How to Implement Quality in Exchanges Webinar sponsored by AcademyHealth
Transcription
How to Implement Quality in Exchanges Webinar sponsored by AcademyHealth
How to Implement Quality in Exchanges Webinar sponsored by AcademyHealth and the National Committee for Quality Assistance (NCQA) April 9, 2012 AcademyHealth AcademyHealth seeks to improve health and health care by generating new knowledge and moving knowledge into action. AcademyHealth collaborates with the health services research community and other key stakeholders to: – Support the development of health services research – Facilitate the use of the best available research and information – Assist health policy and practice leaders in addressing major health challenges National Committee for Quality Assurance (NCQA) The NCQA is a not-for-profit organization dedicated to elevating the issue of health care quality to the top of the national agenda and transforming health care quality through measurement, transparency and accountability. New Report E. Hoo, D. Lansky, J. Roski et al., Health Plan Quality Improvement Strategy Reporting Under the Affordable Care Act: Implementation Considerations, The Commonwealth Fund, April 2012. Available at www.academyhealth.org/AHNCQAQualityinHIXs Downloading the Slides Click “Supporting Materials” on the webpage you are using to view the webinar. Go to the AcademyHealth web site: www.academyhealth.org/AHNCQAQualityinHIXs Questions? To submit a question, Click on “Ask a Question” located in the button bar below this presentation. Complete the form and click “Submit.” Exchanges & Health Plan Quality Reporting Today’s event will: – Examine the Affordable Care Act’s quality reporting requirements for plans participating in the health insurance exchanges; – Highlight examples of how state purchasers have already integrated health plan quality reporting and improvement strategies in their existing programs; and – Review some concrete ways to implement the ACA requirements in phases and by strategically building for the future. Agenda What are the quality requirements for Exchanges? (Sarah Thomas, MS – NCQA) How have state purchasers integrated quality at the plan level into their existing programs? – Wendy Long, MD, MPH - TennCare – Richard KP Sun, MD, MPH - CalPERS How can Exchanges implement the quality requirements? (Ledia Tabor, MPH – NCQA) Questions What are the Quality Requirements for Exchanges? Sarah Thomas, MS Certification of Qualified Health Plans • The Exchange will certify qualified health plans (QHPs) who meet the following requirements: – Are accredited within a specific timeframe – Meet marketing requirements – Ensure a sufficient choice of providers (network adequacy) and provide information on providers – Include essential community providers where available – Implement a quality improvement strategy – Report health plan quality measures – Utilize uniform enrollment form – Utilize standard format for presenting benefit options NCQA and AcademyHealth April 9, 2012 10 Health Plan Accreditation • Health plans (issuers) must be accredited in the following categories by an accrediting entity recognized by HHS (timing determined by state) – – – – – – – – – Clinical quality measures, such as HEDIS Patient experience ratings, such as CAHPS Consumer access Utilization management Quality assurance Provider credentialing Complaints and appeals Network adequacy and access Patient information programs NCQA and AcademyHealth April 9, 2012 11 Network Adequacy Requirements • Health plans must ensure a sufficient choice of providers and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers • Must include essential community providers in health insurance plan networks, where available, that serve predominantly lowincome, medically-underserved individuals NCQA and AcademyHealth April 9, 2012 12 Quality Rating • Secretary to develop a rating system for Exchange health plans in each benefits level on quality and price • Secretary to develop an enrollee satisfaction survey system and make information available through the portal to allow enrollees to compare plans • Exchanges to maintain Internet websites and assign a rating to each qualified health plan offered through such Exchange in accordance with the criteria developed by the Secretary NCQA and AcademyHealth April 9, 2012 13 Quality Improvement Strategy • Implementation of a quality improvement strategy that rewards quality through the use of market-based incentives – Improves health outcomes – Reduces readmissions – Improves patient safety – Promotes wellness and health – Reduces disparities NCQA and AcademyHealth April 9, 2012 14 Federal Guidance to States – Operational