NCQA Population Health Management (PHM) Category

The National Committee for Quality Assurance (NCQA) has been accrediting health plans for over 20 years, providing ratings for plans that cover more than 136 million Americans. For 2018, NCQA has introduced new population health management requirements for health plans seeking accreditation. The Population Health Management (PHM) category was introduced for 2018 to support the Triple Aim and practice transformation to value-based care.

The PHM standards build upon existing requirements for wellness and complex case management, but further enforce the shift from a single-disease state towards a whole-person focus, as well as better alignment with delivery systems. Several elements require robust data integration and population segmentation, which highlight the need for advanced analytics and data warehousing capabilities. Further, interactive contact with eligible members is required to inform them about PHM programs, necessitating the need for multi-modality member outreach options.

PHM Category Standards

This category introduces new standards and elements, as well as combines items from existing standards (*). There are six PHM standards:

    • PHM 1: PHM Strategy (*Includes former QI6/Element B: Informing Members)
    • PHM 2: Population Identification
    • PHM 3: Delivery System Supports
    • PHM 4: Wellness and Prevention (*Includes MEM1: Health Appraisals & MEM2: Self-Management Tools)
    • PHM 5: Complex Case Management (*Formerly QI5)
    • PHM 6: Population Health Management Impact
  • PHM 7: Delegation of PHM

SPH Helps Health Plans Meet PHM Standards

NCQA recognizes health plans may use vendor solutions and delegations to support their PHM programs. SPH Analytics (SPH) is well positioned to support many of the PHM standards and elements, such as patient engagement, data aggregation, and population segmentation. As a vendor already recognized by NCQA for PCMH pre-validation, SPH will also apply for pre-validation for PHM should this anticipated program be introduced by NCQA.

For more than two decades SPH has worked with health plans across the nation to support their Health Plan Accreditation and reporting needs. SPH offers multiple tools and solutions to support compliance with the new NCQA PHM category.

NCQA PHM Standards Supporting Solutions from SPH
PHM 1: PHM Strategy Multi-Channel Member Outreach
(Onsite Healthcare Call Center | Email | Mail)
·   Inform/contact members
PHM 2:  Population Identification

SPH Nexus Platform and Population Care Application
·   Claims- and EMR-based data acquisition and aggregation
·   Multi-factor population segmentation

PHM 3: Delivery System Supports

SPH Nexus Platform and Population Care Application
·   Timely care gap sharing with providers

PHM 4: Wellness and Prevention Multi-Channel Member Outreach
(Onsite Healthcare Call Center | Email | Mail)
·   Member outreach – Health Appraisals
PHM 5: Complex Case Management

Case Management Member Experience Survey
·   Assess members’ experience with case management

PHM 6: PHM Impact

Member Experience Survey Results
·   Measuring effectiveness of PHM functions

Click here for more information about SPH Analytics solutions and the new NCQA PHM Category.

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