FINAL EXAM: PROVIDER PAYMENT AND MANAGING CARE /PERFORMANCE INDICATORS
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POWERPOINT.15.MAY102021.PERFORMANCE.MEASUREMENT.ACCREDITATION.QUALITY.IMPROVEMENT3-43.pptxPOWERPOINT 15: WEEK OF MAY 10, 2021 MANAGED HEALTH CARE: PERFORMANCE INDICATORS ACCREDITATION/QUALITY IMPROVEMENT
HSA.312 SPRING 2021 CLASS
LARRY EITEL – ADJUNCT LECTURER
CONTENTS – SLIDE SUMMARY
SLIDE 1: TITLE SLIDE
SLIDE 2: TABLE OF CONTENTS/SLIDE SUMMARY
SLIDE 3 - 4: NCQA: OVERVIEW OF NATURE AND ACTIVITIES
SLIDE 5 AND 6: WHAT IS ACCREDITATION?
SLIDE 7 - 9: NCQA ACCREDITATION.
SLIDE 10 - 13: THE NCQA ACCREDITATION PROCESS
SLIDE 14 - 16: PERFORMANCE MEASUREMENT – OVERVIEW
SLIDE 17 - 20: MEASURING STRUCTURE, PROCESS, AND OUTCOMES/PATIENT EXPERIENCE
SLIDE 21: HEDIS AND DATA SOURCES FOR PERFORMANCE MEASUREMENT
SLIDE 22: CHOOSING PRACTICAL AND MEANINGFUL PERFORMANCE MEASURES
SLIDE 23 - 24: USES OF PERFORMANCE MEASURES
SLIDE 25 - 26: COMPARISON OF PROCESS AND OUTCOME PERFORMANCE MEASURES
SLIDE 27: CONCLUSION
THE NATIONAL COMMITTEE ON QUALITY ASSURANCE (NCQA): OVERVIEW 1
Is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.
Mission: Improve the quality of health care.
Vision: Better health care. Better choices. Better health.
Key Activities:
Uses measurement, transparency and accountability to highlight top performers and drive improvement.
Began in the early 1990’s by measuring and then accrediting health plans.
Since 2008, its mission has brought it closer to where care is delivered: NCQA has grown to measure the quality of medical providers and practices.
Most of its employees work on HEDIS and our Accreditation, Certification and Recognition programs.
Government and private sector clients hire it through contracts and grants to help them measure and improve quality.
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THE NATIONAL COMMITTEE ON QUALITY ASSURANCE (NCQA) – OVERVIEW 2
Key Accomplishments:
HEDIS: More than 191 million people—over half our country’s population—are enrolled in health plans that report quality results using HEDIS - the Healthcare Effectiveness Data and Information Set. The goal is for Americans to receive better care and lead healthier lives thanks to the accountability and benchmarking that HEDIS makes possible.
Managed Health Insurance Accreditation : NCQA’ accreditation is a rigorous assessment of health plans’ structure and process, clinical quality and patient satisfaction. More than 173 million people are enrolled in NCQA-Accredited health plans.
Patient Centered Medical Home Recognition: A medical home is not a place, but a way to organize primary care so it’s “the way patients want it to be.” Since 2008 NCQA has built the most widely used medical home model. More than 13,000 practice sites and 67,000 clinicians have earned the NCQA PCMH Recognition seal.
Quality Solutions Group Consulting: A consulting team that works with hundreds of organizations to help them measure and improve quality. Different departments at NCQA work on about 50 consulting contracts at a time.
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ACCREDITING MANAGED HEALTH INSURANCE PLANS AND NCQA
READING 4.B. – READ THIS TO GET AN OVERVIEW OF THE NCQA ACCREDITATION PROCESS
WHAT IS ACCREDITATION?: DEFINITION
“Accreditation” is a comprehensive evaluation process in which a health care organization’s systems, processes and performance are examined by an impartial external organization (“accrediting body”) to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with national standards.
More than 45 states currently use accreditation of a variety of health care organizations as part of their overall strategy to evaluate—and at times improve—the quality and cost-effectiveness of care and to promote compliance with state laws.
WHAT IS NCQA ACCREDITATION? - 1
Accreditation is NCQA’s “seal of approval” for managed health care plans
If a health plan is NCQA-Accredited, it has passed a rigorous and comprehensive evaluation process. NCQA assesses not only the core systems and processes that make up a health plan, but the results the plan actually achieves on key measures of care and service.
NCQA Accreditation is designed to help employers and consumers make informed choices among health plans. NCQA began accrediting managed care organizations (MCOs) in 1991, in response to the demand for standardized, objective information about the quality of these organizations.