Capabilities • Consider strategy for using quality information to certify QHPs • Determine what quality information or metrics the Exchange will display to consumers • Build capacity for Exchange system to accept this quality data and report on website • Consider how Exchange will monitor QHP quality during the plan year (monitoring of complaints, appeals and network adequacy) NCQA and AcademyHealth April 9, 2012 15 Quality Improvement Strategies in Medicaid Managed Care Lessons Learned from the TennCare Experience AcademyHealth & NCQA Webinar April 9, 2012 Wendy Long, MD, MPH, Chief Medical Officer Bureau of TennCare TennCare, the Beginning • In 1994, Tennessee restructured its Medicaid program and became the first state in the nation to enroll its entire Medicaid population into managed care, as well as being the only state to offer Medicaid to all uninsured and uninsurable citizens – regardless of income. • This restructured and expanded Medicaid program was renamed “TennCare”. • At inception, the thought was the cost‐savings from a managed care model would allow the state to cover an expanded population (individuals who would not qualify under traditional Medicaid eligibility standards) and additional benefits. • As a revolutionary model, this approach brought about some challenges which prompted the program to change and evolve to become the program it is today. TennCare 1994 Services 1994 Overview At TennCare’s inception, there were 12 different community service areas (CSAs) and a dozen health plans ‐ only two were statewide. TennCare did not restrict the number of health plans; nor did it require a procurement process for plan selection. Prior to TennCare, Tennessee Medicaid was entirely fee‐for‐ service. • 12 Plans total – 8 HMOs; 4 PPOs • Risk Model – All plans were “at‐risk” • Total Enrollment – 1.1 million Carved In • • • • Physical Dental Pharmacy Routine Mental Health Services Carved Out • Long‐Term Care • Specialized Mental Health Services Quality Monitoring 1994 Service Areas TennCare outlined basic quality management requirements in the contracts with the health plans and contracted with an External Quality Review Organization (EQRO) to review and report on MCO quality. Out of necessity, the EQRO’s primary focus was on getting health plans to a point where they had appropriate policies in place. Quality of encounter data – poor Network monitoring focused on Geoaccess mapping of MCO reported primary care providers Appeals were handled by MCOs TennCare Satisfaction Survey: 1994 – 61% 18 TennCare 2003 Services 2003 Overview Carved In By 2003, TennCare required all health plans to be HMOs and serve all areas within each Grand Region in which they participate, resulting in three Service Areas (West, Middle and East). At this time, health plans had begun to experience problems, and some were at risk of becoming insolvent which caused the state to bring them into an Administrative Service Organization (ASO) arrangement. Contributing factors included the impact of lawsuits/consent decrees and a lack of experience and capital on the part of some MCOs. • 9 plans – all HMOs • Risk Model – All plans were brought into an ASO arrangement (no risk) • Total Enrollment – 1.35 million • Physical Carved Out • Behavioral Health • Dental • Pharmacy • Long‐Term Care Quality Monitoring By now the EQRO was able to focus on adherence to policies. 2003 Service Areas Encounter data quality had improved. By the late 90’s, TennCare had commissioned several studies on quality including delivery of preventative services, prenatal care and ER utilization. In addition, an annual Women’s Health report was now being produced. Network requirements were expanded to include specialty standards Management of appeals shifted to TennCare TennCare Satisfaction Survey : 2003 – 83% 19 TennCare 2006 Services 2006 Overview Carved In By 2006, TennCare reform was nearly complete and relief had been obtained from a particularly burdensome consent decree. After the release of a study by McKinsey & Company in 2004 showing that the growth of TennCare was projected to require every new state dollar in just a few short years, the state had to make some difficult decisions to keep the program operating. The most difficult decision was reducing enrollment, but children and mandatory Medicaid enrollees were protected from these reductions. Program reductions included imposing a limit on prescription drugs for most adults and eliminating adult dental coverage. These steps were challenging but necessary and allowed TennCare to return to firm financial footing. • 7 plans – all HMOs • Risk Model – ASOs (no risk) • However, TennCare was in the process of