The Accreditation Advantage

CDPHP®: Accreditation Lays the Foundation for Excellence

For Capital District Physicians’ Health Plan, Inc. (CDPHP), quality improvement is not a department. It is an organization-wide commitment that impacts every member interaction, provider partnership and strategic decision. A regional health plan serving just under 74,000 Medicare Advantage members in upstate New York, CDPHP has built a comprehensive approach to population health that combines data-driven interventions, close provider collaboration and a deeply embedded culture of quality.

At the center of that strategy is NCQA Health Plan Accreditation. Rather than treating Accreditation as a compliance exercise, CDPHP uses NCQA standards as the foundation for continuous improvement and a roadmap for delivering better care and outcomes.

“When you are an NCQA Accredited entity, you are demonstrating a high standard of commitment to your members. It shows that you are willing to go through scrutiny and validation by NCQA to become the best health plan you can be. NCQA Accreditation is the roadmap or guidebook to get you there.”

Cynthia Farrelly, Manager, Quality Program Governance, CDPHP®

Making Strategic Investments to Improve Outcomes

CDPHP’s quality improvement strategy begins with understanding its population and identifying areas where members need the most support. Its investments in population health range from technology and analytics to member outreach and provider engagement.

• Building provider partnerships. A cornerstone of the plan’s approach is its partnership with providers. Through value-based incentives and ongoing collaboration, CDPHP works closely with physician practices to identify care gaps, prioritize interventions and engage members in preventive and chronic care services.
• Investing in information sharing. The health plan continuously shares performance reports and care gap information with providers, helping practices identify members who need appointments, screenings or follow-up care. At the same time, provider feedback helps CDPHP understand barriers to care and develop practical solutions.
• Targeted member communications. The plan has developed sophisticated communication strategies that target the right members with the right message at the right time. These communications go beyond reminders. Members can request assistance with scheduling appointments, respond to outreach and connect with quality staff who help overcome barriers to care.
• Providing a seamless member experience. The CDPHP quality improvement strategy enables internal collaboration by creating a single source for everything that is going on with a member, whether it is a survey, outreach mailing, customer service call or care management interaction. It allows employees to have the full picture and provides a more consistent experience for members.
• Viewing data through an equity lens. CDPHP measures performance through multiple lenses, including analysis of health equity data. The organization routinely examines HEDIS measures by race, ethnicity, language, geography and other factors to identify disparities and inform interventions.

Results

CDPHP exceeded the CMS 4-Star cut point for six HEDIS measures included in the CMS Star Ratings in MY 2024.

“People come up to me and ask, ‘How do you do it?’ It’s like they’re looking for the secret sauce. I tell them that the secret sauce is that everyone has to be invested. Everyone has to own it. Everyone has to come to work every day knowing this is what we need to do.”

Michael Farina, Vice President, Healthcare Quality, CDPHP®

Meeting Members Where They Are: Geisinger’s Whole-Person Approach to Population Health and Quality Improvement

For Geisinger Health Plan (GHP), improving quality starts with a simple but powerful philosophy: care for the whole person, not just a diagnosis. That means addressing clinical needs alongside behavioral health, social determinants of health and barriers to care. GHP is part of Geisinger, an integrated healthcare delivery organization that serves communities across Pennsylvania. Its goal is to be the best by providing exceptional care to all and leading healthcare forward.

NCQA Accreditation can serve as an engine for quality improvement. By providing a structured framework for population health management, performance measurement and organizational accountability, Accreditation helps transform quality initiatives into measurable gains in HEDIS performance, Medicare Star Ratings and member outcomes.

“We’ve been on a bit of a journey with population health and the one thing we really focus on is whole-person care. It is important to meet our members where they are, and where they want us to meet them.”

Erin Griffith, Director, Quality Management, Geisinger Health Plan

Making Strategic Investments in Population Health

GHP’s population health approach extends well beyond traditional case management. It requires an understanding of the needs of the entire population. The plan has invested in programs that bring care directly to members, address social needs and provide highly specialized care for members with complex needs.