NCQA’s Accreditation program is voluntary and rigorous, but even so, nearly half the plans in the country have earned accreditation. These are the plans we recommend. Non-accredited plans often do not measure up.
WHAT IS NCQA ACCREDITATION? - 2
NCQA accredits Managed Health Insurance plans.
NCQA also does the following:
Accredits Managed Behavioral Health Organizations
Accredits and certifies Disease Management functions in a variety of health care organizations.
Certifies Credentials Verification Organizations on behalf of Managed Care Organizations.
Evaluates and certifies the extent to which health plans measure and report the quality and cost of physician and hospital services.
If a health plan is NCQA-Accredited, it has passed a rigorous and comprehensive evaluation process. NCQA assesses not only the core systems and processes that make up a health plan, but the results the plan actually achieves on key measures of care and service.
NCQA Accreditation is designed to help employers and consumers make informed choices among health plans. NCQA began accrediting managed care organizations (MCOs) in 1991, in response to the demand for standardized, objective information about the quality of these organizations.
NCQA’s Accreditation program is voluntary and rigorous, but even so, nearly half the plans in the country have earned accreditation. These are the plans we recommend. Non-accredited plans often do not measure up.
WHAT IS NCQA ACCREDITATION? USES OF ACCREDITATION- 3
Earning NCQA Accreditation encourages health plans to improve. Research has shown that accredited health plans tend to improve much more quickly and consistently than other plans.
Health plans that choose to publicly report on their performance tend to improve even more quickly. These improvements have helped prevent thousands of unnecessary deaths in the past year alone.
Earning NCQA Accreditation also helps health plans distinguish themselves on the basis of quality. Many large employers will not do business with a health plan unless it has earned NCQA Accreditation.
Many states also require health plans that serve state employees to earn accreditation.
And the federal government distributes accreditation information to all 9 million of its employees and retirees, encouraging them to select high quality health plans.
NCQA PROCESS – OVERVIEW - 1
A health plan’s overall accreditation status is based on its performance in three areas:
Clinical performance as measured using HEDIS Standards.
Member satisfaction measured using the CAHPS survey.
A review of key structures and processes using NCQA Standards and Guidelines. That review covers the main areas of Health Plan Review indicated below, and is guided by NCQA Standards and Guidelines as indicated below.
HEDIS and CAHPS® : What Are They?
HEDIS, the Health Plan Employer Data and Information Set, is a comprehensive set of standardized measures of a health plan’s performance. The measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes.
CAHPS®, the Consumer Assessment of Health Plans, is a standardized survey of consumers’ experiences that evaluates plan performance in areas such as customer service, access to care and claims processing. CAHPS® 2.0H is a part of HEDIS. Accredited plans are required to report HEDIS and CAHPS® results.
NCQA ACCREDITATION PROCESS – OVERVIEW – 2 /EVALUATING KEY PERFORMANCE AREAS
AREAS OF HEALTH PLAN REVIEW
Access and Service - Do health plan members have access to the care and service they need? For example: are doctors in the health plan free to discuss all treatment options available? Do patients report having problems getting needed care? How well does the health plan follow up on grievances?
Qualified Providers - Does the health plan assess each doctor’s qualifications and what health plan members say about their providers? Does the health plan regularly check the licenses and training of physicians? How do health plan members rate their personal doctor or nurse?
Staying Healthy - Does the health plan help people maintain good health and avoid illness? Does it give its doctors guidelines about how to provide appropriate preventive health services? Are members receiving tests and screenings as appropriate?
Getting Better - How well does the health plan care for people when they become sick? How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to safe and effective care?
Living with Illness - How well does the health plan care for people with chronic conditions? Does the plan have programs in place to assist patients in managing chronic conditions like asthma? Do diabetics, who are at risk for blindness, receive eye exams as needed?
NCQA ACCREDITATION PROCESS – OVERVIEW – 3 /EVALUATING KEY PERFORMANCE AREAS
NCQA STANDARDS AND GUIDELINES USED TO EVALUATE PERFORMANCE IN THE AREAS OF HEALTH PLAN REVIEW
Quality Management and Improvement ■ A health plan’s systems for continuous improvement of quality of care and service. ■ How the plan makes sure that members have access to the care they need. ■ Specific plan programs that help members with chronic illnesses (e.g., disease management and complex illness or trauma; case management).
Utilization Management ■ How fair, consistent and prompt is the plan when it makes decisions about medical necessity for medical, behavioral health and pharmacy services? ■ Does the plan use evidence-based clinical guidelines and clinical staff—including physicians—to make decisions? ■ Does the plan have a process for members to appeal its medical necessity and coverage decisions?
