NCQA and Accreditation Standards
The National Committee for Quality Assurance (NCQA) was formed in 1979 at the request of the federal Office for Health Maintenance Organizations (HMOs). The NCQA is an independent and not-for-profit organization deriving its revenue primarily from fees for accreditation services. The NCQA is the nation’s largest accreditor of Managed Care Organizations (MCOs)—or health insurance carriers that have health plans.
MCO accreditation entails rigorous reviews of all aspects of the respective organizations, including quality management and improvement, service utilization management, provider credentialing, members’ rights and responsibilities, and communications with subscribers about wellness and prevention.
HEDIS and Performance Improvement in Clinical Operations
MCO accreditation also includes a set of performance measures known as Healthcare Effectiveness Data Information Set (HEDIS). HEDIS provides a standardized method for MCOs to collect, calculate, and report information about their performance to allow employers (who purchase employer-sponsored plans) and other consumers (such as Medicare beneficiaries) to compare plans on costs and quality.
HEDIS is ever-evolving and has seen several iterations. The continuous refinement of the measures happens through rigorous reviews and independent audits. The data set’s measures of MCO performance are separated into five domains: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk-Adjusted Utilization, Relative Resource Use, Health Plan Descriptive Information, and Measures Collected Using Electronic Clinical Data Systems.
HEDIS and Aging Care
Healthcare stakeholders know HEDIS for its ability to assist health system stakeholders in identifying quality gaps and opportunities for improvement and promoting the advancement of evidence-based care. However, there are criticisms of HEDIS. One study showed
that HEDIS is insufficient at measuring care for older adults. This 2018 report takes into account that healthcare for older adults with chronic illness primarily happens outside of the four walls of a hospital. Social Determinants of Health are upstream factors
that play a large role in an individual’s health outcomes. Many believe that a person’s zip code plays a larger role in their future health outcomes rather than expedient medical intervention.
Older adults face their own subset of issues that largely affect their health. Isolation, limited incomes, and inadequate transportation are examples of age-related Social Determinants
of Health. Aging in place is another concern older adults face. Many adults may not have the resources to successfully and independently live on their own as they age.
Home Health Partnerships to Improve HEDIS Measures
Home health agencies can be a wonderful avenue to address these issues and ensure older, vulnerable adults get the care they need as well as improve health plans’ HEDIS clinical measures. Home health brings care into the home promoting accessibility, and many home health models also include social workers who can help address older adults’ Social Determinants of Health. Partnerships between MCOs and home health companies continue to grow as home health proves to be an effective way to deliver to vulnerable populations like the aging population.