restructuring the program and request for proposals were made for at‐risk plans in 1 of the 3 regions. • Total Enrollment – 1.2 million 2006 Service Areas • Physical Carved Out • Behavioral Health • Dental • Pharmacy • Long‐Term Care Quality Monitoring In 2006, TennCare became the first Medicaid agency in the country to require all MCOs be NCQA accredited. In addition, TennCare began requiring that all MCOs report annually on the full set of HEDIS measures. EQRO role shifted to focus on Tennessee specific concerns and to assure annual on‐site monitoring Provider network monitoring was enhanced to include validation of MCO reported data and confirmation of time to appointment Medical necessity rules were promulgated to assure evidence‐based decision making TennCare Satisfaction Survey: 2006 – 87% 20 TennCare 2009 Services 2009 Overview Carved In By 2009, TennCare had secured contracts with two well-capitalized and experienced MCOs in each region. The plans were operating at full risk. These MCOS were selected through a competitive bid process. In addition, one health plan contracted to operate statewide to serve a select population of members and to function as a back-up health plan should another plan falter. Rates were determined by an outside actuary to ensure the rates were sufficient for the plans to provide necessary care and maintain stability. TennCare had also begun implementation planning for the new TennCare CHOICES in Long-Term Care program that would eventually bring LTC services for the elderly and adults with physical disabilities into managed care. • 3 plans – all HMOs • Risk Model – At-risk • Total Enrollment – 1.2 million 2009 Service Areas • Physical • Behavioral Health Carved Out • Dental • Pharmacy • Long‐Term Care Quality Monitoring By 2009, all MCOs were NCQA accredited and HEDIS scores were improving, particularly in the area of child health. Integration of behavioral health allowed for reporting of behavioral health HEDIS measures for the first time. Quality initiatives targeting emergency department overutilization, comprehensive diabetes care and adolescent well care were underway. EQRO tasked with producing annual summary of HEDIS results that includes statewide weighted averages as well as comparisons across MCOs and to national benchmarks. Reports published on TennCare website. P4P program in place relative to selected HEDIS measures TennCare Satisfaction Survey: 2009 – 92% 21 TennCare 2012 2012 Overview Today, TennCare is in the process of extending contracts with its MCOs in order to maintain stability throughout health reform planning. The CHOICES program was fully implemented in August of 2010, bringing LTC for the elderly and adults with physical disabilities into the managed care model and increasing HCBS options for members. Integration of physical health, behavioral health and LTC services promotes improved coordination of care for the “whole person.” • 3 plans – all HMOs • Risk Model – At-risk • Total Enrollment – 1.2 million Services Carved In Carved Out • Physical • Behavioral Health • Long‐Term Care (for E/D) • Dental • Pharmacy • Long‐Term Care (for ID) Quality Monitoring 2011 Service Areas Today, TennCare rates above the national Medicaid average in many quality measures and continues to demonstrate improvement . With the integration of LTC into the managed care model, efforts to monitor quality of care in the elderly and disabled population are a new focus of attention. We continue to enhance quality standards – recently added contractual requirement for all plans to utilize hybrid methodology in HEDIS reporting in cases where either hybrid or administrative is acceptable to NCQA TennCare Satisfaction Survey: 2011 – 95% 22 Examples of Improvements Over Time U.S. Expenditure on Health Care Per Capita Vs. Comparable TennCare Per Member Cost Well‐Child Screening Rates $8,500 100% $7,500 90% $6,500 80% $5,500 70% $4,500 60% $3,500 50% $2,500 TennCare Unadjusted Rate TennCare Adjusted Rate 40% 2004 2005 2006 2007 2008 2009 30% U.S. (OECD Health Data 2011) 20% TennCare (Cost of Comparable Services/Enrollment) 10% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Member Satisfaction Rates 2010 HEDIS Results 100% Improvement in 6 of 8 adult diabetes measures from 2006 to 2010. 90% Improvement in 5 of 6 women’s health measures from 2006 to 2010. 80% 70% Improvement in 12 of 12 child health measures from 2006 to 2010. 60% 10 of 12 child health measures exceed national Medicaid average in 2010. 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 50% 23 Lessons Learned On Quality 1. Access to reliable encounter data as quickly as possible is extremely important. Hard data is needed to dispel misinformation and anecdotes. 