FAQ Directory

Yes. NCQA considers all patient experience results to be measures of quality.

Non-NQF endorsed patient experience surveys are counted as one measure for the entire survey. CAHPS-CG questions or composites count as separate measures.

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.

NCQAs Recognition Program measures meet many of the elements in PHQ.

If an organization takes action based on measures in NCQAs Recognition Programs, the measures meet the elements where specified in the standards. The organization does not need to provide additional documentation about how the measures meet these elements.

NCQAs Recognition Programs are the Diabetes Physician Recognition Program (DPRP); Heart-Stroke Recognition Program (HSRP); Back Pain Recognition Program (BPRP); Physician Practice Connections (PPC); and the Physician Practice ConnectionsPatient-Centered Medical Home (PPC-PCMH).

In the draft standards released for Public Comment in March 2008, NCQA included pay-for-performance but did not use that specific term; instead, we referred to payment strategies. Specifically, NCQA defined the Scope of Review for the majority of elements in PHQ 1 as: NCQA evaluates all measures the organization uses for measuring physician performance for the purpose of taking action.

In the Explanation, NCQA defined taking action as follows.

Publicly reporting physician performance on quality or cost or resource use

Using physician performance on quality or cost or resource use measures as a basis for network design (such as tiering), benefit design or payment strategies

NCQA defined payment strategies in Element M, Using Measure Results as follows.

The organization uses reimbursement to provide incentives for improvement among its physicians, practice sites or medical groups, or uses payment to reward performance.

In the final standards, NCQA used the term pay-for-performance and specifically narrowed the scope of programs included.

NCQA performs surveys on the PHQ standards, but may develop standards for auditing physician measurement and a program for certifying auditors. With such standards, NCQA will consider making external audit a requirement.

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.

Yes. PHQ requirements do not prohibit a collaborative from managing a request for corrections or changes made by physicians, but the organization remains accountable and responsible for responding to complaints from consumers and to requests for changes from physicians or hospitals based on actions taken by the organization.

No. HEDIS RRU measures are specified for assessment at the plan level, not for measurement of individual physician performance.

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.

For Element A, the denominator is all quality measures on which the action is based and the numerator is measures that meet the definition of standardized in the Explanation.

No. Productivity measures are out of scope for the 2008 PHQ standards. Quality, cost, resource use and utilization measures are in scope if the organization takes action based on them.