This week, Chris Altchek, Founder & CEO of Cadence, is joined by Peggy O’Kane, NCQA Founder & President. The two discuss the origins of the NCQA, the role the organization has played since its founding in measuring healthcare quality, the difficulties in data collection, and what the future of quality care looks like as healthcare moves outside the four walls of the hospital.
This episode is hosted by Chris Altchek, Founder & CEO of Cadence in conversation with Peggy O’Kane, NCQA Founder & President.
Their conversation focuses on:
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Introduction
Welcome to Cadence Conversations, where we're talking with prominent physicians, healthcare leaders, and tech entrepreneurs about their experiences driving innovation and progress. This week, Peggy O'Kane, founder and president of the National Committee for Quality Assurance, connected with Cadence CEO, Chris Altchek. The two got to chat about the origins of the NCQA and the need for a standardized measurement of healthcare outcomes. Peggy also shared a vision for the future and offered some advice to clinicians who care about quality. So let's get to this week's Cadence Conversation.
Chris Altchek (CA):
Peggy, good morning. Thanks for joining me today. I'm really excited to discuss the role that the NCQA has played in the US healthcare industry since founding in 1990. But before we talk about that, can you tell us a little bit about your career? What brought you into healthcare initially? And after more than three decades now working on the front lines to improve healthcare quality across the US, why are you so passionate about what you do?
Peggy O'Kane (PO):
Yeah. Well, so I have an interesting biography because I was a French major in college and I graduated from college and said, "I don't want to be a French teacher." So I kind of looked around for what I could do and I landed in respiratory therapy, which was a great way to get a bird's eye view of quality in hospitals because respiratory therapists work in hospitals. And I'm not an engineer, I don't think like an engineer, but even to my naive eyes, it was kind of shocking to me how disorganized the care was. And I would watch, one doctor would come in and say, "Increase this." And then the next doctor would come in and say, "Back off on this and put in that." And it was only if you had a heroic nurse who was watching all this and said, "I'm sorry, you guys need to speak to each other and we need to have a coherent plan here."
So it was a level of disorganization that was just shocking to me. A lot of the things are just about orderly management of patients and designing clinical processes. These were not words that I understood at the time, but I kind of woke up to this and it was at an opportune time to wake up to it. And at the time there really wasn't, there was quality assurance, but it was really not in any way scientifically driven or there was a lot of understanding and industry about how quality is not an accident. It's not just about getting the best people. It really is about discipline and process and self-study and continuous improvement.
CA:
And how did that bring you to the NCQA?
PO:
I graduated from Hopkins. I worked for the Health Services Administration, which was then, it's now HRSA, but it ran community health centers and it did a lot of maternal and child health. They were actually doing, they actually had prototypical quality measures for community health centers. And being I would go out in the field too and visit with states that had maternal and child health programs. So it was a great learning experience, but it wasn't in the field of quality because those jobs were really kind of, not the kind of thing that I wanted to spend my time doing. But what happened in the meantime was, Don Berwick was starting to think about this, a lot of companies in the United States were doing continuous quality improvement, like the autos challenged by Japan. They had to learn what was called the Toyota Production System. So the techniques that Deming had, had to go to Japan to get adopted, were permeating our society. And people in those companies that were buying healthcare said, "What about you, healthcare? We're paying a lot for you and we don't feel like we're getting very much. In fact, we don't know what we're getting." So that was our foothold.
CA:
So interesting. And there's two ideas there. One is, the bringing the Toyota method into healthcare. What have you learned about bringing outside in change into healthcare and driving system wide impact?
PO:
It's really hard. It's really hard. Well, I mean, I think it was a good thing that Don Berwick was such a wonderful evangelist for this stuff. And IHI, he started IHI not much later than NCQA started, and the hospitals were beginning to get a lot of questions about what was happening and could they prove that they were good quality and so forth. And it really was the outside forces. I mean, there are always believers in any industry that really wanted to do better and there's no shortage of people that went into healthcare with all the best intentions and then took a look around and said, "This isn't really why I'm here." So the thing I can point to is one, the idea of population health management, it feels like it's here to stay and maybe we're going to really make it real. And the idea of processes that need to be re-engineered systems that support people towards better care. Those are the things that we stand for and that we've helped to advance, but we're nowhere near where we need to be.
CA:
And where is the focus of the organization today?
