Population Health Management Categories Explained

On December 3, 2018, the National Committee for Quality Assurance (NCQA) launched the new population health program accreditation to determine how programs for defined populations are applied at health care organizations.

Population Health Program (PHP) Accreditation

The NCQA Population Health Program (PHP) Accreditation standards provide guidance to organizations on how their program aligns with evidenced-based care, and how the organization can become more efficient and better at managing complex cases. This helps individuals become healthier by controlling risks and prevents spending unnecessary costs.

The program evaluates organizations in six categories:

  • Data integration
  • Population assessment
  • Population segmentation (stratification)
  • Targeted interventions
  • Practitioner support
  • Measurement and quality improvement

This is the first time that NCQA has used the term stratification rather than segmentation. Stratification allows a health plan to understand its member population and the types of services or interventions that are needed, and develop resources, activities and interventions.

Accreditation can improve patient-centric care by aligning an organization’s programs with Population Health principles, improving operational efficiencies, based on population health needs that reduce duplicate efforts and waste associated with misaligned goals. The new standards also support the implementation of effective, targeted population health programs that meet the needs of employers and health insurers.

A path to new standards

In August 2017, NCQA published its Population Health Management (PHM) standards. PHM standards combined data analytics with wellness and complex case management standards. NCQA also eliminated the Disease Management standard and some practice guidelines.

NCQA customers with Disease Management accreditation will transition to the new Population Health Program (PHP) accreditation standards. Have you developed your transition plan yet? HighPoint can help with the development of a transition plan.

The 2018 NCQA PHM Health Standards had addressed the following:

  • PHM 1: PHM Strategy
  • PHM 2: Population Identification
  • PHM 3: Delivery System Supports
  • PHM 4: Wellness and Prevention
  • PHM 5: Complex Case Management
  • PHM 6: Population Health Management Impact
  • PHM7: Delegation of PHM

On December 3, 2018, NCQA updated the Population Health Management Standards. The2019 PHM standards are part of the Health Plan Accreditation Program.

  • PHM 1: PHM Strategy
  • PHM 2: Population Identification
  • PHM 3: Delivery System Supports
  • PHM 4: Wellness and Prevention
  • PHM 5: Complex Case Management
  • PHM 6: Population Health Management Impact
  • PHM 7: Delegation of PHM

On December 3, 2018, NCQA presented the Population Health Program Accreditation, 2019 Standards and Guidelines for the Accreditation and Certification of Population Health Programs. The standards are effective for surveys with a start date of July 1, 2019, and onward.

The 2019 NCQA PHP standards address the following:    

  • PHP 1: Program Description
  • PHP 2: Data Integration
  • PHP 3: Population Assessment
  • PHP 4: Population Segmentation
  • PHP 5: Targeted Interventions
  • PHP 6: Practitioner Support
  • PHP 7: Measurement and Quality Improvement
  • PHP 8: Individuals’ Rights and Responsibilities
  • PHP 9: Delegation of PHP

Taking a closer look

We will now look closer at the nine new standards.

PHP 1: Program Description

PHP 1 defines how an organization develops its population health management program, and regularly updates the program with relevant information.

A program description shows how it was developed, identifying individuals who are eligible for the program, the services offered, and the program’s goals.

PHP 2: Data Integration

PHP 2 describes how the organization systematically collects and integrates relevant data to produce actionable information.

The organization integrates the following population health functions:

  1. Medical and behavioral claims or encounter data
  2. Eligible individual lists from client organizations
  3. Pharmacy data
  4. Laboratory results
  5. Health appraisal results
  6. Data collected through the utilization management, case management or care management process
  7. Data from health management, wellness or health coaching programs
  8. Electronic health records
  9. Information collected from individuals, practitioners and client organizations
  10. Advanced data sources

NCQA reviews the organization’s policies and procedures for data collection throughout the look-back period. NCQA also reviews reports and other materials (e.g., screen shots) to determine how the health plan integrates or has the capability to integrate types of data, and data from different sources. The organization may submit examples to NCQA that collectively demonstrate integration from all data types and sources, or it may submit a single example that shows the integration of all data types and sources.

PHP 3: Population Assessment

For the PHP 3 standard, the organization uses data to assess its population to properly facilitate interventions.

The organization assesses the characteristics of its population each year, including social determinants of health. It also identifies and assesses the needs of subpopulations, such as children and adolescents. It also assesses the needs of individuals with disabilities, and those with serious and persistent mental illness.

PHP 4: Population Segmentation (Stratification)

In the PHP 4 standard, the organization uses data or other information to segment or stratify individuals into categories for intervention. The organization segments or stratifies its entire population annually into subsets for targeted intervention.

PHP 5: Targeted Interventions

The organization provides targeted interventions to individuals in PHP 5, based on its person-centric goals. The organization demonstrates how its interventions are delivered to individuals based on an intervention plan and the organization’s goals.

PHP 6: Practitioner Support

The PHP 6 standard describes how the organization informs practitioners about the things that need their attention. This may include care opportunities, and assists the organization in collaborating with practitioners to gather their input or advice. Such input or advice can include the types of therapeutic interventions the practitioner uses.

The organization then provides documentation (e.g., case notes, communication between the organization and practitioner, etc.) that shows it collaborates with practitioners.

PHP 7: Measurement and Quality Improvement

In PHP 7, the organization measures, analyzes and improves its customer experience, program effectiveness and individual participation.

Using at least two measurements, the organization evaluates the effectiveness of its programs each year. The organization identifies a process or outcome, uses a valid method that provides quantitative results, sets performance goals, identifies measurement specifications, or uses a population-based measurement.

PHP 8: Individuals’ Rights and Responsibilities

In this standard, the organization is measured on the information that is provided to individuals to help them understand what they are entitled to and what’s expected of them while enrolled in the program.

PHP 9: Delegation of PHP

The organization remains responsible for and has appropriate structures and mechanisms to oversee delegated activities.

As you consider transitioning to the new accreditation standards, HighPoint Solutions’ team of Population Health Management Accreditation Specialists can assist you in developing a new Population Health Management (PHM) Program.

HighPoint’s Accreditation Specialists will conduct an onsite assessment and analyze your current population health models and programs. They will identify potential process and data gaps, which may pose a challenge in complying with the new NCQA PHM Standards. After identifying any gaps, our Accreditation Specialists can assist your team with providing a road map to assist with the transition to the new PHP standards. They will assist with providing clinical business and technical support to accommodate the PHP accreditation requirements.  Highpoint’s Accreditation Specialist can also assist with re-designing your current program, and, if necessary, developing new, cost-effective managed care solutions designed for your members’ unique needs, while also meeting the NCQA PHM Standards.

In our next blog, we will explore the specifics around the NCQA standards.

To learn more about how HighPoint can help you with this transition, contact Chris McShanag, vice president, population health.