Credentialing ■ How thoroughly the plan investigates qualifications and practice history before allowing a physician to join its network. ■ The plan’s process for ongoing evaluation of the physicians in its network.
Members’ Rights and Responsibilities ■ Does the plan clearly inform its members about how to get care and use its services? ■ Does the plan have a process to respond to member concerns and complaints? ■ How the plan protects members’ personal information.
Member Connections ■ How the plan distributes important information to members, such as their health status, plan resources, member care options and the cost of different services and prescription drugs. ■ How the plan promotes wellness and prevention to its members.
NCQA SURVIEW PROCESS – A TWO PART PROCESS
NCQA’s rigorous survey process consists of onsite and offsite evaluations conducted by a team of physicians and managed care experts.
During the offsite survey, NCQA’s surveyors review the plan’s self-evaluation and other materials submitted to NCQA through the Interactive Survey System (ISS). The ISS is the first Web-based tool for health plan accreditation. The ISS provides guidance and feedback to the plan while it performs a survey-readiness evaluation against NCQA Accreditation standards. The survey team reviews the plan’s submitted documentation for compliance with the standards.
The onsite survey is a two-day visit, during which NCQA surveyors review materials that cannot be submitted via the ISS, such as actual case records, meeting minutes and other confidential documents. 1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). 2 Based on CAHPS®3 (Consumer Assessment of Healthcare Providers and Systems), a standardized survey used by all plans. 3 CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
PERFORMANCE INDICATORS
PERFORMANCE MEASUREMENT– OVERVIEW - 1
There is a consensus that scientifically rigorous and valid measurement of performance can be instrumental in improving value in U.S. health care.
In particular clinical areas, such as cardiac and intensive care, measurement has been associated with important improvements in providers’ use of evidence-based strategies and patients’ health outcomes.
Perhaps most important, measures have altered the culture of health care delivery for the better, with a growing acceptance that clinical practice can be objectively assessed and improved.
Nevertheless, despite notable successes and the recent cultural change, substantial shortcomings in the quality of U.S. health care persist.
Furthermore, the growth of performance measurement has been accompanied by increasing concerns about heterogeneity in the scientific rigor, transparency, and limitations of available measure sets, and how measures should be used to provide proper incentives to improve performance.
The challenge ahead is to achieve the promise of measurement while avoiding the potential for unintended adverse consequences.
PERFORMANCE MEASUREMENT– OVERVIEW - 2
The Quality Measurement Enterprise
Measurement is vital to producing a health care system that achieves outstanding results.
Without measurement and transparency, clinicians, institutions, patients, and society cannot readily evaluate the value being achieved in the health care system.
A commonly quoted aphorism that encourages the measurement movement states, “You can’t improve what you don’t measure.” The United States is about 25 years into efforts to bring performance measurement into medicine.
PERFORMANCE MEASUREMENT– Measuring Structures, Processes, and Outcomes -1
Avedis Donabedian, an influential leader in the study of health care quality, developed a widely used, three element model of quality measurement in 1966, which included measuring the following:
Health care structures (the characteristics associated with a health care setting),
Processes (the activities done in a health care setting), and
Outcomes (the results achieved for a patient after a given set of interventions).
More recently – Systematic and structured measurement of the Patient Experience and Patient Satisfaction have been added to the array of Performance Measures used in the evaluation of health care services delivery.
What are the types of quality measures?
Quality measures assess care across the full continuum of health care delivery, from the level of individual physicians all the way up to the level of health insurance plans. Hundreds of different quality measures are used in health care. These measures generally fall into four broad categories:1) structure.2) process. 3) outcome, and 4) patient experience.
No single type of measure can give a complete picture of the quality of care that is provided and received. Each type of measure addresses a key component of care.
Structure
Process
Outcome
Patient Experience
Assesses the characteristics of a care setting, including facil ities. personnel, and/or policies related to care delivery.
DESCRIPTION
Determinesi if the services provided to patients are consistent with routine clinical care.
Evaluates patient health as a result of the care received.
Provides feedback on patients' experiences of care.
MEASURINGHEALTHCAA£QUAUTY: AN CWEl!VIEW
QUAU1YMEASURES
EXAMPLE
Does an intensive care unit (ICU) have a critical care specialist on staff at all times?
Does a doctor ensure that his or her patients receive recommended cancer screenings?
What is the survival rate for patients who experience a heart attack?
Do patients report that their provider explains their treatment options in ways that are easy to understand?
