Pioneering Healthcare Quality: How Margaret O'Kane and NCQA Changed the Landscape

For 11 years running, Margaret E. O’Kane, president of the National Committee for Quality Assurance (NCQA), has been recognized for her contributions to healthcare with a spot on Modern Healthcare’s 100 Most Influential People in Healthcare list. While quality measurement in healthcare has gained recognition as an important aspect of care delivery, that was not always the case in the United States.

When NCQA was first starting out in the 1990s, some health plans used to tell O’Kane that quality was not a business issue. However, there is still a long way to go, O’Kane pointed out.

“We’re working on long-term services and supports (LTSS) for elderly people and people with disabilities,” she explained. “You can’t just take your basic HEDIS approach and say, ‘Did they get this care?’ Because they have much more comprehensive needs, many of which are not medical.”

Instead, measuring quality has to evolve to understand the different ways care has to work for these individuals. NCQA has established new accreditation and distinction programs to assess organizations responsible for coordinating LTSS. The programs establish standards for nonmedical services, such as help bathing, shopping, and cooking, that people may need help with as a result of aging, chronic illness, or disability.

“Those are the new frontiers and what we’re excited to work on these days,” O’Kane said.

Beginning of a Movement

O’Kane began her healthcare career as a respiratory therapist. She worked in a number of hospitals—some good and some not so good.

“Even in the good hospitals it was very clear to me that the way the care was organized was not giving good results,” she said. “There was a … lack of definition of what was supposed to happen. Standards were not widely used.”

Respiratory therapists had guidelines regarding lung volume for patients on ventilators depending on the patient’s size; however, at the time the guidelines were rarely used.

When she started working in quality, it was for a health maintenance organization trade association. O’Kane worked with medical directors to create a quality agenda, but she got the feeling “they didn’t believe you could measure quality.”

When she founded NCQA, the reaction to the organization was varied. But there was one group that really put NCQA on the map: employers.

At the time, Fortune 100 companies were hiring consultants to visit health plans and they were shocked that health plans couldn’t answer basic questions, such as how many people with diabetes were in their population.

“Something magical happened when we got [the companies] all together and said, ‘Why are you all doing this separately? Couldn’t we all do this together?’” O’Kane explained. “And that was the way we got our start.”

Employers also had a big hand in getting the Healthcare Effectiveness Data and Information Set (HEDIS) used across the country. With the implementation of the HEDIS measures, employers had common expectations and began mandating accreditation and HEDIS reporting. Then, NCQA approached states to highlight all the quality measurement HEDIS covered that the state regulation of health plans was missing. States began adopting some version of NCQA’s HEDIS measures.

“We’re recognized in 38 states,” O’Kane said. “So if you get accredited and you report HEDIS, then that will get a bunch of regulatory requirements at the state level waived.”

NCQA followed up the success with Medicare and Medicare Advantage plans.

Leading the Way in Quality Measurement

When NCQA was new, it was sometimes underestimated, or even not taken seriously, O’Kane said. But there were people doing work in the area of quality that NCQA learned from. One was Donald M. Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement, and former administrator at CMS.

Current leadership at CMS, including Patrick Conway, MD, MSc, deputy administrator for innovation and quality and CMS chief medical officer, and Kate Goodrich, MD, director of the Center for Clinical Standards and Quality at CMS, have also done tremendous work in the area of quality measurement, O’Kane said.

As a result of the work CMS has done with the Star ratings system, health plans can no longer say that quality is not a business issue.

“[Now] it definitely is a business issue,” she said. “So that’s gratifying.”

Watch past videos with O'Kane:

Margaret O'Kane Says AJMC Has Helped Share Learnings Across Healthcare

Margaret O'Kane Predicts How Managed Care Will Change in 20 Years