NCQA Release New Standards Category – Population Health Management

New category helps health plans set and achieve population health goals

August 3, 2017

WASHINGTON, DC— The National Committee for Quality Assurance (NCQA) announced the release of its 2018 Health Plan Accreditation (HPA) standards and guidelines. HPA 2018 includes a new category: Population Health Management (PHM). The PHM category is a shift from evaluation of single-disease state toward a whole-person focus.

Within the PHM category, health plans describe their strategy for addressing the needs of members, then demonstrate effective execution of that strategy.

The updated standards combine important components of population health management such as wellness and complex case management, which were long-standing NCQA Accreditation requirements. The new PHM category also recognizes the important role of data analytics for identifying population needs, targeting resources to the right individuals and evaluating the impact of their strategy. This holistic approach allows removal of a number of outdated standards, such as siloed disease management and practice guidelines. Changes resulted in a net reduction of seven elements.

“The future is integration: integration across providers and practices, integration between health plans and the delivery system, integration of strategies to support patients,” said NCQA Vice President for Product Design & Support, Patricia M. Barrett. “These standards take the first step toward that integration, encouraging and rewarding health plans for aligning with the delivery system in pursuit of better population health outcomes.”

Overall, plans demonstrate how they are achieving the Triple Aim: better care, lower costs and improved health.

NCQA recognizes the need for a population health focus on care management in which plans evaluate their membership and connect them to the care they need. NCQA encourages aligning with the delivery system including accountable care entities, practitioners and PCMHs, to meet population heath goals.

The PHM category includes the following standards:

PHM 1: PHM Strategy (NEW)
Plans describe their comprehensive PHM strategy—targeted populations, programs, services and activities offered to members, in addition to demonstrating that they provide basic program information to members and instructions for using program services.

PHM 2: Population Identification (NEW)
Plans integrate data to identify and assess the needs of members and connect them with appropriate programs or services.

PHM 3: Delivery System Supports (NEW)
Plans demonstrate how they support providers or practitioners in their delivery system—providing data directly to ACOs or providing practice transformation support to budding PCMHs—and demonstrate that they engage providers and practitioners in value-based payment arrangements.

PHM 4: Wellness and Prevention
Plans identify members’ health risks and educate them about heathier lifestyles through evidence-based tools.

PHM 5: Complex Case Management
Plans offer case management services to their most complex, highest-risk members.

PHM 6: Population Health Management Impact (NEW)
Plans conduct a comprehensive analysis of their PHM efforts, to determine the effectiveness of their strategy. Analysis includes measures related to clinical processes or outcome, member experience and cost/utilization.

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