The Work Isn’t Done: Margaret ‘Peggy’ O’Kane on Quality, Data, and Driving Change || EP. 192

[00:00:00] There are undeniable differences in health outcomes among different population groups. And I think what we're hearing at this point is that this trying to get at disparities and outcomes is actually okay with the federal government, with this administration. So there remains a lot of clarification that needs to be done.

[00:00:26] But, you know, and, you know, there's, I think, a reluctance to collect data on race and so on. There are ways to work this that are more, maybe not ideal from a research point of view, but, for example, zip code. You can tell a lot about a person's external health risks from their social situation by where they live.

[00:00:52] Now, it's not perfect, but neither is the other way. So, you know, I think people need to kind of be determined to kind of push through what can we learn about how to approach this. This is Inspiring Women and I'm Laurie McGraw. And today I am speaking with Peggy OKane.

[00:01:16] Peggy is a legend. And if we say the word quality, then we're talking about Peggy because 35 years ago she started the National Committee for Quality Assurance, NCQA, as we all know it. It is the epitome of quality in health care today. Peggy, thank you for being on Inspiring Women. It's my pleasure, Laurie. Thank you so much for asking me.

[00:01:44] Well, let's let's just dive in. So, Peggy, it is 35 years of commitment to creating the space of quality and making health care better. So let's just start at the beginning. And why NCQA? Where did it start?

[00:02:01] Yeah. NCQA has its roots in the employer. Well, the employer embrace of HMOs that it started the HMO Act, which was a national piece of legislation to try to advance concept of HMOs passed in 1973.

[00:02:22] And then there was a long period of trying to engage employers in HMOs that was helped along by the what the employers thought were unacceptably high health care costs. And employers were they were fully insured in those days. That's different from today when the typical employer has a one to one relationship with a self-insured plan.

[00:02:50] I mean, the employer is self-insured and they have a plan partner. So so employers were ready to go on HMOs. They love the idea of keeping people healthy, of being accountable for costs and so on. And they were worried because HMOs did not have a great reputation at the time.

[00:03:14] And of course, we know that's been a long term situation where people are very distrustful of the idea of having a fixed amount of money that they agree to take care of a population for. Anyway, we found, you know, I went to graduate school between being a respiratory therapist and and coming out to work and wanting to advance quality.

[00:03:43] And so I got a degree from Hopkins. I learned all about the theories of quality and I learned that really nothing much was happening to advance quality except for doctors reading each other's charts, which was called peer review. So peer review has a very not great reputation because there's a lot of inter-rated reliability. There's kind of attitudinal things like well inside baseball.

[00:04:11] Yeah. And if the patient didn't die, maybe nothing really terrible happened, which is we also know is not true. But these employers and we were very fortunate to work with Fortune 50 employers in the United States. And they were at the same time trying to do continuous quality improvement.

[00:04:28] So we had not only backers of the concept of having an accreditation program and quality measurement, but people who were black belts in quality themselves and who really understood, you know, that if you can't define the population, it's hard to know. Like what, you know, how are you doing? You know, the idea of quality as a system and a population concept was not widespread in health care.

[00:04:56] It was like I take care of the patient in front of me. And maybe if I remember that they haven't been in for a while, maybe I'll remember. You know, this is it was left to human beings to develop the systems that really did not happen because people were not trained that way in health care and so on. And so we were very, very fortunate to have these leaders emerge from the purchaser segment and to help us with the program.

[00:05:24] So there was a very rapid writing of standards and mandates by employers. And so we were kind of we opened our doors and we were immediately a player. And we did a report card pilot project of reporting. I would call it HEDIS version zero, which had been developed by other people.

[00:05:49] And I should give credit to Daniel Wolfson and the HMO group who really developed the idea of taking claims data and seeing how does this care look if you just look at the claims? And the idea of population health was already established by these people. So we you know, I think I'm giving you an idea that we came along at a time when the ground was ready for us. And that was a fantastic thing. Well, it's like lightning. It's lightning in a bottle.

[00:06:19] But Peggy, if I could just ask you, I mean, you were obviously not alone in understanding sort of like the landscape and the need for need for this. But what is it what is it about you that brought everyone together to form NCQA? Because lots of people write about these problems. A lot of people, you know, bemoan the issues.

[00:06:42] It takes something quite special to put together and and move what is you know, you were you were on a journey as a respiratory therapist. You know, you were doing clinical work. But then you said, I'm actually going to focus on this now. So so what is special about you, Peggy? And please don't tell me nothing. It was other people. No, I don't believe in false. But I mean, really, it was it was the ability to kind of.

