The American healthcare system was not designed for patients who carry seven simultaneous diagnoses, take twenty pills a day and see five or more different specialists a year. It was designed for symptoms and episodes, for referrals and handoffs, and the assumption that patients can hold all the pieces together to navigate their own journey through the healthcare system.

Unfortunately, that design fails the most vulnerable patients every single day.

Among Medicare Advantage and Medicaid populations with multiple chronic conditions, fragmentation is not an exception; it is the norm. More than half report difficulty securing timely specialist appointments. One in five would rather visit an emergency department than wait for an office visit. Patients who receive care across more than one health system incur roughly 30% higher annual spending than those managed within a single, coordinated system. The clinical and financial consequences of fragmentation are not theoretical; they appear with every avoidable admission that could have been a phone call or conversation with a doctor, or every medication interaction that is duplicative or goes unnoticed because prescribers don’t talk to each other about their shared patient’s goals and treatment plans.

The question for healthcare leaders, payers and clinicians is not whether the current model is adequate—because we know it is not. The question is how to abandon antiquated practices and implement and scale true multispecialty, integrated care that exceeds what any single clinician or setting can address alone.

The Case for Multispecialty Integration

Patients with complex, polychronic disease, such as those living with heart failure, diabetes, kidney disease, chronic obstructive pulmonary disease (COPD), behavioral health challenges and socioeconomic barriers, do not experience their conditions in silos. Their diseases affect and compound one another; their medications interact; and their social circumstances shape whether any clinical intervention takes hold.

Treating these patients effectively requires a care model that mirrors that complexity. That means cardiology, pulmonology, nephrology, endocrinology, behavioral health, palliative care and pharmacy working from a shared clinical picture, not from separate charts and separate agendas.

When a 75-year-old patient with coronary artery disease, heart failure and diabetes presents with progressive shortness of breath and fatigue, the traditional pathway is a weeks-long relay race. For example, a primary care visit leads to a cardiology referral, which yields a negative workup, which triggers a pulmonology referral, which ultimately diagnoses COPD, prompting an emergency department visit because the process has taken months, yet the disease progression did not wait. By the time the right diagnosis lands, the patient might have been hospitalized several times with no clear direction on how to resolve the true root of their health complication.

If only cardiology and pulmonology could have been evaluating the patient together. Early diagnosis means fewer exacerbations, fewer admissions and treatment plans optimized for the full burden of disease rather than one condition in isolation.

Bringing Care to the Patient

For patients with advanced chronic disease, significant functional limitations and getting to and from appointments can be extremely difficult. Meeting patients in their homes removes access barriers, lowers the risk of disease transmission and creates opportunities for real-world clinical observation, such as addressing social determinants of health, nutrition gaps, behavioral health needs and housing insecurity. The above factors are not incidental details; they are clinical and social variables that determine medication adherence, follow-up rates and disease progression. Without the full picture in mind, traditional healthcare will continue to struggle to identify the most effective treatment plans for its patients.

Of course, technology plays a decisive role in making integrated care at home possible and sustainable. Risk stratification tools that surface the highest-acuity patients before they deteriorate, clinical workflow engines that standardize evidence-based interventions across specialties and ambient AI that reduces documentation burden each contribute to a care model that is both high-quality and operationally feasible today.

A Model Worth Scaling

Integrated, multispecialty care is not a novel concept. What is new is the combination of interdisciplinary workforce development, technology infrastructure, community specialist alignment and home-based care modeling that is approachable for a complex patient population who needs it most. The challenge now is building the systems, incentives and partnerships that make it the new standard of care rather than the exception.

This blog is brought to you by Monogram Health, and the views expressed are solely those of the sponsor.

The post When the System Fails Complex Patients, the Answer Is Integration appeared first on NCQA.

That question took center stage during a keynote session at NCQA’s Health Innovation Summit moderated by Ari Robicsek, MD, Chief Medical Officer and SVP, Quality Science and Innovation at NCQA. Joining the discussion were Shiv Rao, MD, Co-Founder and CEO of Abridge; Mark Sendak, MD, MPP, Co-Founder and CEO of Vega Health and former leader of AI initiatives at ONC; and Daniel Yang, MD, Vice President of AI and Emerging Technologies at Kaiser Permanente.

The panel agreed that the greatest challenge facing healthcare AI is no longer technological capability. It is creating the governance, accountability and trust structures needed to ensure AI improves quality rather than simply adding new layers of risk.

Key Takeaways From This Session

From Productivity Tool to Learning Health System

For Rao, the promise of AI extends far beyond reducing the burden of documentation. He described a vision in which AI helps create the long-discussed “learning health system,” where the right data and insights reach the right people at the right moment to improve outcomes and experiences. AI-powered assistants could synthesize clinical histories, identify care gaps and surface relevant information when it matters most.

The implications for quality improvement are significant. As health systems continue to pursue value-based care, AI could help bridge longstanding gaps between data collection and action, enabling organizations to identify risks earlier, intervene more effectively and continuously learn from patient interactions.

