Introduction to NCQA & SNP Assessment
June 25 and 27, 2013
Purpose of Training
• Provide brief overview • Give a general
of NCQA
understanding of
main components of
SNP assessment
• Describe the SNP
assessment program
NCQA is executing
on behalf of CMS
– HEDIS® measures
– Structure & Process
measures
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A Brief Introduction to NCQA
• Private, independent non-profit
health care quality oversight organization
• Founded in 1990 - Celebrating 23 years
• Committed to measurement,
transparency and accountability
• Unites diverse groups around common
goal: improving health care quality
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NCQA: Mission and Vision
• Mission
– To improve the quality of health care
• Vision
– To transform health care
through measurement,
transparency and
accountability
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NCQA: COMMITTED TO MEASUREMENT,
TRANSPARENCY, ACCOUNTABILITY
Quality measurement
means:
• Use of objective measures based
on evidence
• Results that are comparable
across organizations
• Impartial third-party evaluation
and audit
• Public Reporting
NCQA’s quality programs
include:
• Accreditation of health plans
using performance data
• HEDIS clinical measures
• CAHPS consumer survey
• Measurement of quality in
provider groups
• Physician Recognition
• ACOs
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Achieving the Mission
• Over 70 percent of all Americans enrolled in
health plans that are accredited by NCQA
• More than 90 percent of managed care
organizations report HEDIS® quality data
• 41 states and the federal government rely on
NCQA Accreditation and HEDIS
• More than 42,846 clinicians and 5,804
practices* have earned NCQA Recognition;
6 programs form the basis of quality
improvement programs and P4P nationwide
*As of 5/31/13
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Objectives of SNP Assessment Program
• Develop a robust and comprehensive
assessment strategy
• Evaluate the quality of care SNPs provide
• Evaluate how SNPs address the special
needs of their beneficiaries
• Provide data to CMS to allow plan-plan
and year-year comparisons
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SNP Assessment Process
• Year-to-Year Approach
– Defining and assessing desirable structural
characteristics
– Assessing processes
– Assessing outcomes
• Two main components
– HEDIS Measures-focus on clinical
performance
– Structure & Process measures-focus on
structural characteristics and systems
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Year-to-Year Strategy
FY 2008
FY 2009
SNPs Effective as of January 2007
SNPs Effective as of January 2008
HEDIS 2008
HEDIS 2009
Measure Development
Measure Development
• 13 existing measures
• 13 existing measures
•
Introduced 2 new measures
-- Care for Older Adults
-- Medication Reconciliation Post-discharge
Structure & Process Measures
Structure & Process Measures
• SNP 1: Complex Case Management
• SNP 1-3
• SNP 2: Improving Member Satisfaction
• SNP 4: Care Transitions
• SNP 3: Clinical Quality Improvements
• SNP 5: Institutional SNP Relationship with
Facility
• SNP 6: Coordination of Medicare & Medicaid
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Year-to-Year Strategy
FY 2010
FY 2011
SNPs Effective as of January 2009
SNPs Effective as of January 2010
HEDIS 2010
HEDIS 2011
Measure Development
Measure Development

Same as 2009
•
In development for 2011
Introduced 1 new measure
Plan all-cause readmissions
-- Plan all-cause readmissions
Structure & Process Measures


15 existing measures
Structure & Process Measures
Refinement of existing measures:
SNP 4 & 6
Increased focus on evidence of
implementation


Clarified requirements
Moved analyses to separate elements
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Year-to-Year Strategy
FY 2012
FY 2013
SNPs Effective as of January 2011
SNPs Effective as of January 2012
HEDIS 2012
HEDIS 2013
Measure Development
Measure Development
•
16 existing measures
• 16 existing measures
Includes 14 Effectiveness of Care Measures
plus:
Includes 14 Effectiveness of Care Measures
plus:
--Plan all-cause readmissions
--Plan all-cause readmissions
--Board Certification
--Board Certification
•
Clarified reporting requirements and
methodology
Structure & Process Measures
Structure & Process Measures
 Enhanced documentation requirements • Changed requirements for SNP 1 from Case
Management to Care Management—focus on
 Clarified measure language
assessment and individualized care plans
 Strengthened focus on quality
improvement and implementing
• Revised some existing requirements for SNP 2,
SNP 3 and SNP 4
interventions
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Project Time Line 2013
• June 17 – HEDIS submissions due to NCQA
• June & July – NCQA Releases 2013 Structure
and Process measures in hardcopy and in ISS
• June through September– S&P Training for SNPs
• October 15, 2013 – S&P Measure submissions
due to NCQA
• October 15, 2013 to April 30, 2014 - S&P
reviews conducted by NCQA and Surveyors
• June 2014– NCQA Delivers Final Report to CMS
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HEDIS 101
What Is HEDIS?
