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HSM 420: MANAGING QUALITY IMPROVEMENT IN MANAGED CARE

MANAGING QUALITY IMPROVEMENT IN MANAGED CARE

Table of Contents

I. Introduction
II. Background
III. Challenges for Quality Improvement
IV. Review of the Literature
V. Challenges/Problems Analysis
VI. Recommend Solutions
VII. Implementation of Solutions
VIII. Justification
IX. Summary and Conclusion
X. Works Cited

I. INTRODUCTION

A. Quality Improvement – a part of managed care

1. Managing the quality improvement process in managed care organizations (MCO) focuses on not only the healthcare members receive, it also focuses on how they perceive that healthcare and what is the financial burden of that healthcare. Dr. Donald Berwick former Centers for Medicare and Medicaid (CMS) and former president and CEO now senior fellow with the Institute of Healthcare Improvement (IHI) introduced this “Triple Aim” (Kongstvedt, P. R. 2013). According to the Agency for Healthcare Research and Quality (AHRQ) the IHIs framework for quality assessment includes the following six aims for health care: Safe, Effective, Patient-centered, Timely, Efficient, and Equitable (The Six Domains of Health Care Quality, 2016) MCOs attempt to achieve these goals by the use of teams of medical and other professionals in the form of committees and subcommittees and processes which have oversight of the healthcare delivered.

a. Quality Improvement Committees are generally the governing body of quality management and improvement at the MCO. The committee is commonly comprised of medical and behavioral health practitioners within the MCO. There is an annual work plan devoted to healthcare quality initiatives and improvement (NCQA.n.d.).

b. The role of the medical staff within the MCO includes not only utilization review, case management and disease management as you would expect. It also includes medical staff who are focused on quality improvement. These professionals review the data and the rates and determine what impact they can have on the outcomes using the resources they have.

2. Key Challenges:

a. One key challenge in quality improvement for managed care is the requirement towards higher performance ratings for health outcome measures from external groups such as government agencies and consumers. Another challenge is transitioning to “value-based” payment which means using data to effect change in health care provider behavior. And another is measuring and effecting the socioeconomic differences in healthcare or health care disparities.

II. BACKGROUND

A. HMO Act of 1973

1. The HMO Act offered several enticements to start up and HMO, however it also was the beginning of a type of oversight. This oversight was in the form of the federally qualified HMO. This was the “seal of approval” for HMOs.

a. Requirements - HMOs who elected to be federally qualified had to meet certain requirements:

I. minimum benefit package standards,

II. provider network adequacy,

III. quality assurance program,

IV. financial stability and

V. complaints program

Eventually there were states who would require the same items (Kongstvedt, P. 2013). At this point in the life cycle of HMOs the focus was on utilization and the payment system for providers of healthcare. This act allowed for growth of the HMO type of managed care. By the 1990’s external oversight grew with National Committee for Quality Assurance (NCQA) leading the pact. There is also URAC and Accreditation Association for Ambulatory Health Care (AAAHC). These became the new “seal of approval” for managed care, which is no longer just HMOs, but Preferred Provider Organizations (PPOs), and Point of Service (POS) plans.

b. In 2010, with the Affordable Care Act (ACA), accreditation with an external organization is a requirement. This was put in place to ensure quality in the managed health care sector. Accreditation by an external body evaluates the MCOs structures, practices and their performance measures. Currently at least 45 states require external accreditation for MCOs as oversight and to improve by way of outcome measurement the health outcomes of their constituents (Accreditation to Approve Health Plans and Providers.2011).

B. NCQA Health Plan Accreditation has existed for 25 years. According to NCQA 43% of the United States population is covered by a MCO with NCQA accreditation. NCQA is the only accredited agency which bases their accreditation in part on the results of clinical and satisfaction performance measures. Currently 50 points can be awarded for alignment with the standards and 50 points can be awarded calculated on the rate of the performance measures (Health Plan Accreditation. 2015).