At the same time, Rao cautioned that realizing this vision requires more than powerful models. It requires robust infrastructure, careful evaluation and responsible deployment.

Quality Assurance Cannot Be an Afterthought

While excitement around AI often focuses on innovation, the panel spent considerable time addressing a less glamorous but equally critical issue: quality assurance.

As organizations deploy AI tools into clinical workflows, who is responsible for ensuring they perform safely and accurately over time?

For Daniel Yang, whose role at Kaiser Permanente explicitly includes quality assurance for AI technologies, this challenge is central to responsible adoption. He shared lessons from Kaiser Permanente’s deployment of ambient AI documentation technology across approximately 25,000 physicians. Rather than implementing the solution enterprise-wide immediately, Kaiser adopted a phased approach that continuously collected safety, performance and user feedback data before expansion decisions were made.

One of the most innovative aspects of Kaiser Permanente’s strategy was its decision to crowdsource quality assurance. Rather than relying on a small review team, the organization engaged more than a thousand clinicians to evaluate AI-generated notes with structured assessment tools measuring accuracy, completeness, summarization quality and potential hallucinations and bias.

The result was not only better performance data, but also greater trust.

The Growing Accountability Gap

Although large organizations like Kaiser Permanente can invest significant resources in AI evaluation, many health systems cannot.

That reality concerns Sendak, whose work focuses on helping health systems evaluate and operationalize AI solutions. During his experience working with organizations across the country, he found that many struggle to assess AI vendors, interpret technical evidence and monitor performance after deployment.

Even when health systems receive information about model performance, he noted, many lack the internal expertise necessary to determine what that information means. The problem becomes particularly acute when quality assurance responsibilities are shifted entirely onto the health systems.

“There has to be an effort to shift some of this back to vendors,” Sendak argued, emphasizing the need for developers and distributors to share accountability for performance and outcomes.

He also pointed to the growing role of independent evaluation and public-sector oversight in creating stronger evidence standards for AI technologies. As adoption accelerates, policymakers may play an increasingly important role in establishing frameworks that support transparency, validation and accountability.

Trust is Essential for Delivering Value

Although technological innovation continues rapidly, all three panelists agreed that human trust remains the ultimate determinant of whether AI delivers meaningful value.

Yang emphasized that organizations often focus heavily on technology infrastructure while underinvesting in the people and governance systems required for successful adoption.

“The capabilities we should be investing in are not just the technical capabilities,” he said. “We need to be making investments in our people and bringing our people along.”

Without trust, even highly capable technologies may never move beyond pilot programs. Conversely, organizations that establish clear governance, transparent evaluation and strong feedback mechanisms can accelerate adoption while maintaining confidence among clinicians, patients and leaders.

Breaking Down Silos to Improve Outcomes

As the discussion concluded, Rao offered a broader reflection on what may ultimately determine success: breaking down silos.

Clinical teams, quality teams, risk adjustment teams and revenue cycle teams may pursue different objectives and evaluate AI through different lenses. The greatest opportunity may lie in aligning those perspectives around shared outcomes.

“We have an opportunity right now to bring that accountability back, to hold everyone in the ecosystem accountable to outcomes,” Rao said. “If we can break down those silos and get aligned on what those outcomes are, then we’ll make a lot of progress very quickly.”

For healthcare leaders and policymakers, that may be the most important takeaway from the conversation. The hype phase may be ending, but the hard work of building responsible, trustworthy AI in healthcare has only just begun.

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That question framed a fireside conversation between Dr. Vivek Garg, President and CEO of NCQA, and Dr. Dora Hughes, Chief Medical Officer and Director of the Center for Clinical Standards and Quality (CCSQ) at the Centers for Medicare & Medicaid Services (CMS), at NCQA’s Health Innovation Summit. Drawing on her experience as both physician and patient, Dr. Hughes reflected on the evolution of quality measurement, CMS’s efforts to reduce burden and align programs and the agency’s vision for using technology, data and patient insights to improve care.

Key Takeaways From This Session

A Personal Commitment to Better Care

For Dr. Hughes, the work is deeply personal. During her internal medicine residency at Brigham and Women’s Hospital, she was diagnosed with multiple sclerosis, an experience that exposed her to both the strengths and shortcomings of the healthcare system and ultimately inspired her career in health policy and public service.

“Starting with that experience early in my career sparked my interest in policy and what ultimately led me into federal government,” Dr. Hughes shared.

Turning an Extensive Quality Infrastructure Into Action

CMS oversees a vast quality enterprise, including 27 quality reporting and value-based payment programs and nearly 500 quality measures. Yet Dr. Hughes argued that the next challenge is turning measurement into meaningful improvement.

“We have had success in creating the measures,” Dr. Hughes said. “But where we realize that we have fallen short is translating this understanding of variation in performance to learning from that, to moving to action and then to reaching the holy grail…better outcomes for our patients and our residents.”