[00:07:10] Create a movement of people who who really were thinking along very similar lines or who taught me how to think about it, really, to be honest. So and. I also think it was being grounded in the reality of what was going on in health care and not being in some theoretical mode of research and what could happen and so forth.

[00:07:34] So talking to people who were in health plans and, you know, the medical directors of health plans, many of them had gone to public health school. They understood population health. They were excited about trying to take this HMO concept and really improve people's health through health insurance, which was not the original way people thought about it. OK. Yeah. And so I was just blessed to have a lot of fellow travelers.

[00:08:03] Maybe I shouldn't use that word, but colleagues who really understood what we were trying to do and were excited at the concept. So that that was it. And, you know, there were people in there were plans that believed that they were doing an outstanding job. But it was very hard to tell their story because people would tune them out and say, well, yeah, that's what you tell me. But how can you prove that you're actually doing better than the than the other person?

[00:08:31] You know, so so the idea of trying to create a market and then reward people who really exceeded expectations and did really well, that was coming from the employers and and also from these plans that were frustrated at their inability to kind of reap the rewards of their commitment to quality. Very much a market based idea. Well, and a market based idea that really took took off.

[00:08:59] So so this version 0.1, the pre version when you quickly put it out, then what happened? Well, we had a report card pilot project. It was pretty much of a, you know, learning experience. And a lot of people felt people. First of all, they learned that they weren't doing as great a job as they thought they were and that their data needed to be attended to.

[00:09:27] But I'm going to I'm going to fast forward because I think we really developed together with the plans and with the employers. What did we mean by population health? And we started with preventive measures because there was good sorting of evidence by the preventive services task force. And then we moved on to to things like chronic illness, like diabetes, heart disease and so on.

[00:09:56] We have some behavioral health measures. But the measure set, it's been pretty consistent over the years. And I think people are impatient to see something that feels more comprehensive and more ambitious, to be honest. You know, we're very proud, for example, that colon cancer screening rates about doubled in this country after we launched this. And we know that he just goes beyond what the health plans do.

[00:10:26] So, you know, we're proud of the progress that's been made as a result of I always call that we turned on the lights, you know. So, yeah. But now I feel like we're at a moment and we've we've been at this at NCQA for about four years. How do we move health care more into the future through digital reporting of measures and through the digital enablement of really.

[00:10:55] State of the art care, I guess is what I want to call it. And we're working on a paper right now called Right Care. And it's kind of it's both going beyond the original HEDIS measures. But, you know, trying to tell a story about what is good quality care look like? And we one of them can give you an example. It's people with diabetes. Right.

[00:11:20] Well, we'd like to expand the view to not only people who currently have diabetes, but what about people who have prediabetes? Is there a way to compare one plan to another or even a delivery system to another on how effective they are in delaying the onset of diabetes? So the average time is prediabetes. None of these things are worked out yet. So I'm just foreshadowing some of the things that we think are really interesting.

[00:11:47] Another thing is many people with diabetes go on to develop kidney failure. And we know that's really pretty bad for the patient. It's bad for our national economy. Yeah. It costs a fortune. People feel terrible. They're, you know, often sitting in dialysis centers, spending, you know, the last days of their lives in really not a very happy state. And we know that it's possible to delay the onset.

[00:12:15] So we're looking at things like that. So we're trying to expand the aperture to things that are both clinically important on a population basis. They're important on a cost basis. They're important. And we want to get, we want to take a deeper look.

[00:12:32] And we want to encourage the delivery system writ large, including plans and providers, to be more ambitious and to show us what they're doing to improve the health of Americans. Can you talk about where you started 35 years ago, where we are today? And then so with a more ambitious future. Yeah. Do you feel that we're not, we haven't been ambitious enough?

[00:13:02] I do. And I want to own some of that. Okay. Because, you know, we developed, we developed, you know, Gen 2, Hedis, and we were proud of the work. And we, you know, we knew that it was a pain for clinicians to get the data. Yeah. And I think it was the, it was the constant feedback from clinicians about how hard this was on them and how the measures were actually not even aligned.

[00:13:32] And so they're being told one thing about their individual assessment, one thing about them as a, you know, part of a delivery system and another thing as an agent of the health plan. And so we got on this kind of, and CMS was aware of this and talking to us. So I want to give also full credit to CMS for getting ambitious itself and for wanting more.