1. Health Plan Standards: The health plan standards encompass the structure and processes in which the health plan is run. They are divided into standards, then elements, then factors.

a. Quality Management and Improvement (QI) Standards: There are ten QI standards which cover the quality improvement program, committee, contracting, member experience, case management, disease management, practice guidelines, continuity and coordination of medical care, continuity and coordination between medical and behavioral healthcare. There is also a standard if these standards are delegated to another entity.

b. Network Management (NET) Standards: There are seven NET standards which cover availability pf practitioners, accessibility of services, network adequacy, marketplace transparency and experience, continued access to care, and directories. This also includes a standard if these items are delegated.

c. Utilization Review (UM) Standards: There are 15 UM standards which cover structure, clinical criteria, communication services, appropriate professionals, timeliness of decisions, clinical information, denial notices, policies for appeals, handling of appeals, evaluation of new technology, emergency services, procedures for pharmaceutical management, and triage and referral for behavioral health care. This also includes a standard if these items are delegated.

d. Credentialing and Re-credentialing (CR) Standards: There are nine (9) CR standards which cover policies, committee, initial verification, re-credentialing cycle length, practitioner office quality, ongoing monitoring, notification to authorities and practitioner appeal rights, assessment of organizational providers. This also includes a standard if these items are delegated.

e. Member Connections (MEM) Standards: There are none MEM standards which cover health appraisals, self-management tools, functionality of claims processing, pharmacy benefit information, personalized information on health plan services, innovations in member services, health information line and encouraging wellness and prevention. This also includes a standard if these items are delegated.

f. Member Rights & Responsibilities (RR) Standards: There are six RR standards which cover rights and responsibilities, policies and procedures for complaints and appeals, subscriber information, privacy, and marketing information. This also includes a standard if these items are delegated. (Health Plan Accreditation. 2015).

2. HEDIS® Measures

a. The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of measures created in the 1980’s but now owned by NCQA. According to NCQA they are used by more than 90 percent of America's health plans to measure performance. The measures are reviewed and developed on an annual basis in order to keep with current medical standards and priorities. They cover a range of health issues for example: childhood immunization rates, anti-depressant medication management and persistence of beta blocker treatment after a heart attack. As of 2015, HEDIS® consists of 83 measures across 5 domains of care. In order for a health plan to submit their HEDIS® measures, their data must be audited by an NCQA certified HEDIS® Compliance Auditor. Due to this rigorous review and that all health plans must comply with this to submit the data, the consumer is reviewing “apples to apples” data on the health plan. This process also includes a member experience or satisfaction survey. The Consumer Assessment of Healthcare Providers and Systems (CAHPS), this survey was developed by the Agency for Healthcare Research and Quality (AHRQ) which is an arm of the U.S. Department of Health and Human Services (About CAHPS, 2016). All health plans submitting HEDIS® must also submit CAHPS data to NCQA. The CAHPS® survey is a member self- reported survey with questions created to determine a member’s satisfaction with the care and service they received from the health plan and its network providers.

C. URAC is another health plan health care accreditation organization. According to its website greater than 80 million Americans are covered by URAC-accredited health plans. URAC has a URAC Health Plan Accreditation with measures, this was developed to meet the Affordable Care Act of 2010 (ACA) requirement for accreditation of health plans.

1. URAC standards include:

a. Wellness and health promotion

b. Care coordination

c. Medication safety and care compliance

d. Reward quality

e. Care delivery through a patient centered medical home network

f. Mental health parity

g. Health Insurance Portability and Accountability Act breach requirements

h. Measures – patient-centeredness, coordination of care, patient safety, health plan administration.

i. Effectiveness of care, and health information technology integration

j. Patient experience of care (CAHPS® survey)

2. URAC performance measures are collected by Inovalon (exclusive provider). Beginning in 2017 these measures will require an audit. There are eight mandatory measures which fall under two health care issues: Accessible and affordable care, and safe care (Health Plan. (n.d).