The next chapter, she explained, shifts from quality measurement to quality management, with a focus on helping people live healthier, more independent lives and achieve outcomes that matter to them.

Keeping Beneficiaries at the Center

Some of CMS’s most valuable quality signals come directly from patients and families. Through its beneficiary complaint, appeal and grievance processes, CMS receives more than 800,000 concerns annually, offering a unique view into the patient experience.

“It very much helps to anchor our commitment…to continue to keep the beneficiaries and both patients and residents at the center of everything that we do,” Dr. Hughes said.

Dr. Hughes highlighted AI’s potential to help CMS move from reacting to problems after they occur to identifying risks earlier, allowing the agency to target support and interventions before issues escalate.

Refocusing on What Measures Matter Most

Over the past five years, CMS has reduced its measure inventory from roughly 750 measures to about 490. Dr. Hughes emphasized that the goal is not fewer measures for the sake of fewer measures, but a smaller, more meaningful set that informs decisions and drives improvement.

“Which measures are providing information that can’t be acted upon?” she asked. “It’s not changing a decision. It’s not improving how we deliver care.”

CMS is also seeking a better balance between process and outcome measures. While process measures remain important, Dr. Hughes stressed the need to keep quality efforts focused on whether patients are getting healthier. Dr. Garg echoed that perspective, noting patient-reported outcomes as an important tool for measuring the impact of care.

Alignment and Technology as Enablers

CMS is continuing efforts to align measures across Medicare, Medicaid, Marketplace and Innovation Center programs through the Universal Foundation. Dr. Hughes acknowledged that alignment becomes more complex in implementation than it appears in policy, making stakeholder feedback essential.

“We know that we can’t be successful without having your partnership, your experience, expertise, all of that on board,” she said.

Technology is another key enabler of CMS’s vision. Through initiatives such as QualTech and the broader Health Tech Ecosystem, the agency is exploring ways to reduce burden, improve interoperability and make quality measurement a byproduct of care delivery rather than a separate administrative task. Still, Dr. Hughes cautioned that innovation cannot replace the fundamentals of safe, reliable care.

A Vision for the Next Five Years

Looking ahead, Dr. Hughes described a future in which health data moves seamlessly with patients across care settings, quality and safety information is more transparent and providers can use the same data to deliver care, improve performance and support quality reporting. Greater measure alignment, combined with a National Quality Dashboard, could help healthcare organizations focus their efforts where they can have the greatest impact: improving outcomes.

Realizing that vision will require collaboration among CMS, states, health plans, providers, technology partners, quality organizations and patients.

Dr. Hughes left the audience with a clear message: the future of quality will be defined not by how much the healthcare system measures, but by how effectively it uses those measures, technologies and partnerships to improve people’s lives.

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We will post more insights from the Health Innovation Summit on our blog, so stay tuned.

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During a keynote session at NCQA’s Health Innovation Summit, Julie Seibert, MA, MPH, PhD, Assistant Vice President of NCQA’s Behavioral Health Center, moderated a discussion featuring Kari Clements, Senior Vice President of Quality at Elevance Health; Carin Skapars, LMHC, CPHQ, Chief Quality Officer at Carelon Health; and Debbie Witchey, President and CEO of the Association for Behavioral Health and Wellness. Together, they explored how payment models, quality measurement and healthcare infrastructure can better support integrated, whole-person care.

Key Takeaways From This Session

The Industry Has Moved Beyond Proving Integration Works

For years, healthcare leaders have focused on demonstrating the value of integrated behavioral health. Today, the challenge is no longer proving the concept. The challenge is creating a sustainable financial and operational model that allows integrated care to thrive.

Witchey noted that many existing payment systems were not designed around multidisciplinary care teams and often fail to reward prevention and early intervention, where much of the value of integrated care is realized.

This creates a significant challenge for health plans, clinicians and policymakers. While integrated care can improve outcomes and reduce downstream costs, reimbursement models frequently remain tied to individual services rather than coordinated care delivery. The panelists stressed that lasting transformation requires payment models that support team-based care and incentivize outcomes rather than volume.

Focus on Measuring What Matters

The panelists also challenged healthcare leaders to reconsider what defines success in behavioral health. While access remains a critical issue, particularly in communities facing practitioner shortages, the panelists argued that the industry must move beyond measuring whether patients receive care and focus more directly on whether that care improves their lives.

“We need to measure what matters,” Skapars said. “Is the care that’s being delivered actually improving the quality of life of the person receiving that care? Is it making their life better in terms of work, family? Are they able to do activities they enjoy?”

Prevention emerged as another priority. Current measures often focus on individuals after they have experienced a crisis or acute episode. “I don’t think we should be waiting until someone has one of these events before we’re measuring or doing something to engage them in behavioral healthcare,” Skapars said.

The panel also highlighted the importance of aligning measures across payer types, care settings and delivery models so organizations can create consistency and accountability regardless of where care occurs.