• Delivering home-based services. As part of its philosophy of meeting members where they are, GHP offers home-based programs like case management and nurse practitioner services—not just for members who are homebound, but for members who prefer to receive care that way. The plan also promotes virtual behavioral health services to provide more timely access and align with member preferences.
• Addressing social needs for all members. Historically, social needs assessments were primarily focused on members in case management, but GHP recently launched a social needs hub for its entire membership. The program connects members with specialized support for challenges such as food insecurity, transportation issues, housing instability and social isolation. Certified community health workers and behavioral health specialists work together to connect members with resources and close care gaps before they become larger health concerns.
• Investing in the right vendor partners. GHP recognizes that it can’t be everything to everyone. That’s why it invests in strategic partnerships with organizations that specialize in managing complex conditions such as kidney disease and cancer. These partnerships supplement GHP’s internal expertise while helping members access specialized support, education and care coordination. At the same time, GHP learns from these partners and integrates successful approaches into its operations.
• Looking beyond the data. Data serves as the foundation for GHP’s population health strategy. The plan relies on robust data sources to identify member needs, uncover gaps in care and prioritize interventions. But data alone is not enough. GHP’s population health strategies also account for individual circumstances and social factors that may not always appear in claims or clinical data.

Results

GHP exceeded the CMS 4-Star cut point for seven HEDIS measures included in the CMS Star Ratings in MY 2024 for its HMO plan and eight measures for its PPO plan.

“Our Star Ratings reflect thousands of daily actions focused on keeping people healthy and engaging them in their care. It’s about the care we wrap around our members, how we use data to drive our decisions and how we try to personalize care as much as we can.”

Eileen Evert, Senior Director, Quality and Accreditation, Geisinger Health Plan

Network Health: Building a Culture of Quality Through Accreditation

For more than two decades, Network Health has built its Medicare Advantage strategy around a simple belief: quality is everyone’s responsibility. NCQA Accreditation enables alignment and integration, with clear lines of accountability from executive leadership to analytics teams, care managers, provider partners and community outreach staff. The organization has created a culture of quality where everyone understands that quality is just as important as paying claims or providing excellent customer service.

Network Health sets an ambitious target of 5 Stars for the CMS Medicare Star Ratings and NCQA’s Health Plan Ratings as part of its annual company-wide goals, so every employee has a stake in the results. That organization-wide commitment has helped Network Health achieve strong performance while continuously expanding programs designed to improve health outcomes for Wisconsin communities.

Making Strategic Investments in Population Health

Network Health’s population health strategy focuses heavily on chronic disease prevention and management, particularly for conditions like diabetes and hypertension. Its leaders view HEDIS performance, Star Ratings and Accreditation excellence not as separate goals, but as interconnected elements of a broader commitment to helping people achieve better health.

• Using data to drive improvement. Dedicated analysts embedded within the quality organization monitor HEDIS performance, analyze trends and provide ongoing visibility into progress toward quality and Star Ratings goals. Monthly reviews allow teams to quickly identify areas that need additional attention and redirect resources accordingly.
• Bringing care to members’ homes. To reach members with diabetes, Network Health purchased a portable retinal camera and partners with a local home health organization to capture retinal images. Results are reviewed by a retinal specialist and shared with the member’s primary care clinician for follow-up care when needed.
• Partnering with care delivery organizations. Network Health’s clinician relationships are a cornerstone of its quality strategy. Value-based agreements create shared accountability and monthly care-gap reports and education on coding and barrier identification help to ensure care is documented accurately and quality opportunities are not missed.
• Connecting with the community. Network Health sponsors community-based health initiatives and focuses outreach efforts on populations that may experience barriers to care. One example is a partnership with an inner-city barbershop to host a weekly clinic that provides blood pressure screenings, health education and care navigation support in a trusted community setting.

Results

Network Health Plan exceeded the CMS 4-Star cut point for eleven HEDIS measures included in the CMS Star Ratings in MY 2024.

“NCQA requirements ensure that Network Health has a strong quality program across all departments. Each standard element has a designated owner and that person is responsible for developing their work plan and evaluating the results, which includes quantitative analysis and qualitative analysis of their interventions and how well they worked.”

Sara O’Neill, Director of Quality Health Integration, Network Health

Making Quality Everyone’s Business: How NCQA Accreditation Supports Priority Health’s Stars Success

Priority Health has achieved success in HEDIS and Star Ratings by building a collaborative quality improvement structure, making data-driven decisions and putting members and clinicians at the center of everything it does. Priority Health leaders view NCQA Accreditation not as a compliance exercise, but as a framework that helps organizations build sustainable quality improvement programs.

Quality starts with a strong organizational and governance structure. Priority Health’s quality improvement function is closely integrated with population health, Accreditation and HEDIS operations. These functions report through the same leadership structure, allowing teams to analyze performance data collaboratively, identify opportunities and develop targeted interventions for specific populations.