Healthcare
Effectiveness
Data &
Information
Set
HEDIS is an evolving
set of standard
specifications for
measuring health
plan performance
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Where Did HEDIS Come From?
•Originally developed by employers
and the HMO group in 1991; NCQA
took charge of HEDIS in 1992
•Expanded in 1996 to cover all three
product lines: commercial, Medicare
and Medicaid
•Addresses the leading causes
of death and morbidity
•Includes information on quality,
utilization and cost
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How Are HEDIS Data Used?
• Federal, state and
other regulatory
requirements
• Performance-based
accreditation
• Health plans use for
RFP/RFI preparation
• Quality improvement
activities and health
plan operations
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Data Reporting
• Data are reported to
NCQA in June of the
reporting year
• Data reflect events
that occurred during
the measurement year
(calendar year)
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Data Reporting
•Example:
– HEDIS 2013 data are reported in
June 2013
– Data reflects events that occurred
January–December 2012 (per
specs)
– HEDIS 2013 = 2012 data
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Effectiveness of Care Measures
•Clinical quality of care
Focus
– Preventive care
– Up-to-date treatments for acute episodes of illness
– Chronic disease care
– Appropriate medication treatment
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Collecting
HEDIS Data
Three HEDIS Data Sources
Administrative
Claims
Encounter
Eligibility
Provider
Surveys
Medical
Records
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Selecting an Eligible Population
• Member ID
• Age (DOB)
• Enrollment date and type
• Dates of service
• Diagnosis and procedure
codes
• Provider specialty
• Pharmacy
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Clinical Measures Data Collection
• Defining the denominator is critical
• Administrative: Claims and
encounter data
– Denominator: Based on all eligible
members of the population
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Structure & Process Measures
What is a S&P Measure?
• A statement about acceptable
performance or results
• Assesses a plan’s ability to comply with
specific requirements
• Focus on systems necessary for quality
care
– Policies & procedures, reports, materials
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How are S&P Measures Developed
• Similar to HEDIS measure
development
• Initial literature review
and evidence
• Geriatric Measurement
Advisory Panel (GMAP)
– Diverse set of expert
stakeholders
– Technical expert panels
also formed, if necessary
• Pilot Tests/Public
Comment
– Determine
feasibility/burden
– Input from stakeholders
• Final approval from
GMAP and CMS
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Components of the S&P Measure
•
Standard Statement
A statement about acceptable
performance or results
Components of the S&P Measure
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Components of the S&P Measure
Intent Statement
A sentence that describes the
importance of the S&P measure
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Components
S&PMeasure
Measures
Componentsofofthe
an S&P
ELEMENT
FACTORS
SCORING
DATA
SOURCES
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Components of an S&P Measure
The extent of the organization’s
services evaluated during an NCQA
survey.
The period of time for which NCQA
evaluates the SNPs documentation to
assess performance against an element
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Components of an S&P Measure
Guidance for demonstrating
performance against the element
Descriptive information illustrating
performance against an element’s
requirements. Examples are for
guidance and are not intended to be
all-inclusive
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Data Source Types
Reports
Documented Process
Materials
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Data Source Types--Process
Documented
Process
This policy applies to all ABC Health staff unless otherwise noted.
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Data Source Types--Reports
Report
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Data Source Types—Reports (cont’d)
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Data Source Types--Materials
Materials
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2013 Assessment Against S&P Measures
SNP Assessment Process
• S&P Measures assessment
– Data collection through Web-based
Interactive Survey System (ISS) survey tool.
• Several levels of review:
– Off-site Review (Level 1)
– Executive Review/Plan Comment (Level 2)
– Final Eyes (Level 3)
– Final Stage Review (Level 4)
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S&P Assessment
• Plan Comment Period
– Plans will have an opportunity to provide
additional information to clarify issues from
original submission materials
– Quick turnaround: Plans will have to respond
to NCQA requests for more information
rapidly
– One-time opportunity: Only chance plans
have to provide additional documentation
before data is finalized and sent to CMS
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S&P Assessment
• Plan Comment Period (continued)
– If you have questions, please contact a SNP
team member immediately
– Please ensure additional data submitted is
within the look-back period or it will not meet
the requirements
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Final Stage Review
• Occurs after plans receive preliminary
final scores
• One last opportunity for review
• Only for scoring inconsistencies
– Radio buttons and support text language
differ
– Different scores for similar SNP PBPs
• No new documentation will be reviewed
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Look-Back Period
• What is the Look-Back Period & how does it work?
– The look-back period is the six-month period prior to
survey submission – April 15, 2013 to October 15, 2013.
All documentation must be current as of the look-back
period but it could have been developed before that
time.
– Data used for reports can go back up to 1 year prior to
submission, unless the explanation indicates otherwise.
– For evidence consisting of a policy, an organization
that did not have one in place can develop and
incorporate it into its operations during the look-back
period.
