December 12, 2022
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201
Attention: CMS–0058–NC, Establishing a National Directory of Healthcare Providers & Services (NDH)
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on establishing a National Directory of Healthcare Providers and Services (NDH).
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation, clinician quality and measurement programs. We are a national leader in quality oversight and a pioneer in digital quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate their journey toward an equitable, digitally enabled health care system. Our mission to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models, propels our daily work.
We appreciate CMS’s proposal to reduce burden and improve the accuracy of provider directories through creation of a CMS-developed NDH that leverages FHIR® APIs. The vast adoption and advancement of FHIR and FHIR APIs across health care can revolutionize antiquated processes and provide a better experience for consumers and health care stakeholders. NCQA believes the NDH described is one of many use cases CMS can transform by utilizing FHIR APIs and standardized digital data, like USCDI.
We are encouraged by this proposal, and by CMS’s other proposals to adopt FHIR APIs; however, we recommend that CMS outline how developing an API-enabled NDH aligns with other CMS initiatives such as the Digital Quality Measurement Strategic Roadmap and promotion of electronic prior authorization. NCQA believes efforts must work in concert to realize a more efficient health care delivery system that provides better access and produces higher quality care and outcomes for all Americans. We also caution that any development of a directory be collaborative between the federal government and the broader health care industry, such as private payers and other potential users of the directory, to ensure the needs of all stakeholders are met.
Advancing Health Equity, Addressing SDOH and Increasing Access Through an NDH
We applaud CMS’s interest in data elements and functionalities to decrease health inequities and help underserved populations receive high-quality health care services, and we thank CMS for referencing NCQA’s Health Equity Accreditation program in the RFI. Health care organizations across CMS programs should be rewarded for creating organizational cultures that put health equity front and center, and they should be distinguished for their commitment—not only in an NDH, but also across existing CMS consumer resources, like Medicare Care Compare.
An NDH that includes the option for provider race/ethnicity, languages spoken other than English and cultural competencies, such as recognition under NCQA’s Health Equity Accreditation program, can help patients connect to practitioners who understand their cultural identity. This in turn can lead to improved outcomes and increase trust in health care delivery from often historically marginalized populations.
Health Equity Accreditation guides organizations to create an internal culture that improves diversity, equity and inclusion, and reduces bias. It requires organizations to collect data on race, ethnicity, sexual orientation and gender identity, to identify opportunities to create (and offer) language services, written materials and care delivery that meets their populations’ cultural and linguistic needs. The program also requires organizations to identify opportunities to reduce disparities in clinical performance and to address inequities in care and services.
CMS could also include NCQA’s Health Equity Accreditation Plus in the scope of the NDH. This program builds on Health Equity Accreditation, its prerequisite, by requiring organizations to also collect data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions to improve members’ access to and experience with community-based partnerships and resources, with the goal of improving outcomes.
Tens of thousands of practitioners have embraced patient-centered principles through adoption of the patient-centered medical home model. CMS, HRSA and many states incentivize this leading model of care. An NDH should help consumers identify providers who have committed to this model by including those that participate in either a Patient-Centered Medical Home or a Patient-Centered Specialty Practice.
Other NDH data elements and functionalities could increase patient access and consumer choice. For example, including entities and provider types beyond physicians (e.g., dental and behavioral health providers) could increase access to critical services that impact clinical outcomes. Whether a provider offers virtual services, and types of insurance accepted, is also vital information for enabling patient access.
It is particularly important that an NDH provide an accurate and standard definition of “accepting new patients.” An accurate picture of providers with open panels can highlight disparities in access across specific delivery systems, and can spur action to address inequities in access. Additionally, a directory that specifies whether an office is ADA accessible or provides care for certain populations (e.g., providers specializing in gender-affirming care) can help patients access the care they need.
An expanded NDH also presents an opportunity to include both clinical and nonclinical services that can help mitigate the impact of social risks and address disparities in health outcomes. The current systems that connect health plans, providers and community-based organizations providing nonclinical services are fragmented, and participation in these systems is often constrained by costs. A centralized hub that connects patients with needed nonclinical services could streamline services available in a particular area or that are connected to a clinical need. For example, if a patient does not have transportation to access needed care, the NDH could guide patients to a resource in their ZIP code that could provide transportation.
Finally, it is important to consider how an NDH will function publicly and be accessible to consumers. It will be important to include the right stakeholders, including consumers and other potential users from across health care, in its design and implementation. Technology vendors can support and consider the needs of patients in the design of a patient-facing platform, while community-based organizations, community health workers and other patient advocates can bridge the gap for patients and educate them on NDH use and platforms.
Creating a valid and reliable NDH
We were pleased to see CMS emphasize the need for validation of certain data elements versus relying solely on self-reported data to ensure that consumer safety is paramount. While flexibility in NDH design is important to meet various use cases (federal, state, local), the accuracy of credentialing data derived at a primary source cannot be compromised.
At a minimum, and consistent with national accreditation standards for credentialing, CMS should require a standard process for primary source verification of practitioner credentials before appearing on an NDH. This includes validation of a current and valid license to practice, education and training, work history, a history of professional liability claims resulting in a settlement or judgment and, if applicable, a valid DEA or CDS certificate and board certification status. Other information, such as race, ethnicity and languages spoken, can be self-reported. To the degree that a primary source is available, it should be the gold standard.
We appreciate CMS’s request for industry best practices to allow health care organizations, “particularly providers, to delegate or authorize other individuals, either in their organization or intermediary organizations, to submit directory data on their behalf to reduce burden and ensure that data submission is feasible, timely, and accurate.” Organizations deemed as appropriate CMS intermediaries should be required to meet industry best practices for primary source verification before contributing to digital endpoints on behalf of providers. We recommend CMS leverage existing certification requirements for intermediaries, like NCQA Credentials Verification Organization Certification.
This Certification helps improve verification operations and protects consumers by ensuring a consistent, effective and diligent verification process. NCQA currently Certifies 113 organizations. We encourage CMS to learn from their best practices, particularly with state and local credentialing systems, when rolling out a phased approach to an NDH. Some CVOs have already digitized the process for verifying credentialing information, using blockchain for primary sources, which makes the information secure and reliable, reduces burden and increases value for all stakeholders.
NDH for VBP Models
If CMS’s desire is to link provider contact information and quality data into a streamlined CMS resource that not only brings consumers more accurate information, but also brings value for providers and payers participating in value-based payment models, the NDH should fall under the larger umbrella of an HHS/CMS strategy for digital health data, and should be incorporated into the CMS Digital Quality Measure Strategic Roadmap. We concur with CMS that a phased approach is appropriate and must align to industry development and adoption of FHIR IGs and FHIR APIs. Finally, the success and uptake of the NDH will be dependent on making sure that the needs of all stakeholders are met, or there will continue to be a fragmented system of multiple directories across the federal government and private payers.
Thank you again for the opportunity to comment. We are eager to work with CMS to improve the accuracy and timeliness of provider directory information for consumers and reduce burden for providers and other stakeholders. If you have any questions, please contact Eric Musser, NCQA Assistant Vice President of Federal Affairs, at (202) 955-3590 or at email@example.com.
Margaret E. O’Kane