Interoperability Remains a Critical Barrier

If one issue united all three panelists, it was interoperability. Integrated care depends on timely access to information, yet many healthcare organizations continue to struggle with fragmented data systems and limited information sharing between behavioral health and physical health clinicians.

Skapars noted that behavioral health was largely excluded from the electronic medical record investments that transformed much of primary care following the HITECH Act, leaving many organizations at a disadvantage as the industry moves toward integrated care models.

Clements emphasized the need for greater collaboration with electronic medical record vendors and more standardization across systems to improve data exchange and reduce administrative complexity.

Witchey reinforced the central role data sharing plays in effective care coordination. “A warm handoff is important and critical,” she said. “But if you’re not physically co-located in the same place, then that needs to happen through the electronic health record. And that record has to have everything in it, be very clear and be easy to access.”

Building the Business Case for Integration

The panelists also made a compelling financial case for continued investment in integrated behavioral health.

Clements noted that many emergency department visits, hospital admissions and readmissions have underlying behavioral health drivers. Unmet mental health needs can affect an individual’s ability to manage chronic conditions, adhere to treatment plans and engage in preventive care.

“If you’re depressed or anxious, you’re not thinking about checking your blood pressure, you’re not thinking about eating well, you’re not thinking about exercising,” Clements said.

For health plans operating under value-based arrangements and organizations focused on Medicare Star Ratings and other quality programs, addressing behavioral health can directly influence both clinical and financial performance.

Witchey argued that the strongest long-term business case lies in total cost of care. Earlier identification of behavioral health needs, improved care coordination and stronger treatment adherence can help prevent more serious and costly health issues down the road.

A Vision for Whole-Person Care

Perhaps the most thought-provoking part of the discussion centered on whether healthcare should continue separating behavioral health and physical health at all.

Skapars challenged the audience to rethink the industry’s longstanding distinctions. “Have we artificially created this construct of behavioral health and physical health, when what we really mean is healthcare,” she said.

Clements described a future in which patients experience a seamless healthcare system regardless of where they enter. “I hope there’s no wrong door,” she said. “They walk into their care provider’s office and they are cared for from end to end.”

If those elements align, integrated behavioral health will no longer be viewed as an innovative model or a specialized initiative. It will simply become the standard for delivering high-quality, person-centered healthcare.

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We will post more insights from the Health Innovation Summit on our blog, so stay tuned.

The post Aligning Payment and Measurement: Do Current Incentives Support Quality Behavioral Healthcare? appeared first on NCQA.

That question was at the heart of a panel discussion at the Health Innovation Summit, “Quality in Action: Health Plan Focus on Quality.” Moderated by Dana Erickson, President and CEO of Blue Cross and Blue Shield of Minnesota, the panel included Andrew Bindman, Executive Vice President and Chief Medical Officer of Kaiser Permanente; Gabriel Waterman, Chief Clinical Officer of SCAN Health Plan (known simply as SCAN); and Kelvin Holloway, Deputy Executive Director and Senior Medical Director for the Medical Assistance Plans Division at the Georgia Department of Community Health.

Together, they offered a candid look at how health plans, clinicians and public programs can improve care while reducing administrative burden.

Key Takeaways From This Session

Quality Must Start With the Member

A central theme emerged early in the conversation: quality cannot be defined solely by measurement.

For Waterman, quality begins with understanding what matters most to members. “Quality has to be defined in terms of our members and not measures,” he said.

Waterman explained that quality metrics such as HEDIS^®, CAHPS^® and CMS Star Ratings are important, but should be viewed as validation tools rather than the ultimate objective. The real goal is ensuring members receive reliable, compassionate and easy-to-navigate care when they need it most. He noted that health plans must think beyond scorecards and focus on the experiences that shape trust, satisfaction and health outcomes.

Similarly, Bindman emphasized that quality, affordability and outcomes should not be competing priorities. In value-based care models, he argued, investing upstream through prevention and coordinated care creates a virtuous cycle that improves outcomes while lowering costs. “You get great outcomes and you get great affordability when you’re able to move upstream,” he said.

The discussion reinforced a growing sentiment across healthcare: quality measurement matters, but it should support better care rather than become an end in itself.

Using Data to Move From Measurement to Action

Panelists agreed that data remain the foundation of modern quality programs, but how organizations use data is rapidly evolving.

At SCAN, Waterman described a cross-functional “quality SWAT team” that combines information from quality programs, pharmacy data, member experience scores, call center interactions and other operational sources into a single view. This integrated approach helps the organization identify risks earlier and coordinate interventions more effectively.

The ability to leverage previously untapped sources of information is proving especially valuable. Waterman highlighted how organizations are increasingly using predictive analytics and artificial intelligence to identify members at risk of poor clinical outcomes or poor experiences before problems become more severe. He pointed to AI-enabled appointment scheduling and member outreach as examples of technology being deployed to solve real-world access challenges.

