Holding Health Plans & Providers
Accountable for High-Quality,
Patient-Centered Care
January 23, 2015
NCQA History
• NCQA – a non-profit that since 1990 has
worked with federal, state, consumer &
business leaders to improve quality
• Our Mission
– To improve health care quality
• Our Vision: Transform health care through:
– Measurement
– Transparency
– Accountability
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Holding Plans & Providers Accountable
• Health Plan Accreditation
• Clinical Quality Measures (HEDIS)
• Patient Experience Measures (CAHPS)
• Pay-for-Performance
• Patient-Centered Medical Homes
• Patient-Centered Specialty Practices
• Accountable Care Organizations
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Health Plan Accreditation
• NCQA accredits plans with strong
consumer protections & high quality
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Access/experience of care
Quality improvement initiatives
Must
Pass!
Verifying proper provider credentials
Appropriate denial & appeal practices
Helping enrollees understand/use coverage &
manage their own health & health care
• NCQA “look-back period” ensures that
policies are enforced, not just on paper
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Performance-Based Accreditation
• HEDIS & CAHPS quality scores calculated
for each plan & then:
– Determine accreditation level
• Accredited, Commendable, Excellent
– Translate to report cards for comparing plans
• http://www.ncqa.org/ReportCards.aspx
– Support pay-for-performance
• Medicare Advantage, many states & employers
pay plans & providers based on quality scores
– Determine annual Consumer Reports ratings
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HEDIS Clinical Measures
Healthcare Effectiveness Data & Information Set®
• The most widely used & respected tool
for measuring quality
• 70+ measures of proven, effective care
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Wellness and prevention
Chronic disease management
Children, adults and older adults
Overuse, waste/resource use
• Continuously updated for new scientific
evidence and to “raise the bar”
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CAHPS Patient Experience Measures
Consumer Assessment of Health Providers & Systems
• Survey asks how well plans & providers
meet patient needs (‘experience of care’)
– How often did you get appointments/care as
soon as you thought you needed?
– Did customer service give you help you
needed? Treat you with courtesy and respect?
– Did your doctor listen carefully? Explain things
in a way that was easy to understand? Spend
enough time with you?
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How Measures are Used
• Pay for Performance
– MA Stars, most Medicaid, many private plans
• Accreditation Scoring
– 50% of NCQA plan ratings
– Required for Marketplace/Exchange plans
• ID, prioritize & target improvement efforts
– Critical for ACOs, other delivery system reforms
• Always evolving!
– For new evidence & to raise the bar
– Moving toward patient-reported outcomes
Quality Measures & Physician Payment Reform
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Pay-for Performance (P4P)
• Payment based on quality & service as in
Medicare Advantage
– Bonuses to highest-rated 4/+ Star plans
• Total $2.2B in 2015 for better benefits/lower costs
• 5 Star plans get continuous enrollment
– New enrollees outside open enrollment
• Poor performers (<3 stars)
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Flagged on plan finder
No enrollment via plan finder
Enrollees encouraged to switch plans
Plans can be terminated from the program
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ACA Bonuses Drive both
Enrollment & Improvement
• 40% of Medicare Advantage plans have 4
Stars or more for 2015
– Significant improvement on many measures :
 Advising smokers to quit, body mass index,
colorectal cancer screening, controlling
high blood pressure
• 60% of enrollees will be in 4+ Star plans
– A 31% increase since 2012 when P4P began
– Average premium paid rising just $1.30 as
enrollees move to bonus-fueled low cost plans
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Colorectal Cancer Screening
70.0
65.0
60.0
55.0
50.0
57.6
54.9
54.0 53.3
53.1
52.6
50.4
49.7
47.1
45.0
40.0
35.0
39.5
41.8
60.0
62.1
58.4
64.3
60.8
55.2
Medicare HMO
Medicare PPO
40.1 41.0
ACA
MA
P4P
30.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Quality Measures & Physician Payment Reform
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Patient-Centered Medical Home
Transforming Primary Care
Into What Patients Want It To Be
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Long-term partnerships, not hurried visits
Coordinated care among providers
Better access - expanded hours and online
Shared decisions so patients make informed
choices, get better results
• Lower costs from reduced ER/hospital use
• More satisfied patients and providers
Quality Measures & Physician Payment Reform
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Patient-Centered Specialty Practice
• Compliments PCMHs to improve often
weak primary/specialty care coordination:
– Timely access to care/same-day appointments
– Agreements on sharing information with
primary care providers
– Managing care for individuals & populations
– Coordination with facilities on care transitions
and post-discharge follow-up
Quality Measures & Physician Payment Reform
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Accountable Care Organizations
• Builds on PCMH foundation to coordinate
care across all health care settings
– Payment based on both quality & efficiency,
instead of just the volume of services
• Accreditation assesses essential core
capabilities for ACO success
– Standards are prescriptive when essential, i.e.
patient privacy
– Otherwise flexible to accommodate different
types of ACO structures
Quality Measures & Physician Payment Reform
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NCQA’s ACO Accreditation
• We specifically score ACOs on:
– PCMH foundation
– Patient protections, including privacy
– Ensuring access to & availability of care
– Care management & coordination capabilities
– Monitoring practice patterns & using data to
improve quality
– Decision support to help patients/providers ID best
care
– Stakeholder participation, structure, contracting,
payment arrangements
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