Quality Care: A Unique Perspective Part 1

Since its founding in 1990, the National Committee for Quality Assurance (NCQA) has been one of the primary drivers of health care improvement. And during that time, Margaret E O’Kane, NCQA founder and president, has been in the center of it all. First Report Managed Care recently sat down with Ms O’Kane to talk about how quality care has evolved over the last quarter-century, which significant hurdles have been cleared, and the challenges that remain. 

She also talks about how electronic health records (EHRs) and the Affordable Care Act (ACA) have impacted the quality movement, and explains what she thinks managed care plans should be doing now to move the quality care needle.  

You founded NCQA 26 years ago, giving you a unique and deep perspective on health care quality. Can you talk about how the landscape has evolved over the years and how quality's role has changed? 

First of all, when we started, employers were driving the quality agenda. Medicare and Medicaid weren’t doing that at all. But over the years we’ve watched Medicare step into what is without question the most influential position in terms of health care quality.

The second thing I see is that quality now counts from a business perspective. It’s not just something nice to do. It is part of the business model. Whether you’re for-profit or non-profit, quality is now part of your business imperative. That to me is a very positive development.  

What do you think has been behind employers losing momentum on quality?

Employers have moved away from being fully insured to being self-insured. That has led to a lot of confusion about who is really accountable for quality. I think the voice of the employer is either muffled, or they’re sending mixed messages to the plans. 

So, the shift is due to a combination of the government stepping up its interest in quality, along with employers having strategies that are not particularly aligned. There is less energy being put into commercially insured lives. That remains an area of challenge for us.  

What else has changed over the years? 

When we started, we saw so many things wrong with health care—and we set about to change them. Now we’re in a period where we worry about the pace of change and what we’re asking of people collectively. I think this is particularly true for clinicians—it’s an incredibly challenging time for them. The plans are asking for things, as is Centers for Medicare and Medicaid Services (CMS).  

In the midst of this, NCQA is trying very hard to align with all parties and serve as an accreditation channel in order to provide a consistent message about what’s important and how it’s going to be rewarded. I worry about doctor burnout. Collectively we’re doing a lot of different things and that results in a lot of stress on the system. 

Speaking of burnout, can you discuss the positives and negatives associated with EHRs? 

The digitalization of health is an incredible advancement. We’re only in the early days, an awkward stage for us with EHRs. They take up a lot of the clinicians’ time, and right now these systems don’t seem to be giving back the information that clinicians need at the point of care.  

The point of quality measurement is really to reflect the operations of the system. In some ways, the actual data is less important than getting it into clinicians’ hands at the time they need it so they can do the right thing.  

I think we’re on the right path, even though we’ve had some bad surprises along the way.  I think we’ll get there just because the imperative is too strong. Still, you get impatient watching it evolve.

What do you consider the most significant hurdles cleared in recent years in terms of delivering real quality care? 

One of the very rewarding parts of my job is that we create standards that lead to better care and the triple aim: better quality, better patient experience, and lower costs. The real beauty happens when those who are being evaluated figure out how to do things better. I love learning from the entities that we accredit. There is a real sense of excitement about how care is going to be delivered in the future and they’re pushing the boundaries.  

Can you give an example of a success story you have seen through implementation of quality care initiatives? 

In the oncology practices we’ve recognized, we’re seeing open access systems where patients and their families have a number to call when they’re sick from their medications. Patients are able to resolve problems without going to the emergency room or being admitted to the hospital. That not only is nicer and kinder for patients, it also means they’re not exposed in their immunosuppressed state to germs in the emergency room and hospital. 

As I listen to oncologists talk about this, it’s incredibly heartwarming. It is also a shame that everybody can’t have this kind of care. 

Can you give our readers another example of care coordination in action?  

The Gastroenterology Associates of Piedmont (GAP) in North Carolina, ensures care coordination by using what they call “curbside cards” to help GAP physicians keep an open line of communication with referring providers.

How does that work?

The cards contain contact information such as direct office phone number, cell phone number, fax number, and e-mail address. These cards are distributed to referring providers to offer quick and easy access to nonvisit consults when specialty assistance is desired. Small things like that can make a big difference.

How are the new NCQA Health Insurance Plan Ratings helping in terms of quality? 

Medicare has demonstrated that plan ratings can drive people to higher quality plans. There is a lot of focus on quality there because of the CMS star system, but we’re not seeing the same energy at the commercial level. So, we’re hoping that release of our ratings is the first step on a journey to make sure people are working to improve the quality of commercially insured lives as well. 

How has the ACA impacted quality?

I think it is important to understand that the ACA was as good as we could get at the time given the political climate. It passed, and now a lot of people are insured who at one time were not. There is a lot to be said about that. 

However, the mandate hasn’t worked as well as intended. A sicker population has signed up than what was expected, which has led to significant losses for insurance companies and bankruptcies for some co-ops that probably priced their premiums too low.  There is only one company left standing in many markets, and that’s not the kind of competition that you want at the exchange level. That’s the biggest downside.