The DMCB understands the adage that a) quality cannot advance without measurement and that b) the NCQA methodology has resulted in untold jumps in quality and lives saved. Kudos to the NCQA for taking this assessment hammer to a new set of nails.
Yet, the DMCB has three concerns about the proposal:
Well executed disease management raises all boats: While DM programs can always do a better job of documenting and reporting their clinical outcomes, the DMCB believes effective population-based coaching programs that successfully engage patients in self care will spin off increases (for example) in A1c testing in diabetes, appropriate prescriptions for asthma and flu shots when chronic heart failure is present. The opposite is not true: prompting patients to get process-based lab testing, prescriptions or flu shots will not necessarily promote optimum self care. After these specifications are finalized and approved, the DMCB hopes disease management organizations will resist the temptation to issue (for example) a directive to its nurses to stop educating and start directing, to coach less and document more.
The definition of the 'medical record is changing: In true NCQA fashion, many ‘numerator’ criteria rely on traditional medical record documentation or insurance claims to fulfill criteria and obtain credit. Yet, the DMCB believes registry data collected by disease management organizations in the course of their outreach are also a resource. Patient self reports, documented by a DM nurse outside of claims or physician encounters, are a measureable and auditable source of measurement that are going untapped by much of the proposed NCQA methodology. While patient self reports are prone to error, so are insurance plans with pharmacy deductables. What’s more, what happens if the personal health record really takes off? Why not aggressively include patient self-reports in the numerators?
Patients may reasonably elect to not comply with NCQA criteria: Consider this scenario: a fully coached and empowered patient with chronic illness reviews the recommended menu of preventive services, understands the benefit of each, gauges at his or her needs, the doc’s recommendations, the out of pocket expenses and reasonably decides to forego recommendation “A” and adhere to recommendation “B.” This DMCB thinks that is not unreasonable not only because it happens in primary care clinics everyday, but because all medical interventions are not created equally. Why not include empowered patient refusals in the numerators?