PO:
HEDIS originally was the brainchild of a benefit consultant and some plans. And it was, can we have a common way of measuring things that we want the healthcare system to do. Immunization rates, or was the right thing done for a person with diabetes? How's the blood pressure on this person? But they were all doing it differently. And so HEDIS had the idea of let's have really common and clear descriptions of how this needs to be done. And so we started creating all these rules so that we could have some confidence that when this plan has an 85% immunization rate, and this one has a 80% immunization rate, that's actually a meaningful difference. It's not just that they played with their data more effectively. So we've created a whole infrastructure around ourselves. But what became clear to us maybe five years ago, is the kind of, at the practice level what was happening was a lot of noise, irritation, practitioners having to go and comb through records to find data and so forth.
PO:
And we thought this is not going to work. If the people that are delivering the care are alienated and disgusted by quality measurement, that's wrong. So we embarked on a journey to digitalize HEDIS. And it turns out digitalizing performance measurement is, it's a good thing to do and it's especially helpful to organizations that have their data organized properly. But it turns out most of the delivery system doesn't have that. So we're working on digitalizing HEDIS, but there's a larger thing that's happening, which is people trying to figure out how to have the data at their practitioner's fingertips at the moment that they need it. The idea is not to judge failure or to say you're better than you are, it's to really enable success at the point of care. And the fact that that's not digitally enabled the way it needs to be in most places, has become our passion project. That's the thing that makes us get up in the morning.
Interlude: At Cadence, we have a world-class care delivery team who serves as an extension of our hospital system partners and help manage patients' care on a daily basis. In care delivery stories, we'll hear from one of our team members about the impact Cadence is having on their patients.
April Clarin: A patient who recently enrolled in Cadence's program had no history of heart disease, but had multiple cardiovascular risk factors. During an initial visit when our care delivery team did a deep dive into their symptoms, medical history, and medication, the patient told us they were experiencing chest pain with exertion.
The patient's physician was notified, who immediately got back to us to let us know that they ordered a nuclear stress test to check for a possible blocked coronary artery. Cadence's program helped to identify this at-risk patient and facilitate quick diagnostic testing with our partnering physician, potentially saving them from a major cardiac event.
CA:
Yeah. I mean, there's so many themes there from a Cadence standpoint, a big part of our mission is making it really easy for clinicians, primary care doctors, cardiologists, to help their patients achieve guidelines and do it without creating more work for the physicians, do it in a way that's safe and is empowering for patients. And that is one of the big promises of technology and services that if we can put those things together, we can help standardize and achieve these great outcomes without creating a lot of burden on clinics that just can't absorb any additional burden today and shouldn't have to and ideally it reduces the burden. As you think about the next five years, what are you most excited about?
PO:
The potential for digital transformation of the care process, I think, is the thing that, now let me give you an example, because that sounds like who knows what I'm talking about. I think about continuous glucose monitoring. So we do an annual digital quality summit and last year we had a whole track on diabetes and what was happening with diabetes. And I think you're probably aware that people wear these remote monitors and they get real time feedback on what's going on with their blood sugar. And I think it has tremendous potential as a motivator if it's done right, but a lot of it right now is just kind of giving people too much data and not enough information. And then there's a whole, there are some companies that are sort of taking over the care management process and there are companies that have actually reversed type two diabetes, and they've actually gotten people off insulin, if not off all meds and so forth.
PO:
And I mean, to me, if that's possible to do, and I know it's not possible for everybody, of course, but it really ought to be a first line of attack, I think. Now sometimes, one of the doctors that works at NCQA said to me, "Oh my God, my colleagues hate that stuff because it comes flooding in, they don't know what to do with the data, they turn it off." And it doesn't even feed into the electronic health record at the moment. So, I mean, I think what you're doing, trying to kind of figure out how do you organize that information, how do you give it to them in a way that they are empowered with it? That's a fantastic mission. I feel very excited about stuff like that, because we're still practicing in ways that are pre-digital. Every other industry has been transformed and we've seen tremendous benefits.
CA:
We couldn't agree more. And what we're seeing is helping some of these patients with chronic condition, whether it's heart failure or hypertension, diabetes, achieve guidelines, sometimes requires medication, titration and coaching every week or every two weeks for-
PO:
Exactly.
