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Quality Assurance Toolkit for Primary Care Physicians

Quality Assurance Measures for PCPs addressing the needs of Patients with Behavioral Health and Substance Use Disorders.

What is NCQA?

The National Committee for Quality Assurance (NCQA) is an organization that accredits health plans and Managed Behavioral Healthcare Organizations like Optum. This Accreditation is posted nationally and used by consumers as a way to identify organizations that have a strong focus on quality and outcomes.

What is HEDIS®?

Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans.

There are HEDIS® measures for both behavioral health and physical health conditions. Examples for physical health include: Immunizations, Diabetes, Mammography, Cholesterol, High Blood Pressure, etc. 

  • Centers for Medicare and Medicaid Services (CMS) requires all health plans that provide services to Medicare or Medicaid consumers to collect HEDIS® data

Why is HEDIS® Important?

  • HEDIS® results have a significant impact on health plans accreditation
  • Many plans also have state incentives or penalties related to HEDIS® performance
  • Improvement in HEDIS® measures demonstrates that enrollees are generally experiencing better outcomes