2001: NCQA Accredits First PPO Plan
August 7, 2015 · NCQA
25 for 25: A series of 25 blog posts marking NCQA’s 25th anniversary. As part of our anniversary celebrations, NCQA will post a series of 25 blog posts highlighting milestones in our 25 years of improving health care quality.
When PPOs first passed HMOs in market share in the early 90s, NCQA certainly took note, but resisted the urge to develop an accreditation program suited to this growing sector. The reticence was partly pragmatic: at the time, the term “PPO” was a loosely defined, referring to a range of different plan types. And within that range even more structured PPOs didn’t typically perform all the functions—such as credentialing and utilization review—covered in NCQA’s HMO accreditation program.
“We knew we needed to be in the PPO space,” says Kathi Mudd, NCQA’s former VP of Product Delivery. “But we also knew that we needed to stay true to our principles and only offer a rigorous accreditation program. The industry just wasn’t ready for it at the time.”
And so, for a long time, NCQA didn’t review PPOs. Even as PPO enrollment surged in the mid to late 90s, NCQA waited, planned and watched. By 2000, the timing for a PPO accreditation program was finally right. The market had matured to the point where a handful of leading PPOs were using most of the standards and tools NCQA built for HMOs.
NCQA’s initial PPO Accreditation program, announced in 2000, was similar but not identical to its HMO Accreditation counterpart. Standards that weren’t applicable were omitted and others were phased in over several years, an attempt, Mudd says, to “meet the industry where it was and also signal where it needed to go.”
But developing PPO standards was just a first step. NCQA had to find early adopters, too. Mudd recalls NCQA’s Product Development Team working hard to find enough early adopters to show that the program had strong industry and employer support. “Tweaking the usual survey pricing structure helped,” she said. “But the program ultimately sold itself. Our message was, ‘It’s going to pay to distinguish yourself in the market and this is how you do it.’”
In January 2001, NCQA announced the first PPO to earn NCQA Accreditation – Medical Mutual of Ohio. A half dozen additional plans came through the program in the months that followed. And fifteen years later, Medical Mutual still proudly holds NCQA Accreditation. So do 467 other PPOs, and NCQA-Accredited PPOs collectively cover more than 85 million Americans.
NCQA has expanded its product offerings many times and in many directions since 2001. NCQA’s current evaluation programs span nearly every aspect of the health care system: 10 accreditation programs, usually for large organizations, such as health plans; 9 certification programs for organizations that work with health plans; and five recognition programs for clinical care facilities and individual providers.
Branching out into PPOs was a major in NCQA’s evolution—a process of continuous change that is both a cause and consequence of an improving health care industry.
A cornerstone of NCQA’s 25th anniversary year will include a look ahead through the eyes of tomorrow’s leaders. This November 9, NCQA will convene Quality Talks: Inspiring the Future of American Health Care, a “TED-style” symposium held at the Knight Conference Center at the Newseum in Washington, DC. bringing together hundreds of health care and public policy professionals, including government regulators, thought leaders and Congressional staff.
