Ratings Examiner Report on New York Health Plan Methodologies

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Requirement Details

Measuring Quality of Care by Physicians
The organization measures the quality of its individual physicians, practices or medical groups choosing measures first from those endorsed by the National Quality Forum (NQF) and second from those accepted by the Ambulatory Quality Alliance (AQA) or developed by national accreditors, American Medical Association’s Physician Consortium for Performance Improvement (AMA’s PCPI), specialty medical boards or government agencies.
Measurement Methodology
The organization's methodology addresses:
Verifying Accuracy
The organization employs a process that includes the following to verify that its measurement methodology is accurately applied when it conducts measurement.
Frequency
The organization takes action using measure results that reflect recent physician performance by measuring at least every two years.
Working With Physicians
The organization works with its physicians, practices or medical groups on quality and cost, resource use or utilization measurement activities, including:
Requests for Corrections or Changes
The organization's responses to physician requests for corrections or changes contain the following information.
Principles for Use of Results
The organization uses results of physician measurement in accordance with the following principles.
Reporting Methodology to Customers
The organization makes measurement methodology available to the following customer groups.
Making Information Available
The organization prominently places the following information in clear, understandable language near information its publishes on physicians.
Feedback on Reports
With the goal of improving its physician reports, the organization annually:
Policies and Procedures for Complaints
The organization has a process for registering and responding to oral and written consumer complaints about its physician measurement activities that includes:
Handling Complaints
The organization follows its process for registering and responding to oral and written consumer complaints about its physician measurement activities, including:
Collaborating on Physician Measurement
To make data more representative and to reduce redundant measurement the organization:
Seeking Input During Development
The organization seeks input into the development of its physician measurement and reporting activities, including measure selection, methodology for reporting differences in performance and reporting format, from the following groups.
Standard Quality Measures
The organization uses measures from standardized sources to assess the quality of its individual physicians, practices or medical groups.
Measuring Cost
The organization measures cost, resource use or utilization of physicians, practices or medical groups:
Define Methodology
The organization's methodology addresses:
Adhere to Key Principles
The organization uses results of physician measurement in accordance with the following principles.
Frequency
The organization uses measure results that reflect recent physician performance by measuring at least every two years.
Verifying Accuracy
The organization employs a process that includes the following to verify that its measurement methodology is accurately applied when it conducts measurement.
Results Reflect Data Beyond a Single Payer
To make data more representative and to reduce redundant measurement, the organization uses data from other sources that are representative of a physician's performance or participates in a multi-payer collaborative for quality or cost, resource use or utilization measurement.
Transparency of Measures and Methods
The organization shares information about measurement activities with its physicians, practices or medical groups.
Opportunity to Correct
The organization provides its physicians, practices or medical groups the opportunity to request corrections or changes and receive a timely response, including:
Requests for Corrections or Changes
The organization's responses to physician requests for corrections or changes contain the following information:
Transparency of Measures and Methods
The organization prominently places key information in clear, understandable language near information it publishes on physicians, including:
Transparency with Customers
The organization makes measurement methodology available to the following customer groups:
Policies and Procedures for Complaints
The organization has a process for registering and responding to oral and written consumer complaints about its physician measurement activities that includes:
Handling Complaints
The organization follows its process for registering and responding to oral and written consumer complaints about its physician measurement activities, including:
Seeking Input During Development
The organization seeks input into the development of its physician measurement and reporting activities, including measure selection, methodology for reporting differences in performance and reporting format, from the following groups:
Feedback on Reports
With the goal of improving its physician reports, with each measurement cycle, the organization:
Program Impact
To maximize the impact of its physician measurement program, the organization annually assesses the program by:

Overview

Under the New York Attorney General agreements with Health Plans, NCQA reviews the methods used by health plans to measure physician performance to assess compliance with the requirements below. NCQA reviews the policies and procedures and methodologies that plans have in place related to their physician performance measurement programs, including actual communications to physicians and consumers about the programs. NCQA also visits the health plan to confirm that specified policies are followed. The review team includes at least one physician trained to evaluate against the NCQA standards and the requirements of the NY Attorney General. The team may also include other experts in measurement methodology. This rigorous evaluation of plan methodologies is also reviewed by members of NCQA’s expert physician panel which makes the final scoring decisions.

The New York Attorney General requires health plans that have implemented physician performance measurement programs in the state to fully comply with the requirements based on specified minimum criteria or institute corrective action within six months or such shorter time period as the Attorney General or NCQA may direct. Each plan is subject to review against the requirements at least every two years and may be reviewed in the interim if it makes changes to its programs.

