NCQA’s acclaimed health plan accreditation program will extend its highly regarded standards for managed care organizations to require preferred provider organizations (PPOs) to measure and report on the quality of care delivered to their members.  The new standards represent the most significant expansion of health plan accountability in the past decade.

Since 1999, HMO and point-of service plans have been required to meet rigorous quality reporting requirements in order to obtain NCQA Accreditation. As a result, more than 76 million Americans have access to understandable quality data that allows them to make informed health care choices for themselves and their families. Today, more than 150 million Americans are enrolled in plans PPOs that do not report consistent, audited quality data. Employers, consumers and public purchasers of health coverage are demanding change.

What is Accreditation?

NCQA Accreditation is recognized by consumers, employers, labor unions, regulators and health plans as the gold standard in evaluating and improving health care quality. Accreditation is a rigorous evaluation of the key systems and processes that define health care organizations. It assesses the care and service that plans deliver in important areas of care, including:

• Access and Service – Do health plan members have access to the care and service they need? Does the health plan resolve grievances quickly and fairly?
• Qualified Providers – Does the health plan thoroughly check the credentials of all of its physicians, hospitals and other providers?
• Staying Healthy – Does the health plan help people maintain good health and avoid illness? Does the health plan publicly report performance on clinical performance measures (HEDIS^®) and member experience (CAHPS^®)?

The Need to Act

For consumers and employers, health care quality is an issue that hits the bottom line. We know that when we are in good health, we are more productive – able to work, care for our families, learn and grow. Poor quality health diminishes the competitive edge of American businesses in the global marketplace. With increasing premiums, the question purchasers ask, “How much does this health plan cost?”  has become “How much value does this health plan provide?”

Today, more than two thirds of Americans covered by private health insurance are enrolled in PPO plans, the fastest growing sector of the health care industry. Yet we currently know alarmingly little about the quality of care delivered by PPOs. While a growing number of PPOs voluntarily collect and report data on care quality, most do not.

What are the significant changes in Accreditation 2008?

NCQA´s new Accreditation standards:

• Require all plans—including, for the first time, PPOs—to report on the quality of care through HEDIS® and CAHPS®.
• Require PPO plans to evaluate their disease management, wellness and complex case management programs.
• Establish common requirements for all plans, allowing consumers, employers and purchasers to compare performance across all plan types.
• Allow PPOs to achieve an “Excellent” Accreditation outcome for the first time. 
• Increase the emphasis on quality by increasing the value of HEDIS and CAHPS results in Accreditation. For 2008, NCQA has added four new HEDIS Effectiveness of Care measures to Accreditation scoring, increasing the weight of HEDIS and CAHPS results to almost 40 percent of scoring for all health plans.

Why is NCQA Making These Changes?

• The quality of health care in the U.S. remains highly variable. Respected studies find that, on average, Americans receive the right care only slightly more than half of the time.
• Consumers, employers and other purchasers of health care services are demanding greater value for their significant investment in health care coverage.
• Quality measurement and reporting drives improvement. Today, children in health plans that measure and report on quality are three times as likely to have had all recommended immunizations as they were 10 years ago; diabetics in these plans are twice as likely to have their cholesterol controlled to recommended levels as they were in 1998.