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
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39.541.8
40.141.0
55.2
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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
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