To assure that the requirements represent best practices, NCQA – with the approval of the New York Attorney General and notice to the plans – periodically updates the requirements. The most recent update was effective for reviews conducted after January 1, 2011; these updated requirements are described below. If a plan has not been reviewed since January 1, 2011, the results displayed here are based on the prior requirements. To see a complete list of the prior requirements, click here . When you view an individual plan’s results on that plan’s detail page, it will show the requirements used at the time of the plan’s review.

Requirement details

Evaluation Requirement	Summary	Why is this requirement important?
Measuring Quality of Care by Physicians	This requirement addresses whether the health plan uses measures of the quality of physicians that are developed or endorsed by health care experts. For a more detailed description of this requirement, please click here.	This requirement is important because it determines whether the health plan is using widely accepted measurements based on clinical evidence.
Measurement Methodology	This requirement addresses whether the health plan has addressed important issues relating to its methodology for measuring physician quality and cost. For a more detailed description of this requirement, please click here.	It is important that plans address key issues in their physician measurement methodologies to assure valid and reliable results.
Verifying Accuracy	This requirement addresses how the health plan verifies that its methods for measuring physician quality are applied correctly each time they measure. For a more detailed description of this requirement, please click here.	This requirement is important because it confirms that the health plan’s methods for physician quality measurement are accurately and uniformly applied every time physician quality or cost is measured.
Frequency	This requirement addresses whether the data the health plan uses for its quality and cost measures is current. For a more detailed description of this requirement, please click here.	This requirement is important because physicians should be measured on as recent activities as possible so measures reflect their recent performance.
Working With Physicians	This requirement addresses how the health plan involves physicians before, during and after the measurement process. For a more detailed description of this requirement, please click here.	This requirement is important because physicians should be given the opportunity to play an active role in the measurement process.
Requests for Corrections or Changes	This requirement addresses the health plan’s process for responding to a physician's request for corrections or changes to the data. For a more detailed description of this requirement, please click here.	This requirement is important because physicians need to know that their health plans follow a fair process for handling requests for corrections or changes.
Principles for Use of Results	This requirement addresses how the health plan uses the results of physician quality and cost measurement. For a more detailed description of this requirement, please click here.	This requirement establishes some key principles for health plans to follow when using findings from their physician quality and cost measurement programs.
Reporting Methodology to Customers	This requirement addresses to whom the health plan makes information about how it measures quality and cost available. For a more detailed description of this requirement, please click here.	It is important for health plans to make information about physician quality and cost measurement processes available to customers.
Making Information Available	This requirement addresses whether the health plan provides some specific information about its measurement process and physician results in a user-friendly format. For a more detailed description of this requirement, please click here.	This requirement is important because health plans should provide some important information in a format and manner that is in common language, clear and understandable.
Feedback on Reports	This requirement addresses whether the health plan seeks feedback from the public about the usefulness of the physician quality reports. For a more detailed description of this requirement, please click here.	This requirement is important because it looks at whether the health plan seeks to improve the usefulness of its reports by seeking feedback.
Policies and Procedures for Complaints	This requirement addresses the health plan's process for handling complaints from its members about its physician measurement activities. For a more detailed description of this requirement, please click here.	It is important for plans to have a process to accept, process, and resolve complaints from members about the plan’s physician quality measurement process.
Handling Complaints	This requirement looks at whether the health plan follows its process for handling member complaints about its physician measurement activities. For a more detailed description of this requirement, please click here.	It is important to know that the health plan follows a fair process for responding to member complaints about its physician measurement activities.
Collaborating on Physician Measurement	This requirement addresses whether the health plan collaborates with other organizations that evaluate physician quality and uses data from other sources in addition to data it collects. For a more detailed description of this requirement, please click here.	This requirement is important because health plans can increase the quality of their data on physicians and make the process more efficient when they work with other organizations on physician measurement.
Seeking Input During Development	This requirement looks at whether health plans seek input from physicians, consumers, and purchasers of health care (such as employers or states) when it develops its measurement and reporting program. For a more detailed description of this requirement, please click here.	This requirement is important because these parties use or are affected by the information in the program and can provide important information to help make the program more useful or valuable.
Standard Quality Measures	Does the organization use measures from standardized sources to assess the quality of its individual physicians, practices or medical groups? For a more detailed description of this requirement, please click here.	Determines whether an organization uses widely accepted measurements based on clinical evidence.
Measuring Cost	For a more detailed description of this requirement, please click here.
Define Methodology	Has the organization addressed important issues relating to its methods for measuring physician quality and cost? For a more detailed description of this requirement, please click here.	An organization should address key issues in its physician measurement methods to achieve valid and reliable results.