III. Challenges for Quality Improvement

A. Higher Performance Rating

1. There is a requirement towards higher performance ratings for health outcome measures from external groups such as government agencies and consumers.

a. NCQA offer a tool to encourage MCOs to benchmark their outcome measures and improve them, this tool is called Quality Compass® “For more than five straight years, these reports have shown that participating commercial health plans recorded meaningful improvements across a wide range of clinical quality measures. For example, since NCQA began measuring beta-blocker treatment rates, performance in this critical area has gone from about 60% to well over 90%. Consequently, thousands of Americans every year will avoid a potentially fatal or debilitating second heart attack (Performance Measurement. n.d).” HEDIS® measures are half of the accreditation score and not just submitting but improving the outcomes is a part of the score. This means that resources must be put to best practice outreach to their members to encourage compliance with these standards of care.

b. URAC requires eight mandatory measures, in 2017 these measure will also be subject to auditing from a third party to assure alignment. Soon URAC will include a benchmarking device like NCQA’s Quality Compass® and the remainder of the MCOs will need to improve performance. .

B. Value based payment

1. Another challenge is transitioning to “value-based” payment which means using data to effect change in health care provider behavior.

a. Pay for Performance (P4P) programs which reward physicians for improved outcomes instead of focusing on the management utilization are a part of value based payment (Kongstvedt, P. R. 2013). Medicare has begun this type of payment for hospitals with the Hospital Value-Based Purchasing (VBP) Program. This program measures value either by how well a hospital improves compared to itself or compared to other hospitals. Where CMS goes the MCOs follow, however in this case MCOs began working through P4P programs in some form or another for at least 30 years. The design of the programs and limited evidence of improved outcomes due to the design makes these programs challenging (Parast, L., Doyle, B., Damberg, C. L., Shetty, K., Ganz, D., Wenger, N.S., Shekele, and P.G. 2015). These programs focus on structure, process and outcome, and so require valid sources of data. For many of the P4P HEDIS®® is used because it has already been vetted through the audit process and has comparison and threshold data via Quality Compass®. Goals are defined for each measure and payments are based on the practitioner reaching those goals. The intent of government P4P is to make this type of incentive “budget neutral” in that poor performers “pay to” high performers by relinquishing a certain amount of payment. For MCOs it is possible that they create a bonus pool from capitation payment and in effect use the model above.

b. Patient Centered Medical Home – The concept of the patient centered medical home is caring for the patient using a team oriented approach. This approach to individual healthcare also includes the coordinated efforts focusing on chronic conditions or actions such as overuse of ER. This approach according to AHRQ is promising in transforming primary care which is the foundation of healthcare in the United States (Transforming the organization and delivery of primary care.2016). This type of change in the primary care healthcare system processes includes a focus on outcome improvement which is demonstrated via performance or outcome measures. m

C. Measuring and effecting the socioeconomic differences in healthcare or health care disparities.

a. Equitable Access to Care:

I. The issue of access to quality healthcare is not new has been a part of the Healthy People initiative spurned on by the IHI report Crossing the Quality Chasm discussed earlier in this report. According to Healthy People, access to health services “…means the timely use of personal health services to achieve the best health outcomes. (Access to Health Services, 2016). This would seem common sense, however disparities exist and they are the root cause of poor health outcomes in these disparate groups.

b. Healthcare disparities - The term disparities encompasses the scope of inequality that endures in the United States, the focus here being healthcare. Entire groups of people experience hardships in just obtaining healthcare based on socioeconomic, racial/ethnic, linguistic, religion, gender, disability, gender identification and geographic location. According to Healthy People 2020, in 2008 approximately 100 million people self-identified as belonging to a racial or ethnic minority population, 154 million or over half of the US population were women. An estimated 23% of the US population lived in rural areas, and estimated 4% of the entire population identify themselves as lesbian,

gay, bisexual or transgender (Healthy People. 2008). It is imperative to measure and track the outcomes of these groups in order to remove the barriers to equal healthcare.