“NCQA’s Health Plan Accreditation is a pathway for quality improvement. It provides a certain level of guidance and gives us an extra push to make sure we complete the full cycle of quality improvement. It makes quality everyone’s business.”

Alexandria Tusek, Director of HEDIS and Accreditation at Priority Health

A Multi-Channel Approach to Closing Member Care Gaps

Priority Health developed a process called Next Best Action that drives its member outreach activities. At the beginning of the year, the team analyzes its population to identify members that fall within the denominator for each HEDIS measure used in the Star Ratings. Outreach approaches vary based on each member’s health condition and other circumstances, but generally follows this hierarchy:

• The first contact is a letter or email that encourages the member to visit their primary care clinician and includes a suggested list of health topics they need to discuss, such as preventive screenings or lab tests that may be needed.
• If the member does not have a claim for a primary care visit or complete the recommended screening within the first six months of the year, Priority Health initiates more frequent contact with the member via letter, email or phone call to encourage them to schedule an appointment.
• For high value care gaps—the HEDIS measures that have a higher weighting in the Star Ratings—Priority Health has a designated care team that calls the member and offers to help with scheduling, arranging transportation or whatever barriers prevent them from getting the care they need.
• For members who still do not complete the necessary test or screening, Priority Health partners with home test kit vendors to send screening kits directly to members’ homes, in collaboration with the member’s primary care clinician.

“There are a lot of barriers to getting a colonoscopy, whether it is related to appointment wait times or members being unwilling to do the preparation. We know that if we can get a home test kit into the member’s hands and they can just drop it off at their local lab or put it in the mail, they are much more likely to complete the screening.”

Ian Straayer, Former Director of STARS at Priority Health

The key to success for the Next Best Action outreach is the continuous flow of claims and chart review data into Priority Health’s systems so the teams can conduct targeted outreach to support the members who need it most.

Results

Priority Health exceeded the CMS 4-Star cut point for eight HEDIS measures included in the CMS Star Ratings in MY 2024 for its HMO plan and seven measures for its PPO plan.

UPMC Health Plan: Accreditation Supports Whole-Person Care

For UPMC Health Plan, NCQA Accreditation supports a whole-person approach to care and better outcomes. As part of the University of Pittsburgh Medical Center (UPMC) integrated health care delivery system, UPMC Health Plan is committed to providing its members with better health, more financial security and the peace of mind they deserve.

Today, the health plan serves approximately 226,000 Medicare Advantage members across multiple plan offerings while maintaining a strong focus on population health and quality improvement.

“From my perspective, the value is that Accreditation really encourages us to move beyond good intentions and helps us demonstrate that we have a reliable structure for understanding our population, identifying gaps, acting on those gaps and working to sustain improvement over time.”

Lisa Gerdes, Director, Quality Improvement, UPMC Health Plan

Making Strategic Investments to Improve Outcomes

At UPMC Health Plan, population health is not viewed as a collection of individual programs. Instead, it is an integrated strategy that brings together clinical teams, care management, quality improvement, analytics, providers, pharmacy and community engagement staff to address the needs of members holistically.

NCQA Accreditation provides a framework that helps align these efforts and turn quality goals into sustainable practices, such as:

• Creating a more complete picture of member health. One of UPMC Health Plan’s biggest investments has been data acquisition and integration from a variety of sources—clinical, supplemental, health risk assessments and member experience surveys—to gain a more complete understanding of the members it serves.
• Identifying and removing barriers to care. The UPMC Health Plan teams are relentlessly curious, using data to understand the barriers to care and, more importantly, why those barriers exist. Armed with that information, they develop creative ways to intervene earlier and more effectively to remove those barriers.
• Creating targeted pathways to care. The team groups members into different populations based on their risk level and develops individualized outreach, communication plans and care paths to engage members in their care through health coaching, care management, medication adherence reviews and visits with their primary care clinician or specialist.
• Integrating community engagement approaches. Historically, UPMC Health Plan’s quality initiatives were focused on what happened in traditional care settings, but it has broadened that approach through community partnerships and outreach efforts designed to meet members where they live, work and play. These holistic approaches focus on access to care, health literacy, social and emotional needs and improving members’ ability to understand their benefits.

“Once you hit a certain performance level, I think you have addressed all your low-hanging fruit opportunities. NCQA has got us thinking about different populations and the people we’re missing. We have seen big improvements in our Star Ratings and quality performance because of how we have been able to come together and focus not just on the individual measures, but on our overall population health strategy and engaging with those high-risk populations.”

Mariah Osborn, Director, Medicare Stars, UPMC Health Plan