Holding Health Plans & Providers Accountable for

High-Quality, Patient-Centered Care

January 23, 2015

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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– Access/experience of care– Quality improvement initiatives– 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

Must Pass!

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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– 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?

8Quality Measures & Physician Payment Reform

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

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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)– 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

11Quality Measures & Physician Payment Reform

Colorectal Cancer Screening

200420052006200720082009201020112012201330.0

35.0

40.0

45.0

50.0

55.0

60.0

65.0

70.0

52.654.053.3

50.453.1

54.957.6

60.062.1

64.3

49.747.1

39.541.8

40.141.0

55.2

58.460.8

Medicare HMOMedicare PPO

ACA MAP4-PAC

12Quality Measures & Physician Payment Reform

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

13Quality Measures & Physician Payment Reform

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

14Quality Measures & Physician Payment Reform

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

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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