I. Cultural and linguistic appropriate services – The U. S. Department of Health human Services, Office of Minority Health has created the National Standards for Culturally and Linguistically Appropriate Services (CLAS). These standards are the structural foundation of many State requirements for Medicaid health plans and are the cornerstone for the Multi- Cultural Healthcare Distinction offered by NCQA. There are 15 standards which fall under the following issues:

I. Governance, Leadership and Workforce

II. Communication and Language Assistance

III. Engagement, Continuous Improvement and Accountability (The National CLAS Standards. 2016).

The standards focus on the type and processing of healthcare offered to people in a way that they can easily understand from a cultural and a linguistic perspective. Not only is it important to collect data but to improve the outcomes by evidence based processes.

c. Rural healthcare – healthcare disparities of people in the rural areas of the United States are determined by several risk factors including: geographic isolation, lower socio-economic status, higher rates of health risk behaviors, and limited job opportunities (Rural Health Disparities.2014). Teen birth rate alone compared to urban counterparts is larger by 10.3 percentage points. Preventable hospital stays are greater by 14.7 percentage points (Rural Health Disparities. 2014). Because of the rural isolation many people are not enrolled in Medicaid which uses managed care to control some of these outcomes. Poverty is a social determinant in rural areas that effects access to care specifically in the United States where the majority of the healthcare insurance is supplied by employers. Outreach will be key in these rural areas.

IV. Review of the Literature

A. NCQA –2015 State of Health - On an annual basis NCQA publishes a report which reviews HEDIS® and CAHPS® measures over time. For the 2015 report NCQA took a broader view evaluation three to five year trends.

1. Medicare Star Measures – These measures use HEDIS® measures and measures specific to Medicare Health Plans. They focus on:

a. Screening and test

b. Chronic conditions

c. Member experience (CAHPS®)

d. Complaints about the Health Plan

e. Customer service

They are rated by one to five stars, five stars being the highest rating. From 2014 to 2015 measures year (MY) the number of 4 and 5 star plans increased from 40 to 45%. Consumers also took note and as 60 to 70% of enrollees chose those health plans with the higher star ratings. NCQA goes on to report that of the 136 measure they are reporting on, 46 measures over a 3 to 5 year period had statistically significant improvement. In statistical terms this means that there is at least a 95% probability that this improvement are not due to chance but to actual sustained improvement. They report that 15 of the measures during this same time period had consistent statistically significant declines. The obesity measure, which is assessing adult BMI has had statistically significant gains over all types of health plans (commercial & Medicare HMOs & PPOs, Medicaid HMOs). The behavioral health measures show some improvement and declines or no change over this period (State of Health Care Quality. 2015). Clearly though overall the trend is improvement in these measures and the healthcare consumer is watching and making choices regarding how well the health plan fairs with these health outcome measures.

B. Value Based Payment

1. One of the big questions regarding performance is, are health plans the entity to measure performance? “Our current health plan performance measurement approach is flawed inasmuch as it relies excessively on measuring plans rather than providers. It is as if one were trying to measure blood pressure by using a thermometer, or using a scale to measure one's height. Our science, technology, medical care, understanding of what works and what does not in medicine are the best in the world (McIntyre, D., Roger, L., Heier, and E.J. 2001)”. This is from an article written in 2001 which took an overview of performance payment in the 50 years prior to the article. The basic outlook is quality of care and how is it that tangible. The old adage, mentioned in NCQAs State of Health Care Quality – 2015, “what get measured gets improved” needs the addition of, what gets improved gets higher wages. This system isn’t only used by health plans it is also used by CMS with their original value-based programs beginning with hospital payment schemes which are budget neutral, in other words less value means less pay, higher value means greater pay (What are value based programs?. n.d.) .

Clearly value-based healthcare is cemented into our government programs and private insurance as well.