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Who Reports
• HEDIS measures
– All SNP plan benefit packages with 30+
members as of February 2012 Comprehensive
Report (CMS website)
• S&P measures
– All SNP plan benefit packages
– Plans with zero enrollment are exempt for
certain elements
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SNP Reporting
• Returning SNPs— all SNPs that were
operational as of January 1, 2012 AND
renewed for 2013 AND have previously
submitted.
– SNP 1-6
• New SNPs — all SNPs operational as of
January 1, 2012 AND renewed for 2013
AND are reporting for the first time.
– SNP 1 A-D, SNP 2, SNP 4-6
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2013 S&P Measures
• SNP 1: Care Management – Major changes to
measure to align with MOC requirements
– All SNP Types
– Focus on assessment, individualized care plans,
how SNPs coordinate services and manage care
for members
• SNP 2: Member Satisfaction – Added examples
– All SNP Types
– Focus on monitoring member satisfaction to
identify areas for improvement & take action
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S&P Measures: What’s New for 2013
• SNP 3: Clinical Quality Improvement – revised
methodology for calculating significant
improvement to address small numbers
– All SNP types
– Focus on demonstrating quality improvement
• SNP 4: Care Transitions – Added new factor in
Element E
– All SNP Types
– Focus on how SNPs manage and support members
through planned and unplanned transitions in care
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S&P Measures: What’s New for 2013
• SNP 5: Institutional SNP Relationship With Facility
– No major changes
– I-SNPs only
– Focus on how SNPs communicate with facilities to
monitor services and members’ needs
• SNP 6: Coordination of Medicare and Medicaid
Coverage – No major changes
– Different requirements for Duals and I & C SNPs
– Focus on coordination and administration of benefits
for Duals
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SNP Data & Reporting
Data Submissions
• S&P measures
– Submission date: October 15, 2013
– ISS data collection tool
– No Fees required to submit
– All SNPs that were operational as of January 1,
2012, AND renewed in 2013.
– Plans with zero enrollment are exempt for certain
elements
NCQA will verify enrollment using CMS Comprehensive
Report—publicly available enrollment data
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What happens after submission?
• NCQA Analysis of HEDIS and S&P
measures
– Comparison to MA plans (HEDIS) and to other
SNPs
– Demographic (size, type, region)
– Statistical significance
• Deliver report to CMS
– CMS will make all decisions regarding the use of
the data
– NCQA will not publicly report any of the SNP data
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And now…
Questions?
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Contacts
Brett Kay
Assistant Vice President, SNP Assessment
202-955-1722
kay@ncqa.org
Casandra Monroe
Assistant Director, SNP Assessment
202-955-5136
monroe@ncqa.org
Sandra Jones
Assistant Director, SNP Assessment
202-955-5189
jones@ncqa.org
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Contacts
Anthony Davis
Accreditation Manager, SNP Assessment
202-955-1713
ahdavis@ncqa.org
Nidhi Dalwadi
Accreditation Manager, SNP Assessment
202-955-3585
dalwadi@ncqa.org
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Contacts
Priyanka Oberoi
Accreditation Manager, SNP Assessment
202-955-5130
oberoi@ncqa.org
Ling Chen
Accreditation Manager, SNP Assessment
202-955-3548
chen@ncqa.org
Delia Ponce
Coordinator, SNP Assessment
202-955-1742
ponce@ncqa.org
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Additional Resources
• NCQA SNP Webpage:
http://www.ncqa.org/snp
• FAQs
– Training descriptions & schedule
– Final HEDIS and S&P measures
• NCQA Policy Clarification Support (PCS)
http://ncqa.force.com/pcs/login
• HEDIS Audit information
http://www.ncqa.org/tabid/204/Default.aspx
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Additional Information
• HEDIS 2013 Volume 2 Publication
http://www.ncqa.org/Publications
• Specifications Update
http://www.ncqa.org/Publications
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Additional SNP Trainings
• Introduction to NCQA & SNP Assessment
– June 25 ~ 2-4:00 pm
– June 27 ~ 2-4:00 pm
• Structure and Process Measures (S&P 1-3)
– July 9 ~ 2-4:00 pm
– July 11 ~ 2-4:00 pm
– July 16 ~ 2-4:00 pm
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Additional SNP Trainings
• Structure and Process Measures (S&P 4-6)
– July 18 ~ 2-4:00 pm
– July 24 ~ 2-4:00 pm
– July 30 ~ 2-4:00 pm
• Interactive Survey System (ISS)
– August 6 ~ 2-3:30 pm
– August 13 ~ 2-3:30 pm
– September 12 ~ 2-3:30 pm
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Additional SNP Seminars
• Open Door Forums
– August 15 ~ 2-3:00 pm
– September 10 ~ 2-3:00 pm
– September 25 ~ 2-3:00 pm
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