For Bindman, data’s greatest value lies not in tracking process measures, but in understanding outcomes. “It isn’t about chasing down the quality metric for the sake of passing the test,” he said. “It’s actually doing the things that are meaningful for our members.”

Looking ahead, he sees data helping organizations move beyond evidence-based care to generate new evidence from real-world practice and continuously improve care delivery.

The Growing Need for Alignment

One of the strongest points of consensus at this keynote session centered on the burden of fragmented measurement systems.

Across Medicaid, Medicare and commercial markets, plans and clinicians frequently navigate multiple sets of measures, methodologies and reporting requirements. Panelists argued that this complexity consumes resources that could otherwise be devoted to improving patient care.

Bindman described the challenge as a “scavenger hunt” across different metrics and payers, noting that clinicians generally do not change how they care for patients based on insurance coverage.

Holloway echoed that sentiment from the perspective of a state purchaser, emphasizing that clinicians face increasing stress as they attempt to satisfy numerous measurement programs simultaneously.

“It shouldn’t be about the measures, it shouldn’t be about the metrics, it should be about the outcomes,” Holloway said.

The panel also discussed how excessive focus on process measures can unintentionally discourage innovation, particularly when payment incentives are heavily tied to achieving specific scores. Several speakers suggested that future quality programs should place greater emphasis on improvement, outcomes and learning rather than rigid compliance targets.

A Vision for the Next Five Years

When asked what single change could have the greatest impact on quality while reducing complexity, panelists delivered a remarkably consistent answer: standardization.

Holloway called for consensus around the measures and outcomes that matter most.

Bindman urged the industry to become more disciplined in focusing on what is truly important and expressed optimism about AI’s potential to illuminate previously inaccessible aspects of quality.

Waterman offered perhaps the clearest vision: “One standardized set of measures across Medicaid, Medicare and commercial, that would go a long way.”

Combined with stronger interoperability and shared data standards, the panel suggested that a more unified quality ecosystem could reduce administrative burden, accelerate innovation and allow organizations to focus on what matters most: improving health outcomes for the people they serve.

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We will post more insights from the Health Innovation Summit on our blog, so stay tuned.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

The post Quality in Action: Health Plan Leaders Call for a Simpler, More Outcomes-Focused Future appeared first on NCQA.

That reality framed a keynote discussion at NCQA’s Health Innovation Summit featuring Asaf Bitton, MD, MPH, Executive Director of Ariadne Labs; Anna Flattau, MD, Chair of Family and Community Medicine at Thomas Jefferson University; Kyu Rhee, MD, MPP, President and CEO of the National Association of Community Health Centers (NACHC); and Daniel Stein, Founder and President of Embold Health.

Key Takeaways From This Session

Community Health Centers Demonstrate Primary Care’s Value and Vulnerability

Community health centers represent one of the strongest examples of primary care’s ability to improve access and advance health equity at scale. Today, they serve 52 million people, or one in seven Americans, at more than 17,000 locations nationwide while accounting for only about 1% of healthcare spending.

But this success exists alongside mounting financial pressure. Because they serve patients regardless of ability to pay, coverage and funding reductions could leave them caring for more uninsured patients with fewer resources.

Balancing ‘Big Q’ and ‘Little Q’ Quality

Panelists emphasized that quality measurement should support, not overshadow, the core elements of primary care.

Flattau distinguished between “big Q” quality, which includes access, continuity, comprehensiveness and trust, and “little Q” quality, such as screening rates and chronic disease control. “If we engage in the big Q quality,” she said, “the little Q quality will come afterward.”

The panel argued that strengthening these foundational dimensions of care creates the conditions for sustainable improvement across individual quality measures.

Create a Simple, Portable Measure Set

A recurring theme was the need to simplify measurement. Rhee called for a small, consistent set of primary-care-sensitive measures that could be used across Medicaid, Medicare, commercial and employer-sponsored coverage.

“I’d love a top 10 list of measures that we all consistently agree are improving our nation’s health,” he said. Blood pressure control, diabetes control and colorectal cancer screening were cited as examples of measures that could remain consistent regardless of a patient’s coverage type.

A more aligned approach could reduce administrative burden and help organizations focus more resources on improvement rather than reporting.

Access Is a Quality Issue

For patients, quality begins with access. Can they get an appointment? Can they see a clinician who knows them? Can they get the care they need when they need it?

Stein noted that employers increasingly recognize primary care’s value, but access remains a major obstacle. “We keep hearing from employees, ‘It’s a six-month wait,’ or, ‘I’m not taking new patients,'” he said.

These challenges are fueling interest in virtual-first, AI-enabled and employer-based primary care models. While innovation may help expand capacity, panelists stressed that it should strengthen, not replace, continuous, relationship-based care.

