Health Plan Watchdog Still Seeks Progress After 25 Years

By Phil Galewitz
Kaiser Health News, January 8, 2016

The nation’s oldest private arbiter of what defines high-quality health plans turned 25 last year. The National Committee for Quality Assurance (NCQA) started soon after HMOs became popular in the 1980s, measuring the effectiveness of the first managed care plans as millions of consumers flocked to join them.

Today, NCQA accredits health plans in every state, covering 109 million Americans or about 70 percent of all Americans enrolled in private coverage.

Founding and current president Margaret “Peggy” O’Kane discussed her organization’s past and future recently with KHN’s Phil Galewitz.

Phil Galewitz:  What do you see as NCQA’s biggest achievement after 25 years?

Margaret O’Kane:  Just getting the measurements out there in a systematic way. We are now finally at a stage where the delivery system is getting it and trying to reorganize itself with primary care medical homes and accountable care organizations.

Galewitz:  Is the United States doing a better job for consumers in measuring health plans’ quality of care?

O’Kane:  Maybe the glass is half full on measurement, or less than that. I think our strategy was to always walk behind the evidence. We have good measures where there is good evidence on preventive services and chronic diseases like hypertension and diabetes. What we are missing is often in areas where the science is unclear. These also tend to be high-stakes areas of care, like cancer or other complex illnesses.

Galewitz:  Are health plans receptive to being evaluated by NCQA?

O’Kane:  It’s less than voluntary, I would say. It’s in the health law for exchange plans (to be accredited by NCQA or another accrediting group) and has been driven by employers traditionally. Some plans really question whether it matters what (their) quality is. You see narrow networks emerging and if they are chosen just based on price, that isn’t going to go well among consumers.

Galewitz:  How much has NCQA’s work improved the quality of health care that Americans receive?

O’Kane:  In the areas we have measured, you can point to real improvements. My main gripe now is what I see as contradictory strategies of high deductibles versus a delivery system reform promoting primary care. If you have to spend out of your own pocket $2,000 or $5,000 before you get to see your primary care physician (for free), many Americans don’t have that money. We are reforming the delivery system and then people can’t afford to see their primary care doctor. That makes no sense.

http://khn.org/news/a-health-care-watchdog-for-consumers-turns-25/

As our health care system is being refined to supposedly replace quantity with quality in the delivery of health care services, we should learn from the experience of the National Committee for Quality Assurance (NCQA) – one of the more credible and experienced organizations attempting to improve quality in health care. Their founder and president, Margaret “Peggy” O’Kane, has a few lessons for us.

How are we doing on quality measurements? The glass is “half full… or less.” We are not doing well on “high-stakes areas of care, like cancer or other complex illnesses.” How can you ignore the quantity of care that is required for these complex cases and pretend that you are going to make payments based instead on quality that you can’t measure?

And the reception by the exchange health plans of the ACA requirement that they be accredited for quality? O’Kane says that the involvement of the plans is “less than voluntary.” She says, “Some plans really question whether it matters what (their) quality is.” Wow! Plans are setting up narrow networks that are based on price (while ignoring quality – DMc).

Her most important message: “My main gripe now is what I see as contradictory strategies of high deductibles versus a delivery system reform promoting primary care. If you have to spend out of your own pocket $2,000 or $5,000 before you get to see your primary care physician (for free), many Americans don’t have that money. We are reforming the delivery system and then people can’t afford to see their primary care doctor. That makes no sense.”

As the policy and political communities divert their efforts to structural reforms that have not been demonstrated to have more than a negligible impact on quality, the private insurance industry has moved forward with changes that are making health care unaffordable and inaccessible for far too many Americans. When what we need is a strong primary care infrastructure, our health care leaders are allowing the insurers to erect intolerable financial barriers to care. As O’Kane says, “That makes no sense.”

It’s great that we have dedicated organizations such as NCQA and AHRQ to help ferret out and correct quality problems. But we cannot let that distract us from what we really need to do: enact a well designed single payer national health program that will bring us the structural reforms that we desperately need, so all of us can have affordable, accessible, high quality health care.