Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
No. The PHQ standards evaluate organizations that measure physician performance; PPC recognizes physician practices that use systematic processes and information technology to enhance quality of patient care. The two programs serve different purposes. In particular, PPC 8: Performance Reporting and Improvement focuses on the practices internal measurement and quality improvement process. It does not address the methodology required in PHQ, but focuses on the QI process.
To achieve certification, the organization must score at least 50% on Element A, Measuring Physician Performance. The 50% score threshold requires that at least 50% but fewer than 60% of the measures used by the organization to measure physician quality for taking action meet the element (i.e., are standardized). To achieve full points (100%), at least 70% of the measures used by the organization to measure physician quality for taking action must meet the element (i.e., must be standardized)
Case-mix adjustment considers variations in the health of physicians populations, often defined by age and gender. Severity is a patients degree of illness for a specific mix of conditions (e.g., cancer stages), morbidity or comorbidity. Together, case mix and severity are often called risk. Risk can be either the risk for needing a mix of medical services (utilization and associated costs) or the patients likelihood of achieving a specific level of quality-related outcome.
Risk adjustment may not apply to quality measures, particularly process measures. For quality measures, NCQA requires the organization to demonstrate that it has considered whether to risk-adjust measuresand that it has an explicit methodology if it does and an explicit rationale if it does not. If the organization determines that case-mix and severity adjustment do not apply to a quality measure, it provides documentation that supports the determination. If the organization adjusts measures for case-mix or severity, it provides documentation describing the methodology used.
NCQA does not evaluate coding accuracy and quality. Element D, Verifying Accuracy requires an organization to have a process to evaluate the accuracy of its measure results. The organization may use external auditors to verify its methodology, but is not required to do so. In the future, NCQA may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.
Certification in PHQ, PQ or HQ is valid for two years. Organizations must undergo a survey against the standards at least every two years to maintain their certification status. Provisional Certification is valid for 12 months; it is a temporary option and will not be offered after June 30, 2009.
Yes. The organization may not take action based on cost, resource use or utilization results alone. This is a must pass requirement for certification and is consistent with the Consumer-Purchaser Disclosure Project Patient Charter.
The organization is required to consider quality in conjunction with cost, resource use or utilization when it takes action. To the extent that the organization develops and presents a composite score or rating using cost, resource use or utilization and quality measures, it must disclose the specific measures for each category and their relative weight when it determines the composite or rating.
Element C, Measurement Methodology requires the organization to have a method for determining measurement error and measure reliability. Element H, Principles for Use of Results sets requirements for minimum observations or levels of measure reliability or confidence intervalsas applicable for quality and cost, resource use or utilization measures.
For calculating measure reliability for PHQ, the organization must use the method described in the Explanation in Element C under the subhead Measurement error and measure reliability. Measure reliability is defined as the ratio of the variance between physicians to the variance within one physician, plus the variance between physicians.
NCQA does not prescribe the method used to calculate confidence intervals because the appropriate method may vary based on the parameter (e.g., mean or proportion).