C. Equitable Care

1. The Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHQR) have a combined report National Healthcare Quality and Disparities Report. The report focuses on access to care, patient safety, person & family centered care, care coordination, effective treatment, care affordability, and priority populations (National Healthcare Quality and Disparities Report.2014). The key findings of this report are from a peak of uninsured in the U.S. in 2010 of 22%, in 2014 Apr-June it had dropped to 15.6%. In the first 6 months of 2014 the decline in uninsured was larger among Black and Hispanic population. However people in poor households (family income less than the federal poverty level) had the largest number of disparities, followed by Blacks and Hispanics (Key Findings. April 2015). Clearly health disparities is a struggle that will continue and managed care using population health outreach can be a large player in the decrease of these disparities specifically with Medicaid and Medicare managed care.

V. Analysis

A. Quantitative analysis

1. For managed care, in order to meet the requirements set forth by state and federal mandates health plans find it in their favor to be accredited by a third party. For a large number of those health plans NCQA is the accreditation body, and NCQA requires HEDIS® measure submission. HEDIS® measure improvement either against itself or a percentile of aggregate data from all plans factor into the score of the health plan as well. These measures have for the most part improved over time (3 -5 years) which has required resources from these health plan to reach out to members and providers to encourage this improvement. HEDIS® measures have also become half of the score for accreditation, when they started at 23% of the score (State of Health Care -2015). Value based programs continue grow within government pay schemes for Medicare/Medicaid to hospitals and practitioners. All of these health care indicators can be measured through the lens of healthcare disparities. Healthcare quality improvement via health plan interventions and resources are currently on the rise.

B. Qualitative analysis

1. The overview of improvement of several of these measures and which health plans received the ‘higher score’ or Stars (if looking into Medicare plans) has increased the consumer expectation. Healthcare is measured and reported from the health plans perspective to the practitioner perspective to allow transparent information to the person getting the care, they can decide before they get care, who they want to get it from. ACA 2010 has also made a move to level the playing field in that more people, who could not afford health insurance have health insurance and they can also decide where their health dollars will be spent. People are the consumers of healthcare and the decisions for that healthcare is more in their court, patients are no longer saying – You’re the doctor you know best.

VI. Recommended Solutions

A. Have a Quality Champion: In order for health plans to meet the challenge of accreditation, which includes improvement in health care indicators there must be a foundation which supports quality initiatives. For most health plans this will include what is known as a Quality Champion. The Health Resources & Services Administration (HRSA) stresses the importance of a culture of quality and a cohesive quality team (Quality Improvement. n.d). This champion is a clinical leader in position of influence who is well –respected within the health plan. This leader will be the one to champion the cause to upper management when resources are needed to reach goals specific to quality improvement.

B. Accreditation and HEDIS® is an ongoing process not a project:

1. In order to infuse quality improvement throughout the health plan, the culture of the health plan needs to include accreditation standards as part of the health plans way of doing business. Too often accreditation becomes focused on the immediate needs during the look back periods when it needs to focus on these standards on and ongoing basis. Quarterly review of data and a work plan which includes a review of the standard reports and documents is a key factor in including quality in the structure of the health plan.

VII. Implementation of Solutions

A. Within the NCQA Quality Management and Improvement Standards, the outline of the committees and issues addressed is an included. Continuous improvement methods are a part of this structure, where a committee focused on quality is maintained and reports to the board of directors. What is not ‘required’ is the quality champion and the quarterly review. Health plans are required to have a medical doctor to review their utilization cases, this physician often times steps up as the quality champion or has oversight of the quality champion. The review of the reports and the increments of improvement demonstrated is of interest to the health plans and the quality champion to determine if the resources directed to the measures improvement are working. Adding this data and a review of the standard reports to the quality management committee quarterly meetings will improve the discussion around implementation and possibly invoke further resources to the measure.