[00:13:58] So what we see now is we're at this kind of awkward stage. We have converted the Hedis measures to electronic digital measures. They can be reported. The delivery system and the plans, the state of data is, I would say, fairly chaotic at the moment. Yeah. And we are working with various partners, with some vendors.

[00:14:24] So we have people who, like us, see the promise of having this digitally enabled delivery system and who are very excited about it and want to be part of moving us forward. So we're in that stage. And it's been a very great learning process. We have partners that we're excited to work with.

[00:14:48] But it's still not at a place, I think, where the clinicians are excited about it. You know, quality has gotten kind of a bad brand with a lot of clinicians who, I mean, I think there's a fundamental instinct to say, why are you grading me? Or like, I didn't control that. But, you know, there are a lot of reasons why there is this reaction. But mostly it's called the pajama time, right?

[00:15:15] When the doctors are home at night filling out their quality reports. And so like finishing their electronic health record test. Exactly. Exactly. So it needs to be better. But we're very excited about the promise of this. And so let me pause there. See what you want to ask me about that. I'd like to know what the promise is. So in terms of, you know, if the promise were fulfilled, what would the state of quality look like?

[00:15:43] Well, first of all, it wouldn't just be MA plans that are seriously accountable. And, you know, I think one of the things I think is that CMS needs to think about people who are choosing at the time that they become Medicare eligible. And what kind of information do they have on all their options? So they've got some very little information about perhaps choosing an accountable care organization. It's kind of confusing.

[00:16:12] And there are different models and so on. Classic Medicare, there's no quality information. Now, I think often people think, well, I have a good doctor and they can manage me. They can help me navigate the system. And that may be true if they're lucky enough to have a doctor or a system that has that kind of capabilities. But when we look at the data, we don't see that reflected.

[00:16:36] And, you know, I'm remembering years ago there was a classic Medicare quality management demonstration. And it turned out that like many people with diabetes, to go back to that example, haven't seen a doctor in four or five years. Yeah. So they were on a fast track to very bad things happening. Outcomes, right.

[00:16:57] So is there a way to think about that or at least to benchmark what we're getting with classic Medicare, with ACOs and with Medicare Advantage? And to kind of encourage people to choose one that makes more sense for them. I'm going to say that I think plans need to demonstrate that they can do this at an affordable cost.

[00:17:22] And the fact that there's a lot of resentment of the fact that plans often are getting more money than, you know, other players in the system. Now, to be fair, they're often doing additional things. They're offering additional benefits. But I think if you're thinking about zooming back to the big picture of this country, we're close to 20 percent of the spend on health care.

[00:17:48] And that has been taking away money that might be spent on other things. So I think we're not at a crisis or some people would say we are. But it doesn't feel like the health care system believes we're at a crisis yet, of course. But I think we're getting there fast. And as the baby boomers really start using more and more services, it'll quickly become a crisis. So I think health care has a responsibility to step up to that.

[00:18:18] In so many ways. And it's more than just the cost equation. I mean, just the overall system has become more complex. There are more options. For the average consumer, you know, you are confused in terms of how to navigate your health and care options. Absolutely. That are out there. So if we think of a more ambitious state for quality in terms of where you want the work to go,

[00:18:45] who are the key constituents that need to be aligned with NCQA to get to that more ambitious quality opportunity? Yeah. Yeah. Well, it's the plans. It's the delivery systems. Yeah. It's vendors who are enabling a lot of, you know, there's kind of, I'm thinking about like a vendor that kind of surrounds primary care practices.

[00:19:15] I won't call out a name. But there are vendors like that. They're pretty famous. They're doing a good job of showing these practices their data. They're identifying care gaps and helping them with the outreach to bring people in for whatever they need. So it's the payers, the providers, and the vendors, I think. Now, CMS is a critical partner. Right. They've been a very good partner.

[00:19:41] They've been, I think, responding a lot to back pressure from providers who don't want to report digitally. Yeah. And that's been frustrating. So we would like everybody to kind of like get the courage to kind of take this stuff seriously and push forward.

[00:20:00] There is a big job for like convincing consumers that systematic care is really what they want and that they, you know, and we don't want them to just accept our reassurance that they're going to get the care they need. We need to have better measures that show them that they're getting better care. To build trust and in many places restore trust. We know that trust is including, you know, particularly in the larger brands and systems and the like.

[00:20:28] But I actually don't want to go there. Actually, Peggy, what I want to ask you about, you've been a strong advocate and speaker on measures for health equity, racial disparities, things of that nature. Can you just talk about that? Because I believe that is critically important to improve outcomes, to change the cost curve, do all of the important things. Yet we are getting more pressure to take those measures and that recognition out of the system.