Set Concrete Targets for Primary-Care Investment

The panel translated primary care’s challenges into three measurable goals:

• Increase primary care spending from 5% to 10% of healthcare expenditures.
• Expand access to a usual source of care from 10% to 20%.
• Increase the share of physicians entering primary care from 20% to 40%.

Panelists also encouraged quality leaders to connect quality improvement efforts to financial outcomes. Stein advised attendees to “make that CFO your friend,” arguing that understanding how organizations evaluate ROI makes it easier to demonstrate the value of primary care investments.

Looking Ahead

The panel concluded with a simple but powerful message: primary care is not separate from quality. It is foundational to it.

As healthcare organizations work to improve outcomes, advance equity and control costs, success will depend on stronger investment in primary care, simpler measurement and better alignment across the healthcare ecosystem.

As Bitton reminded attendees, “You can’t have a quality strategy without primary care.”

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The post Advanced Primary Care at a Turning Point: What’s Changing, What Matters and What’s Next appeared first on NCQA.

Moderator Susannah M. Bernheim, MD, MHS, Vice President, Program and Strategy at The John A. Hartford Foundation engaged in a lively discussion with panelists Alice Chen, MD, MPH, Chief Health Officer at Centene; Caleb Stowell, MD, Chief Analytics Officer at Providence; and Arjun Srinivasan, MD, Deputy Chief Medical Officer at The Joint Commission.

Key Takeaways From This Session

Simplify Measures and Manage Their Consequences

Panelists spoke about streamlining quality measurement around a small number of clear and purposeful measures while retaining the data needed to understand and improve the system. Every measure exists for a reason—someone thought it was important to close a gap in care. Before removing a measure, identify the care gap it was intended to close and ask what the consequences are and whether we can mitigate them.

Separate Accountability Measures From Learning Signals

Measurement systems need both external accountability and internal tools for learning, but those purposes should not be confused. Keep public and purchaser-facing measures few, stable and purposeful, while using richer internal signals—including observations and patient data—to understand systems and guide improvement without turning every data point into a ranking mechanism.

Connect Care Processes to Meaningful Outcomes

Process measures such as screening or treatment completion can support improvement, but organizations should also test whether the care improves a patient’s function, symptoms or clinical status. Measures should also focus on what matters to the patient, including their goals and lived experience. Patient-centered outcome measures can help clinicians and patients judge whether care is producing meaningful improvement, not merely whether a process was completed.

Build Infrastructure for Usable, Real-Time Measurement

Timely, trusted measurement requires reporting infrastructure, data standards and workflows that move information from records into clinicians’ hands—where decisions are being made. Data that arrive years later may support accountability, but cannot support real-time improvement.

Turn Large Datasets Into Timely Clinical Action

Real-time measurement requires more than dashboards or raw data feeds. Analytic tools should translate large datasets, record review and clinical observations into concise insights and tangible steps, then place them in workflows where clinicians and facilities can act.

Coordinate Measurement Transformation Across the System

Measurement reform cannot succeed through isolated indicator changes. Government, states, purchasers, health plans, health systems, clinicians and patients need coordinated roles and a shared strategy connecting priorities, payment, implementation and information flows. To transform the system, these groups must work together.

Pair Aligned Priorities With Payment and Implementation

Purchasers and health plans can reduce fragmentation by agreeing on a small, shared set of priorities and tying them to financial incentives. Common measures drive sustained change only when they are paired with clear payment programs and implementation projects.

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The post Beyond the Scorecard: Real-Time, Patient-Centered Measurement That Clinicians Trust appeared first on NCQA.

“A year ago, many of you met me for the first time on this stage, when Peggy O’Kane handed off an organization she spent more than three decades building,” Dr. Garg said. “I’ve spent the year since mostly listening.”

That year of listening, he said, clarified NCQA’s mission and reinforced a central belief: “we cannot write quality’s next chapter alone.”

Quality Is Personal

Dr. Garg anchored his remarks in a deeply personal story about his mother, who lived with bipolar disorder and experienced both the strengths and shortcomings of the healthcare system.

“My first understanding of quality didn’t come from a scorecard, or a boardroom, or even from medical school,” he said. “It came from my mother.”

Although her appointments were completed and treatments documented, his family often found themselves navigating the healthcare system alone. The difference, he explained, was not technology or resources, but whether someone took responsibility for helping her improve. “It was whether anyone was accountable for her getting better,” he said.

That experience shaped his career as a physician and healthcare leader and informed one of his defining messages: “Quality isn’t an abstract property of an institution. It’s what happens to a person.”

Honoring NCQA’s Past

While emphasizing the need for change, Dr. Garg also celebrated the quality movement’s accomplishments and the role NCQA and its partners have played in transforming healthcare. “There was a time when healthcare quality was, functionally, in the dark,” Dr. Garg said. “You could not reliably tell a strong health plan from a weak one. And improvement was nearly impossible, because you couldn’t see where care was failing.”

He pointed to NCQA’s Accreditation programs, HEDIS^® and Patient-Centered Medical Home Recognition as examples of initiatives that helped create transparency, accountability and a shared language for improvement.

