Co-authored by: Suzanne Kunze, RN, CCM, MBA
Accreditation programs demonstrate the quality of a health plan to consumers and employers.
For health plans achieving a high accreditation rating means they have programs that are fully developed, implemented, and continuing to improve.
Having achieved accreditation holds health plans accountable and drives them to improve so they can better serve their members.
Organizations achieving NCQA Accreditation status (ranging from interim to excellent) show compliance with NCQA requirements and its performance on health issues, such as monitoring blood pressure, breast cancer screenings, and asthma medication use, as well as consumers’ experiences and satisfaction with their health plan.
To achieve NCQA accreditation, health plans must show they are compliant in five categories: access and services, qualified providers, ensuring members are staying healthy, helping members improve their health, and assisting members who must live with an ongoing illness.
Health plans looking to achieve initial accreditation or for those being re-accredited, means they must participate in a survey every three years, or more frequently based on the health plan’s survey results.
NCQA, one of several national accreditation organizations, offers several health plan accreditation programs that demonstrate a health plan’s excellence in care quality, wellness, and health equity.
NCQA Health Plan Accreditation
NCQA Accreditation helps health plans achieve their objectives of reducing costs and improving the health of their members. An accreditation program bases its results on actual measurements of clinical performance (i.e., Healthcare Effectiveness Data and Information Set (HEDIS)) and consumer experience, including the Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems (CAHPS).
Organizations can benefit from accreditation by performing a gap analysis and determining areas for improvement. The accreditation process provides a framework for implementing evidence-based, best practices to help health plans demonstrate their commitment to quality in the following areas:
- Quality management
- Population health management
- Provider network management and access to care
- Utilization management processes
- Credentialing and recredentialing processes
- Members’ rights and responsibilities
- Member connections
- Medicaid benefits and service requirements
New Population Health Management standards
In August 2017, NCQA published new Population Health Management (PHM) standards. The new standards combine data analytics with wellness and complex case management standards.
In December 2018, the Population Health Program (PHP) accreditation will become available to health plans. The PHP program includes the PHM Standards that are noted below.
PHM can become a growth opportunity for health plans by reducing clinical variation, improving outcomes in care, increasing patient access, and encouraging in-network referrals.
The new PHM standards eliminated the previous disease management standard and some practice guidelines. The PHM standards in PHP Accreditation include:
PHM 1: PHM Strategy
PHM 2: Population Identification
PHM 3: Delivery System Supports
PHM 4: Wellness and Prevention
PHM 5: Complex Case Management
PHM 6: PHM Impact
PHM7: Delegation of PHM
We will explore each of the PHM standards in a future blog.
What we do for you
HighPoint can help health plans meet their PHP program goals by defining a structure for Population Health Management, bridging gaps and supporting the transition to population health and ACOs, and developing risk segmentation, consumer analytics, quality reporting, member/patient engagement.
We will also evaluate and deploy the necessary tools to support physician adoption, providing thought leadership and subject matter expertise, and will align workflows, as well as clinical and claims data integration.
In our next blog, we will begin to explore the new NCQA Population Health Program Accreditation standards and how they may affect your health plan.
To learn more about the HighPoint Solutions Population Health practice, please reach out to Chris McShanag, vice president, population health.
Co-author Suzanne is an associate director with HighPoint's Population Health Management practice.