VIII. Justification

A. Healthier people equals lower cost in health care: Delaying, preventing or managing chronic conditions in the population saves healthcare dollars. Just taking a look at Polio vaccination attest to this:

The CDC has stated that the “economic benefits of polio eradication are $40-50 billion through year 2035. What does this have to with health plans? Childhood Immunization rates has been a HEDIS® measures since its inception, IPV or Inactivated Polio Virus, the polio vaccination is a part of this measure. In 1990 in the commercial health plan population 82.6 % of children were immunized against polio, the Medicaid population measure began in 2001 at 79.1% immunized. In 2014 both Commercial and Medicaid IPV immunization rate increased by 10 percentage points (92.3% and 89% respectively) (State of Health Care. 2015). Looking at chronic condition measures for diabetes, such as monitoring nephropathy the improvement is larger 49.2 percentage point increase for the commercial population and 38.3 percentage point increase in Medicaid population (State of Health Care . 2015) . The improvement in the quality of care is justification for the recommendations to health plans to invest in a solid quality program.

IX. Summary

A. Health care quality improvement measures and outcomes are evolving. Consumers are demanding better value. As people live longer, quality of life is important and the pursuit of higher performance in health care aims to offer that. Managed care is at the forefront of measuring the quality of care that their members receive from the network of healthcare providers offered. As the healthcare consumer becomes savvier in reviewing their health plans outcome measures, it will be up to the health plan to put their money where their mouth is and deliver on the promise of the original HMOs and truly be a health maintenance organization.

X. Works Cited

Key Findings. Content last reviewed April 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/key1.html

About CAHPS. Content last reviewed June 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cahps/about-cahps/index.html

Parast, L., Doyle, B., Damberg, C. L., Shetty, K., Ganz, D., Wenger, N.S., Shekele, P.G. (March 2015).Challenges in Assessing the Process-Outcome Link in Practice. Journal of Internal Medicine. Vol. 30 Issue 3 pp 359-364. Retrieved from: http://link.springer.com/article/10.1007%2Fs11606-014-3150-0

The Six Domains of Health Care Quality. Content last reviewed March 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html

Access to Health Services (2016) Healthy People 2020, Office of Disease Prevention and Health Promotion. Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

The State of Health Care Quality 2015 (2015). National Committee for Quality Assurance. Retrieved from: http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality

Transforming the organization and delivery of primary care. (2016) AHRQ PCMH Patient Centered Medical Home Resource Center. Retrieve from: https://www.pcmh.ahrq.gov/

McIntyre, D. Rogers, L., Heier, J.E. (2001, Spring) Overview, History, and Objectives of

Performance Measurement. Health Care Finance. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194707/

Marjoua, Y., Bozic, K. (2012 December) Brief History of quality improvement in US Healthcare. Current Reviews in Musculoskeletal Medicine. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702754/

Accreditation to Approve Health Plans and Providers. (April 2011) National Conference of State Legislators, Retrieved from: http://www.ncsl.org/research/health/accreditation-to-approve-health-plans-and-provider.aspx

Disparities. (2008) Healthy People Retrieved from: https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

The National CLAS Standards. (2016) U.S. Department of Health and Human Services Office of Minority Health. Retrieved from: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53

Rural Health Disparities. (2014) Rural Health Information Hub. Retrieved from: https://www.ruralhealthinfo.org/topics/rural-health-disparities

Health Plan. (n.d) URAC. Retrieved from: https://www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/health-plan/

Healthcare Plan Information. (n.d) OMP.GOV. Retrieved from: https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plan-accreditation/

Health Plan Accreditation. (2015). NCQA. Retrieved from: http://www.ncqa.org/Programs/Accreditation/Health-Plan-HP.aspx

Kongstvedt, P. R. (2013). Essentials Of Managed Health Care, 6th Edition. [VitalSource Bookshelf Online]. Retrieved from https://devry.vitalsource.com/#/books/9781284023169

What are the value-based programs? (n.d.)Centers for Medicare & Medicaid Services. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html

Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives. (July 26, 2010). Evidence-Based Clinical and Public Health: Generating and Applying the Evidence. Healthy People 2020. Retrieved from: https://www.healthypeople.gov/sites/default/files/EvidenceBasedClinicalPH2010.pdf

National Healthcare Quality and Disparities Report (2014) U. S. Department of Health and Humans Services. Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/intro.html

Quality Improvement. (n.d.) Health Resources & Services Administration. Retrieved from: http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/part2.html

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