NCQA’s Peggy O’Kane Talks 35 Years of Healthcare Quality Leadership

The retiring leader stresses the need for quality to be embedded in healthcare’s systems as a business imperative.

On its website, the National Committee for Quality Assurance notes: “Before NCQA, health care was operating data-free and ‘in the dark.’ We were founded as an independent nonprofit in 1990 to ‘turn on the lights.’”

Margaret (Peggy) O’Kane was the leader who helped turn those lights on. As the founder and long-time president of NCQA, O’Kane and her team pioneered U.S. healthcare quality measurement, improvement and the accreditation of health plans and providers.

After 35 years at the helm, O’Kane is retiring and took time to reflect with HealthLeaders on the state of healthcare quality measurement, the industry itself, and the key question that remains: Why isn’t healthcare better at getting better?

O’Kane’s conversation with HealthLeaders included the industry’s unfinished business, structural problems, what she’s learned from working in healthcare for more than three decades, and her hopes for the future.

“We stood up NCQA in a hurry.”

About the founding of NCQA, O'Kane says: "I don't think it could have happened at a different time."

Citing the HMO dynamics of the late 80s, O’Kane recalls how working with large employers helped reveal the knowledge and infrastructure gaps that health plans had about their members and how to improve outcomes.

This "confluence of readiness factors," as O'Kane calls them, helped her and her collaborators move quickly. In healthcare today, she sees a confluence of “stasis factors, paralysis, the most important being the sheer complexity of the system.”

Noting that in healthcare “one person’s waste is another person’s income,” O’Kane cites the way doctors are paid, the bias toward higher-cost specialty care, inadequate support for primary care, outdated inpatient models.

"Hospital leaders must be born again into the world to value-based payment,” says O’Kane.

“Hospitals still operate on the heads-in-beds model: 'If I keep somebody out of the hospital, I'm losing money.’ You've got to have the incentives aligned. It's a design problem, it's the payment models, it's the business models, a lot of underlying health policy."

Returning to NCQA’s work, she adds: "And then you put the quality rewards on top of that, which are a fraction of the overall system incentives, it's no wonder that the quality signal doesn't really get through."

The evolution of healthcare quality measurement

As the founder of NCQA, O’Kane has been in a position to drive how the industry thinks about and pursues quality.

“People think that quality is something that just happens if you have a lot of good people working together — but it really doesn't,” O’Kane adds. “There are so many fragments of the system that have to integrate to optimize health."

"The original idea of having quality measurement was to define expectations in a clear way. But the change management challenge is huge . . . a really different mindset is needed about what quality healthcare is.”

After 35 years, none of it has gotten any easier, O'Kane notes — including NCQA’s efforts to digitize quality measurement.

"When we started on this journey of digitalizing quality measurement, we thought it would make everything easier and that people would like quality measurement better, but it’s been quite difficult.”

The nature of data is part of the problem.

"Unfortunately, data today is very transactional: I'm going to this doctor for that, getting my flu shot over here, having my mammogram over there. Unless somebody is gathering that data and putting it together, the complete picture of the patient's care is missing."

“We also feel like this is way bigger than we are, and we need to recruit more allies,” says O’Kane.

Those allies include employers, providers, health plans, and the Medicaid directors who sit at the crossroads of state and federal policy.

A different mindset and the next generation of leaders

Like all the best healthcare leaders, O'Kane has a passion for population health and systems thinking.

"There's a way of thinking about measurement that is grounded in the performance of a hospital and not necessarily the health of the population that the hospital serves."

"I'm super proud and grateful for all of the people who helped us get to where we are today — who helped really tell a story about population health that nobody used to care about but that I think people do care about now."

"I'm going to miss this work,” says O’Kane. “Who gets to have a job with this kind of meaning?”

While her own next move is not yet decided, she knows that the promise of healthcare can’t be realized in one lifetime.

She's also optimistic.

"I think being a doctor in the future is going to be amazing." Noting the helpful role AI can play, O'Kane adds: "In an ideal world, the doctor will use the time that's given back to them to do the kind of relationship management and coaching that patients really do need."

She also cited the incredible role nurses play and emerging treatment approaches like hospital-at-home for frail populations who have historically been underserved before they wind up in in-patient care.

"These are the kind of unmet promises of the healthcare system and of technology that I'm hoping will actually be fulfilled."