 points for a three year accreditation.
  • Top possible survey score is 67
  • Top possible HEDIS score is 33
  • NHP goal is to consistently achieve 90 or above for an "excellent" rating.

Conclusions

  • NCQA Standards provide the structure for quality focused care and service.
  • Submitting HEDIS measurements provide NHP an opportunity to compare itself with national and regional benchmarks.  A successful NCQA accreditation allows NHP to remain competitive in it's current market.