Margaret E. O'Kane
President, NCQA

Critics complain that some HMOs withhold data, but NCQA President Margaret O'Kane responds that HMOs are exemplary in measuring and reporting quality.

Margaret E. O'Kane

President, NCQA

A recent JAMA article, critical of efforts to evaluate and report on the nation's HMOs, attracted a good deal of attention in the trade press, including this publication ("Has the Time Come for NCQA to Get Tough with HMOs?" October 2002). We believe that this unfounded criticism deserves a response, and we appreciate the opportunity to do so here.

The article's central criticism is based on an analysis of old data showing that poorly performing plans tended not to report their data publicly the following year. This observation was last valid in 1998, coincidentally the same year that NCQA itself first reported this disturbing pattern. The following year, NCQA established a requirement that all accredited health plans publicly report their data, effectively removing the option to "drop out" for accredited plans. Today, in fact, the vast majority (85 percent) of HMOs in NCQA's database allow their data to be reported publicly, huge progress from the 40 percent that withheld their data in 1997. Fewer still drop out of the public reporting process; excluding plans that went out of business or merged, only five plans that reported data publicly in 2001 did not do so this year. All five were unaccredited.

But all this talk of declining percentages of "nonpublic reporters" (plans that give us data but don't allow us to share it publicly), perhaps misses the larger point. HMOs are the one segment of health care that has broadly embraced accountability. It's true that there are still health plans that don't share their data publicly, but in an environment in which performance data are not available for over 70 percent of the industry — the fee-for-service sector, PPOs — shouldn't we focus on encouraging other sectors of the system to share their results? This would seem to be more productive than criticizing efforts that have not only been embraced by the industry, but that have led to meaningful improvements in quality that have saved thousands of lives.

I suspect that NCQA and the article's authors would find common ground on one point: We would all benefit from broader, more inclusive health care report cards. Assuming that we are in agreement, the real issue becomes how to make broader accountability a reality.

To that end, NCQA has been active on several fronts — in particular, the promotion of provider-level measurement and recognition. NCQA and the American Diabetes Association jointly sponsor the Diabetes Physician Recognition Program (DPRP), which recognizes and rewards physicians or medical groups that meet or exceed national thresholds for diabetes care. In September, we reported that physicians recognized by the program deliver consistently excellent diabetes care, outperforming the national average in key indicators, such as the percentage of patients with properly controlled blood sugar levels.

Early next year, NCQA and a coalition of large employers will introduce a "pay for quality" program that will provide incentive payments to physicians that achieve DPRP recognition. NCQA is also developing a recognition program related to excellence in cardiovascular care.

The accountability model — measuring performance, collecting data, and reporting the results publicly — is a proven approach to driving quality improvement. Its continued success, however, depends on the support and collaboration of diverse groups and individuals. We look forward to continued progress in our mission to improve the quality of health care and we invite interested parties to work with us to build on our success.

Margaret E. O'Kane has served as NCQA president since 1990.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.