[00:20:58] So as you think about the work that you have done in NCQA and what needs to be done in front of us, how do you, what's the advice? What is your words of wisdom that we must continue to stay focused on for the future? Well, I mean, I think that there's been a lot of pushback on what's called DEI, right? Diversity, equity and inclusion. And a lot of that has become problematic for those that contract with the federal government.

[00:21:28] So leaving that aside, because that's all being worked out. There are undeniable differences in health outcomes among different population groups. And I think what we're hearing at this point is that this trying to get at disparities and outcomes is actually OK with the federal government, with this administration.

[00:21:54] So there remains a lot of clarification that needs to be done. But, you know, there's, I think, a reluctance to collect data on race and so on. There are ways to work this that are more maybe not ideal from a research point of view. But, for example, zip code.

[00:22:18] You can tell a lot about a person's external health risks from their social situation by where they live. Now, it's not perfect, but neither is the other way. So, you know, I think people need to kind of be determined to kind of push through what can we learn about how to approach this.

[00:22:40] There's also kind of we're early days in this stuff and best practices need to be identified and shared and people need to learn what to do because it's relative. We're in this learning situation. And what you might think is the right thing to do may not turn out that way. That health care is filled with examples of things that sound like a good idea and then they don't pay off.

[00:23:06] So what we need to do is build out this best practices idea, share it widely, and help people kind of have a coordinated attack on disparities. So stay determined on focus on the disparities. Follow the data. Follow the data. Avoid the noise. Follow the data and work on the outcomes and stay ambitious and courageous.

[00:23:30] Peggy, as we, I just want to, two more questions, just as we think about all of the work that you've done at NCQA, this ambitious future and this courage that is needed. How do you think about the legacy that you are leaving this industry with NCQA? Well, I feel like there's so much work that's undone. And there are just a lot of things that need to be addressed.

[00:23:58] The payment model is really not conducive. The fact that if you're a delivery system, you can be quite happy doing things the old-fashioned way, not really thinking about populations, not improving health. There's an old cliche called heads in beds. That model is still strong. And so it's kind of like, this is not, this was not going to be accomplished in my career. And, you know, like I hope it's accomplished.

[00:24:28] It's not even in my lifetime. You know, honestly, it's a big deal. And everybody's been trained to work in the current model, right? So people, you're asking things to do, do things, people to do things that are really kind of upside down from how they learned. And so it's just a matter, it's persistence, it's curiosity. It's not getting too wedded to your own ideas of what good is, because that will make you blind to things that aren't working.

[00:24:57] So it's all of those things. It's like character building for the healthcare system. That's what's needed. Well, you have brought tremendous character to the healthcare system. So Peggy, as we close out with this Inspiring Women conversation, and you reflect on what you're proud of that you've accomplished, but as you want to inspire the next generation of amazing leaders to carry the torch.

[00:25:22] You know, what, as you reflect, like, what is it that either you want people to do exactly like you did or do differently from all that you've learned to push ahead for the future that you see available to us? Well, I think it's listening. It's listening a lot to people that are doing our programs. And, you know, sometimes they tell us, you know, this stuff is really a pain and it's really a burden. And we took a long time to respond to that.

[00:25:53] It's really more about, it's kind of like we have the means now to do things in an incredible way with, you know, with the data. And so we can learn, we can learn to customize care so that, you know, like not everybody is the same kind of person with diabetes. They, you know, everybody's kind of different. I just, I feel so excited for the future of this.

[00:26:21] And, you know, I think that the biggest lesson of all, though, is patients are very unhappy with American health care. And we need to take that in. We need to learn from them about better ways of doing what we're doing. And also not just patients, but doctors and nurses. Let me just go to them who have really not recovered from their burnout and their disillusionment and moral injury from COVID.

[00:26:50] And so the people, you know, as we're bringing in, you know, new tools like artificial intelligence, we've got to really stay with the people. And what are they, what do they need in order to bring their best selves to healthcare every day? That is an incredible North Star to leave us with. I've been speaking with Peggy O'Kane. She is the founder and the president of the National Committee for Quality Assurance, NCQA. Peggy, you're a legend.

[00:27:20] It's been my honor to speak to you. Thank you so much. Thank you, Lori. Great. It was a pleasure. Have a great day. This has been an episode of Inspiring Women with Lori McGraw. Please subscribe, rate, and review. We are produced at Executive Podcast Solutions. More episodes can be found on inspiringwomen.show. I am Lori McGraw, and thank you for listening.