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TYPES OF QUALITY MEASURES: OVERVIEW
PERFORMANCE MEASUREMENT– Measuring Structures, Processes, and Outcomes - 2
Structural measures include requirements imposed by payers and regulators, such as specifications for the physical plant, management systems, board certification, and staffing ratios.
Process measures determine whether evidence-based care guidelines were followed, but do not indicate whether a patient’s health actually improved. Process measures, in essence, are used on the assumption that better outcomes should result from evidence-based care processes. Examples of process measures include the rate at which patients experiencing a heart attack are administered aspirin and beta-blockers.
Outcome measures seek to determine whether the desired results are achieved. Examples of clinical outcome measures are whether a patient was readmitted to the hospital within 30 days of discharge and, for some conditions, whether the patient is alive at 30 days after admission.
Examples of patient experience instruments include the Patient Reported Outcomes Measures Information System, which includes modules that address physical health, mental health, and social health; HealthActCHQ, which has developed pediatric quality of life questionnaires, among others; and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys developed under the auspices of AHRQ.
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PERFORMANCE MEASUREMENT– Measuring Structures, Processes, and Outcomes - 3
Data Sources Used to Calculate Quality Measures:
The data needed for determining performance with established measures are obtained through three sources:
Administrative data,
Medical Records, and
Patient Surveys.
Primary Uses of Performance Measure Data:
In the United States, performance measure data are predominantly used in public reporting and provider incentive programs as well as provider-led quality improvement efforts.
PERFORMANCE MEASUREMENT– MORE INFORMATION CONCERNING HEDIS
WHAT IS HEDIS?
HEDIS is a performance measurement tool that is coordinated and administered by NCQA (National Committee for Quality Assurance) and used by Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of managed care organizations
All managed care companies who are NCQA accredited perform HEDIS reviews the same time each year
A subset of HEDIS measures will be collected and reported for the Marketplace (healthcare exchanges) product lines
HEDIS is a retrospective review of services and performance of care
Results are used to measure performance, identify quality initiatives, and provide educational programs for providers and members
HEDIS data are collected three ways:
Administrative Data: Obtained from our claims database.
Hybrid Data: Obtained from our claims database and medical record reviews.
Survey Data: Obtained from member and provider surveys.
PERFORMANCE MEASUREMENT– CHOOSING MEANINGFUL AND PRACTICAL QUALITY PERFORMANCE MEASURES
Characteristics of quality measures: It is important for quality measures to be practical. The RUMBA rules of quality measures help achieve this :
Relevant to the problem/concern: Will the quality measure actually reflect an increase/decrease in quality?
Understandable: Will the stakeholders be able to interpret the data collected?
Measurable: Is there an ability to quantify quality in the area of concern?
Behaviourable: Can the quality measure be altered by a change in attitudes and conduct?
Achievable: What are the likelihood goals will be met? [9] The RUMBA rules will be important in the evaluation of process versus outcome measures.
PERFORMANCE MEASUREMENT– SOME USES OF PERFORMANCE INDICATORS
PUBLIC REPORTING:
Measuring and reporting on the quality and cost of care serves several important functions, including:
Enabling patients to make informed choices about their care and be more involved in medical decision-making;
(2) Allowing health care professionals to identify areas for improvement and providing them with the motivation to do so; and
(3) Providing consumers, purchasers, and taxpayers some level of accountability for their substantial expenditures on health care.
While ample evidence exists to demonstrate how publicly reporting the performance of health care providers can spur quality improvements, there is mixed evidence about how well public reporting informs consumer choice.
PERFORMANCE MEASUREMENT– SOME USES OF PERFORMANCE INDICATORS
PAY-FOR-PERFORMANCE:
Apart from promoting more informed consumer choice, the Federal Center for Medicare and Medicaid Services (CMS) also uses performance measurement data in a number of its pay-for-performance initiatives, which provide direct financial rewards or penalties to health care providers based on their performance on quality measures.
These initiatives include a suite of new “value-based purchasing” programs (Congress’s term for pay-for-performance) to reward providers who deliver better performance for beneficiaries at lower cost.
Some of these programs include: The End-Stage Renal Disease (ESRD) Bundled-Payment and Quality Incentive Program; performance bonuses for Medicare Advantage (MA) plans based on star ratings; the Hospital Value-based Purchasing Program:and the Physician Value-based Payment Modifier.
PERFORMANCE MEASUREMENT– STRENGTHS AND WEAKNESSES OF PROCESS AND OUTCOME MEASURES FOR PERFORMANCE MEASUREMENT
SEE NEXT SLIDE
CONCLUSIONS