“Care gaps that were invisible became visible. Organizations built improvement capabilities that simply had not existed before,” Dr. Garg said. “NCQA did not do that alone. It happened because quality leaders translated standards into daily operations, clinicians changed how they practiced, purchasers demanded accountability.”

At the same time, he stressed that honoring the past does not mean preserving every process exactly as it exists today.

“Thirty-five years ago, healthcare needed more light. Today we have a thousand lights,” he said. “And when enough valid lights point in enough different directions, you don’t get illumination. You get glare.”

Listening to the Field

Dr. Garg shared some of the lessons he learned from stakeholders over the past year. Across conversations with health plans, clinicians, employers, states, federal agencies and technology partners, three themes emerged.

The first theme was clear: help us focus. Stakeholders told NCQA that quality programs have become too numerous and too disconnected from the outcomes that matter most.

The second was to align. Organizations want quality programs, standards and measures to work together as a more cohesive system.

The third was to prove it. Stakeholders are asking whether quality programs and accreditation efforts actually produce measurable improvements in care and outcomes.

“Not one person told me NCQA should step back,” he said. “What I heard, everywhere, was that this field wants NCQA to step forward, differently.”

The First Step Toward ‘Proving It’

Dr. Garg announced that NCQA recently published a report examining how NCQA Health Plan Accreditation relates to Star Ratings performance in Medicare Advantage (MA) across 838 plans, 13 HEDIS measures and three years of data.

“You’ve asked, fairly, whether any of this actually makes people healthier. That is the right question. Here’s how we’re starting to answer it,” he said.

The report found that Accredited MA plans reached four or more Stars 66% of the time compared with non-Accredited plans at 52%, a 14-percentage-point difference in Measurement Year 2024. Accredited MA plans averaged 4 percentage points higher across the 13 HEDIS measures NCQA analyzed.

These findings are associational, not causal. Accredited plans may differ from non-Accredited plans in other meaningful ways. But the consistency across measures and years is striking.

View the full report here.

Looking to the Future

For NCQA, the path forward comes down to three priorities: Focus on what matters. Align around it. Accelerate measurable improvement.

No single organization can cut through the glare alone. But together, the quality improvement community can connect those lights—and make the next right action clear.

“For more than thirty-five years, this community helped this country see quality,” he said. “The next chapter is about helping every person and family get the care they deserve. Let’s write it together.”

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We will post more insights from the Health Innovation Summit on our blog, so stay tuned.

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Health plans are under pressure to do more with less. An aging population with complex care needs is driving demand for services while financial and regulatory pressures push organizations to operate more efficiently. Clinical data has immense potential to help health plans address these pressures, but only when it is put to full use: when it determines the next best action for patients, when it is fast and reliable and when it is used to create a prospective view of members’ clinical status and predict outcomes.

When harnessed strategically, clinical data can empower health plans to improve operational performance and maximize the value of their technology investments. Too often, though, that data remains siloed.

The same clinical data that supports quality measurement can also power a broader digital transition. When standardized and aligned across the entire organization, that data can improve how health plans verify eligibility, configure benefits, manage utilization, support members and providers, and more. By strengthening data exchange and access, health plans can improve efficiency, support strategic decision-making and elevate performance.

Why Data Silos Occur

Health plans often rely on multiple vendors for different clinical data needs. Without a roadmap for how the organization should source and use data, divisions may manage them independently, leading to duplicated systems and inconsistent standards.

Navigating clinical data exchange with providers adds further complexity. Providers approach payer access differently, with wide variations in how much access they are comfortable granting and what types of access they allow. As a result, data sharing tends to be inconsistent, slowing processes and increasing administrative burden for staff.

These challenges impact health plans both strategically and operationally. Strategically, fragmented data limits the population-level insight—like identifying members who may benefit from earlier intervention—that needs a fuller clinical picture. Operationally, it forces day-to-day decisions to be made with incomplete information. In both cases, the imperative is clear: health plans need to align their clinical data efforts across the enterprise.

Maximizing Clinical Data Assets Across the Enterprise

Improving how data is shared and used requires treating data integration as a strategic priority. The strategies below outline how health plans can put this into practice.