Adhere to Key Principles	How does the organization use results of physician quality and cost measurement? For a more detailed description of this requirement, please click here.	Establishes key principles for an organization to follow when it uses findings from its physician quality and cost measurement programs.
Frequency	Does the organization uses measure results that reflect recent physician performance by measuring at least every two years? For a more detailed description of this requirement, please click here.	Confirms how often an organization measures performance of physicians in its provider network.
Verifying Accuracy	How does the organization verify that its methods for measuring physician performance are applied correctly every time? For a more detailed description of this requirement, please click here.	Confirms that the organization’s methods for measurement are accurately and uniformly applied every time it measures physician quality or cost.
Results Reflect Data Beyond a Single Payer	To make data more representative and to reduce redundant measurement, does the organization use data from other sources that are representative of a physician''s performance or does the organization participate in a multi-payer collaborative for quality or cost, resource use or utilization measurement? For a more detailed description of this requirement, please click here.	An organization can improve the quality of its physician data and make the measurement process more efficient by using performance information from other sources or collaborating with other payers.
Transparency of Measures and Methods	Do physicians have an opportunity to understand the program including its measures, methods and actions and contribute data to help make their own results as accurate as possible? For a more detailed description of this requirement, please click here.	Physicians need to be able to interpret and use information to ensure their results are representative of their performance.
Opportunity to Correct	Does the organization provide its physicians, practices or medical groups the opportunity to request corrections or changes and receive a timely response? For a more detailed description of this requirement, please click here.	Physicians need to know that an organization follows a fair process for handling requests for corrections or changes.
Requests for Corrections or Changes	What is the organization’s process for responding to a physician’s request for corrections or changes to data? For a more detailed description of this requirement, please click here.	Assesses that an organization follows a fair process for handling requests for corrections or changes.
Transparency of Measures and Methods	Does the organization prominently place key information in clear, understandable language near information it publishes on physicians? For a more detailed description of this requirement, please click here.	Information an organization makes available to consumers should be clear and useful to consumers.
Transparency with Customers	Does the organization make measurement methodology available to customers (i.e. current and prospective consumers and purchasers)? For a more detailed description of this requirement, please click here.	An organization should make information about physician quality and cost measurement processes available to its customers.
Policies and Procedures for Complaints	Does the organization have a process for registering and responding to oral and written consumer complaints about its physician measurement activities? For a more detailed description of this requirement, please click here.	An organization should have a method for accepting, processing and resolving member complaints about its physician quality measurement process.
Handling Complaints	Does the organization follow its process for registering and responding to oral and written consumer complaints about its physician measurement activities? For a more detailed description of this requirement, please click here.	An organization should follow a fair process for responding to consumer complaints about its physician measurement activities.
Seeking Input During Development	Does the organization seek input into the development of its physician measurement and reporting activities, including measure selection, methodology for reporting differences in performance and reporting format from consumer representatives, physicians, practices or medical groups (or their representatives) and purchasers? For a more detailed description of this requirement, please click here.	Physicians, consumer groups and purchasers should have the opportunity to play an active role in developing physician measurement programs.
Feedback on Reports	Does the organization seek public feedback about the usefulness of physician quality reports? For a more detailed description of this requirement, please click here.	An organization should use feedback to improve the usefulness of its reports.
Program Impact	Does the organization assess the program by identifying areas for improvement and implementing changes in areas identified for improvement? For a more detailed description of this requirement, please click here.	To maximize the impact of its physician measurement program, the organization should regularly assess how effective the program is in achieving predetermined objectives.

How These Standards Were Developed

The National Committee for Quality Assurance (NCQA) is an independent, non-profit organization dedicated to improving health care quality. Since 1990, NCQA has developed programs to accredit health plans and, more recently, recognize physicians in key areas of care. NCQA has been a leader in developing standards and measures of health care quality; NCQA’s Physician and Hospital Quality, issued in 2006 and updated in 2008, was the first independent effort to assess how health plans measure physicians.

The requirements against which NCQA conducts its Ratings Examiner reviews for the New York Attorney General are adapted from NCQA’s Physician and Hospital Quality (PHQ) standards. The PHQ standards evaluate how health plans measure physicians to confirm that the health plans use standard measures of quality and valid and reliable measures of cost when measuring and reporting on physicians. They also evaluate if the process is fair and useful to physicians, purchasers, and consumers. The PHQ standards were developed with the input from physicians and physician groups, consumer advocates, employers, representatives from state and local agencies and health plans. NCQA also consulted with physician measurement experts on methodology and considered feedback from a formal public comment period.

The PHQ standards were also approved by NCQA’s multi-stakeholder Standards Committee and by the NCQA Board of Directors.

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