NCQA: A national measuring stick Featured

5:57am EDT December 22, 2004
"Value" and "quality" are two extremely charged words in the world of health care. While everyone can agree that there is value in receiving quality care, who can agree on what constitutes quality? And how could you possibly determine what it is worth?

When it comes to health insurance, employers cannot afford to treat value and quality as vague concepts or terms to be debated in a philosophical argument. Instead, it is their responsibility to provide their employees with the highest quality health care at the best price.

In such an environment, you need an impartial observer, an arbiter of quality that will set a standard that all parties can recognize and accept.

In health care, that impartial arbiter is increasingly the National Committee on Quality Assurance. NCQA is a private, not-for-profit organization dedicated to improving health care quality. Its funding comes from a variety of sources, including government contracts, grants from private foundations, private corporations, educational conference fees, publication sales, and accreditation and certification survey fees.

NCQA's primary identity has been as a watchdog of the managed care industry, but it also surveys individual doctors and medical groups.

NCQA's board of directors represents many constituencies, each of which has a stake in the health care system. These include employers, policy-makers, consumers, physicians and health plans. The goal is to improve health care by building programs that meet the diverse needs of all those groups. Because of its structure, NCQA must work to gain the input and support of all of its constituencies and to reflect those diverse interests in its programs.

Since 1991, NCQA has been accrediting and rating managed care organizations. Participation is voluntary, but to date, more than half of the HMOs in the country (with more than three-quarters of HMO enrollees) are reviewed by NCQA. Thirty states recognize NCQA accreditation as meeting certain regulatory requirements for health plans.

Each fall, the release of NCQA's annual "State of Health Care Quality" is anticipated by health plans. NCQA results point out areas where health plans have made good progress and areas where progress has been slow. What NCQA's statistics reveal most clearly is how much improvement is needed in all care categories. Annual results are a good way to keep health plans focused on the difficult task of making those improvements.

Among NCQA's overall findings for 2004:

* The U.S. health care system is plagued by quality gaps that contribute to between 42,000 and 79,000 avoidable deaths each year.

* 66.5 million avoidable sick days are attributable to the health care system's routine failure to provide needed care.

* More than $1.8 billion in excess medical costs can be traced to the health care system's routine failure to provide needed care.

These statistics illustrate clearly the value of quality health care. However, NCQA accreditation has historically only been of interest to large employer groups.

According to a 2003 survey by the Kaiser Family Foundation that polled 2,808 randomly selected employers, NCQA accreditation is a feature that only 3 percent of companies look at when selecting a health plan. In contrast, plan cost was cited as a factor by 80 percent of employers.

All employers can understand the impact on their bottom line associated with high premium costs, but shouldn't they also try to calculate the value of knowing their employees receive better care, stay healthier and miss less work? Is a less expensive, lower-quality health plan really a good value if it results in, say, 10 percent more sick days and 10 percent less productivity?

For employers, value in a health care plan is defined in different ways. There is the quality of care employees receive, the effectiveness and efficiency of a health plan's disease management programs and its member outreach network, and how it pays or rewards its provider network. Those are all things that NCQA measures.

It is up to each employer to decide what has most value for his or her company and employees. To make such decisions, they need unbiased information gathered by an impartial, trusted source. The NCQA is one such source. Its findings can be of value to consumers, employers and health plans. It is the responsibility of each constituency to maximize that value.

Ronald J. Vance is vice president of sales and marketing for UPMC Health Plan. The Health Plan, with 440,000 members, is part of the University Pittsburgh Medical Center's integrated medical delivery system and is the only provider-led health plan in western Pennsylvania. Reach Vance at (412) 454-7642 or vancerj@upmc.edu.