Ratings Examiner Report on New York Health Plan Methodologies


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 July 1, 2013; these updated requirements are described below. If a plan has not been reviewed since July 1, 2013, the results displayed here are based on the prior requirements. 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 RequirementSummaryWhy is this requirement important?
PQ 1: Element A:Standard Quality Measures Does the organization use measures from standardized sources to assess the quality of its individual physicians, practices or medical groups? Determines whether an organization uses widely accepted measurements based on clinical evidence.
PQ 1: Element C:Define Methodology Has the organization addressed important issues relating to its methods for measuring physician quality and cost? An organization should address key issues in its physician measurement methods to achieve valid and reliable results.
PQ 1: Element D:Adhere to Key Principles How does the organization use results of physician quality and cost measurement? Establishes key principles for an organization to follow when it uses findings from its physician quality and cost measurement programs.
PQ 1: Element E:Frequency Does the organization uses measure results that reflect recent physician performance by measuring at least every two years? Confirms how often an organization measures performance of physicians in its provider network.
PQ 1: Element F:Verifying Accuracy How does the organization verify that its methods for measuring physician performance are applied correctly every time? Confirms that the organization’s methods for measurement are accurately and uniformly applied every time it measures physician quality or cost.
PQ 1: Element G: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? 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.
PQ 2: Element A: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? Physicians need to be able to interpret and use information to ensure their results are representative of their performance.
PQ 2: Element B: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? Physicians need to know that an organization follows a fair process for handling requests for corrections or changes.
PQ 2: Element C:Requests for Corrections or Changes What is the organization’s process for responding to a physician’s request for corrections or changes to data? Assesses that an organization follows a fair process for handling requests for corrections or changes.
PQ 3: Element A:Transparency of Measures and Methods Does the organization prominently place key information in clear, understandable language near information it publishes on physicians? Information an organization makes available to consumers should be clear and useful to consumers.
PQ 3: Element B:Transparency with Customers Does the organization make measurement methodology available to customers (i.e. current and prospective consumers and purchasers)? An organization should make information about physician quality and cost measurement processes available to its customers.
PQ 3: Element C: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? An organization should have a method for accepting, processing and resolving member complaints about its physician quality measurement process.
PQ 3: Element D:Handling Complaints Does the organization follow its process for registering and responding to oral and written consumer complaints about its physician measurement activities? An organization should follow a fair process for responding to consumer complaints about its physician measurement activities.
PQ 4: Element A: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? Physicians, consumer groups and purchasers should have the opportunity to play an active role in developing physician measurement programs.
PQ 4: Element B:Feedback on Reports Does the organization seek public feedback about the usefulness of physician quality reports? An organization should use feedback to improve the usefulness of its reports.
PQ 4: Element C:Program Impact Does the organization assess the program by identifying areas for improvement and implementing changes in areas identified for improvement? 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 previously updated in 2013, 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.