CA:
... four months. And obviously the way PCPs are set up today, they're not resourced in a way to be able to achieve that. They don't have the data and they don't have the clinical support, the team based care model. And so by supporting, by helping it and making it easy for all those things to happen and taking a lot of that work that's not at the top of a license for a PCP and having an APP do it or an RN support, there's huge advantages to the PCP actually being able to spend the time in person with a patient on the stuff that is more challenging and that really only they can solve. You've been doing this for so long, you've seen big changes before, as you think about the impact of COVID, are we in a new era now and what are the things that are going to really push these programs forward in a way that they've been not, maybe haven't moved as fast as we'd hoped previously? And then sort of, what advice do you have to all the people who do care about quality? What kinds of things should they be doing? Who should they be engaging with? How do we really create a lot of momentum here?
PO:
What we've got to do is learn from what's happening. And I keep looking with envy at Israel because, Israel has its own problems but when it came to vaccinations, I think, they have four HMOs actually in Israel, they're all on electronic clinical databases. I guess, the Ministry of Health of Israel reached out to Pfizer and said, "We can give you real time information on how the vaccines are working because we process our information that effectively." And so they got an early, they got more than other countries did. We haven't really set up a situation to learn from what we're doing. Now, Israel spends 7% of GDP on healthcare. We spent three times that, and we should be getting more. The idea that you're able to learn in real time from the practice of medicine, to me, that is really the north star here.
CA:
Maybe just to wrap up, NCQA is always on the cutting edge of care delivery transformation. What new programs can we expect you to be thinking about over the next five years?
PO:
Well, you can help us think about care at home. I mean, we had a lot of hospital at home, interesting stuff happening. It seems to have died down, but I think we need to be rethinking care models and you're in a great position to help us think about it. Because, do I think everything's going to happen in the home? No, I don't, actually. Do I think it can enhance the, I mean, it changes healthcare and this is not my idea, but from a visit to a relationship, right? And you don't always need a relationship, but in many cases you do. And so enabling that in a way where it's not harassing patients and it's not harassing practitioners, but there's an intermediary that's kind of translating it, teaching, figuring out new ways of getting to goals and so forth. I think that the job of being a doctor is going to be so much more exciting in the future, and even a nurse or the other people on the care team, I think it really is great. And we've just got to get ourselves organized. I mean, the chaos factor is such a negative for everybody that works in healthcare.
CA:
Yeah. We couldn't agree more. And actually we're also seeing a lot of interest and demand from clinicians for these new types of roles, whether it's remotely monitoring patients or remotely titrating medications, we're seeing people want to practice in different forms, virtual and in person or mixed. And just creating more opportunity for clinicians is actually, I think, going to unlock a lot of things because there's some deep frustration with some of these where you can only work in a hospital and there's one career track. So the last question, what advice do you have for clinicians who care about quality?
PO:
Well, I think, it's not only up to them. So let me just put that out there because, I think, the primary care work core in this country has been abused and it's a very, very hard way to make a living. And when you see a practice that's humming along with team based care, I'm thinking of a practice in Hudson, New York that I visited about 10 years ago, where they had the whole team sitting there and it was really population health management in action and they had electronic medical record. But it wasn't the futuristic model, it was what was possible at the time. So I think it's kind of figure out how to organize the work so you're not underwater all the time, because you're never going to be happy and you're never going to be as effective and you're never going to be able to kind of evolve the practice until you kind of get your head above water, I think, that's the thing. But, I think, that everybody that works with, I mean, that's what, I think, you're trying to do. I think a lot of them are very worried that they're going to be replaced and even medical boards, medical societies, I think, have a role to play in helping people move into this new way of practicing. So.
CA:
We agree and we hope that, I mean, we're seeing it in some places in the country where the PCPs are becoming the quarterbacks of the whole patient's entire care.
PO:
Absolutely.
CA:
And that's a really exciting future.
CA:
Peggy, thank you so much for spending time with us today. We really appreciate it. Very excited to see the future for the NCQA and thank you for everything you've done.
PO:
Oh, thank you. I enjoyed it.
Conclusion:
Thanks again to Peggy for visiting with Chris this week. To make sure you get updates on our future conversations, please subscribe to Cadence Conversations wherever you listen to podcasts. And for more information about Cadence and how to get involved, visit cadence.care. At Cadence, we believe that everyone deserves to receive the best care possible and we won't stop working until that vision becomes reality.