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 2 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 3 Health Plan Accreditation • NCQA accredits plans with strong consumer protections & high quality – – – – – 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 4 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 5 HEDIS Clinical Measures Healthcare Effectiveness Data & Information Set® • The most widely used & respected tool for measuring quality • 70+ measures of proven, effective care – – – – 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” 6 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? 7 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 8 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) – – – – Flagged on plan finder No enrollment via plan finder Enrollees encouraged to switch plans Plans can be terminated from the program 9 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 10 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 11 Patient-Centered Medical Home Transforming Primary Care Into What Patients Want It To Be • • • • 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 12 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 13 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 14 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 15