• Build an enterprise data roadmap. Instead of allowing divisions to manage data independently, health plans should create a roadmap for how data are sourced, integrated and used throughout the organization. A shared roadmap keeps data investments aligned to strategic priorities and avoids duplicative processes.
• Standardize data across systems. To improve data access and quality, organizations need a way to work with data across all types of Electronic Health Record (EHR) systems. Working with a partner that can normalize and standardize data from a large variety of EHRs, including smaller ones, ensures that the data are consistent and usable once they reach the health plan.
• Find a true enterprise partner. Exchanging clinical data is only part of the equation; the real value comes from applying it across functions like quality measurement, utilization management and payment integrity. Rather than using several different vendors, health plans should consolidate partners where it makes sense, prioritizing those that understand their needs and can translate clinical data into results across every function. In addition to streamlining operations, this reduces the costs and complexity of managing multiple vendors.
• Make data sharing worthwhile. Providers are more likely to share data consistently when they trust it is handled carefully and see clear value in return. To build that trust, health plans can communicate the value to providers—whether that’s faster turnaround on prior authorization, transparency in how the data are used, or financial incentives—and work with a data exchange partner that follows strong privacy and security practices and facilitates sharing only the minimum data necessary for each specific use. This ensures providers are granting the right access to the right systems at the right time.
• Measure value on an ongoing basis. Defining success metrics—such as efficiencies gained in risk adjustment processes and medical records retrieval for measure calculations, reduced prior authorization turnaround, or more accurate payment processing—demonstrates the return on a shared data investment. Tracking these metrics supports quality improvement efforts and helps organizations identify where data are delivering value.

Looking Ahead

As payers and providers face increasing pressure to deliver high-quality care at lower cost, and as quality measurement becomes more digital, the need to securely access and share data more effectively will only grow. By improving how clinical data is shared and used, and how it is incorporated with administrative data to get a better view of patients’ health status, health plans can respond faster to new demands, perform prospective improvement initiatives, identify the next best action for their members, reduce unnecessary costs and build a stronger foundation for growth.

This blog is brought to you by MRO, and the views expressed are solely those of the sponsor.

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Practice Spotlight: ProHealth Physicians

What does patient-centered care look like in action? For ProHealth Physicians, it means helping patients feel supported at every step—with coordinated care, trusted relationships and resources that meet people where they are.

Since becoming a PCMH-Recognized organization, ProHealth Physicians has continued to strengthen how it supports whole-person care. The organization helps patients navigate their healthcare needs through coordinated services, strong patient relationships and connections to resources that support better outcomes.

Comprehensive Care Planning

That approach is especially clear in ProHealth Physicians’ comprehensive care planning. Care plans include problem lists, medication management, treatment goals, expected outcomes and scheduled reviews. The organization also recognizes that social and financial factors can affect a patient’s ability to manage their health. Care teams work with patients to address these barriers and, when additional support is needed, connect them with case managers and community resources.

“Providing a true medical home for our patients has always been part of ProHealth Physicians’ DNA. Our commitment to patient-centered care means helping patients navigate every stage of their healthcare journey through trusted relationships, coordinated support and a focus on quality outcomes,” says Heather Goodness, MBA, Associate Director of Quality at ProHealth Physicians, part of OptumCare.

Continuity of Care

This commitment comes through in the processes ProHealth Physicians has built to support patients across care settings. Using information from the electronic health record, care teams identify patients who have visited the emergency department or been admitted to the hospital, track their progress and follow up after discharge. The practice also maintains communication with hospitals during admissions, helping support continuity of care as patients move between settings.

Medication Management

The patient-focused approach also extends to medication management. Most of its practices achieved at least a 90% rate for documenting, reviewing and updating patient medications during visits. This consistent process helps care teams identify medication-related concerns and support patient safety.

Case Management

ProHealth Physicians also expanded case management and social services to connect patients with the support they need. “One of our most significant service enhancements has been the expansion of case management and social services, ensuring patients have access to the clinical, behavioral and community-based resources they need to achieve better health outcomes,” says Goodness.

Together, these efforts show how PCMH Recognition can support organizations in building practical processes that improve care coordination, address barriers to care and keep patient needs at the center of care delivery.

For ProHealth Physicians, the work reflects a continued commitment to making care easier to navigate and more responsive to patient needs. Its focus on coordinated care and patient support demonstrates how PCMH Recognition can help organizations turn strong processes into meaningful improvements in practice.

Simplifying Annual Reporting

NCQA is introducing two ways to make the Annual Reporting process easier for PCMH practices.

Tiered Sampling for Care Plans

NCQA has introduced an optional tier-based multi-site sampling approach for Care Management requirements in Annual Reporting. Designed for larger organizations, this approach reduces reporting burden by allowing eligible organizations to submit care plans from a subset of sites selected by NCQA.

Who Is Eligible?

• Organizations with nine or more sites.
• Sites must share the same reporting date.

 What This Means

• Eligible organizations may submit care plans from a subset of sites selected by NCQA.
• Sampling is based on organization size.
• Reduced documentation requirements can help streamline the Annual Reporting process and lessen administrative burden.

Organizations interested in using this option or confirming their eligibility should contact their NCQA Representative through My NCQA.

New Notebook Hints in Q-PASS

Notebook hints are now available in Q-PASS, providing quick access to evidence requirements directly within applicable Annual Reporting criteria. This in-platform guidance helps organizations better understand expectations, prepare documentation with confidence and streamline evidence collection.

Together, these enhancements create a more efficient and user-friendly Annual Reporting experience, allowing organizations to focus on demonstrating the high-quality, person-centered care they can provide.

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