2. Quality requirements should be spelled out for health plans – e.g. accreditation requirements and timelines, performance measure reporting requirements. Accreditation takes time so clear milestones should be established to assess progress toward the goal. Consider P4P arrangement to reward plans for accreditation level received. 3. Independent, external review (EQRO, accrediting body like NCQA) goes a long way to quelling stakeholder concerns. 4. MCO required reporting of standardized, evidenced‐based performance measures allows for tracking trends over time and for comparison to national norms (e.g. HEDIS). 5. Consider developing a state level survey that will allow you to track issues of interest to the state over time. This would be in addition to MCO level surveys like CAHPS. 6. Pay for Performance incentives tied to specific performance measures can be used effectively to target attention to your highest priorities. 7. Network monitoring should include three components: • Establishment of network standards for various provider types (e.g. geographic, appointment time • Tracking compliance with standards based on network information self‐reported by MCOs • An audit process to validate MCO self‐reported information 8. Tracking and analysis of enrollee appeals can be an important quality monitoring tool 24 CalPERS Health Plan Quality Data: Sources and Uses Richard KP Sun, MD, MPH California Public Employees' Retirement System CalPERS and Health Benefits Sources of Quality Data Uses of Quality Data • • • • Publications Health Plan Chooser Public Presentations to Board Contract Requirements NCQA and AcademyHealth April 9, 2012 25 CalPERS and Health Benefits • Vision statement (excerpt): “...data-driven, costeffective, quality, and sustainable health options for our members and employers” • Will spend about $7 billion in 2012 on health benefits for >1.3 million active and retired state & local employees and their family members • Major plans ("Basic" and "Medicare"): 6 self funded PPO plans administered by Anthem Blue Cross, 6 HMO plans (with Blue Shield of California and Kaiser Permanente) Source: “Facts at a Glance: Health” at http://www.calpers.ca.gov/eip-docs/about/facts/health.pdf NCQA and AcademyHealth April 9, 2012 26 Sources of Quality Data • HEDIS (CalPERS-specific for PPO plans) • CAHPS – "Health Plan Member Survey" – random sample of 1,100 eligible members from each Basic and Medicare plan with 2,000 members • Health Care Decision Support System (HCDSS, "data warehouse") with claims & other data 2003-present Sources: http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201012/item-3b.pdf, http://healthcare.thomsonreuters.com/thought-leadership/iifl/donneson/ NCQA and AcademyHealth April 9, 2012 27 Use of Data in CalPERS Publications Example: 2012 Health Benefit Summary Source: http://www.calpers.ca.gov/eip-docs/about/pubs/member/mbr-pubs/2012-health-prg-pubs/2012-healthbenefit-summary.pdf NCQA and AcademyHealth April 9, 2012 28 Use of Data in Health Plan Chooser (I) • Web-based tool allowing members to compare CalPERS plans on costs, doctors, plan performance ratings, etc. • Includes CAHPS data in bar graphs (excerpt below), HEDIS data for Basic plans in table (excerpt next slide) Source: https://calpers2012.chooser2.pbgh.org/ NCQA and AcademyHealth April 9, 2012 29 Use of Data in Health Plan Chooser (II) Source: https://calpers2012.chooser2.pbgh.org/Pages/Help.aspx?ContentType=CalPERSClinicalScores. Asterisks indicate HEDIS measures collected via hybrid (as opposed to administrative) method. NCQA and AcademyHealth April 9, 2012 30 Use of Data in Board Presentations (I) Selected HEDIS Scores for CalPERS Plans: Number Above or Below National HMO or PPO Averages for Reporting Years 2008, 2009, & 2010 Above National Average Below National Average Number of HEDIS Measures Above Or Below National Average 15 10 5 0 -5 -10 2008 2009 2010 2008 2009 2010 2008 2009 2010 2008 2009 2010 BSC Kaiser Care Choice Health Plan and Reporting Year Source: Attachment to December 14, 2010, CalPERS Health Benefits Committee Agenda Item 3b at http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201012/item-3b-attach.pdf NCQA and AcademyHealth April 9, 2012 31 Use of Data in Board Presentations (II) Percent of Expenditures on Potentially Avoidable Complications, By Episode Type – CalPERS PPO Plans vs. US Benchmarks Note: CalPERS HCDSS data for these analyses were from 2008-2009. Source: Attachment 2 to February 14, 2012, CalPERS Pension and Health Benefits Committee Agenda Item 7 at http://www.calpers.ca.gov/eipdocs/about/board-cal-agenda/agendas/pension/201202/item-7-attach-2.pdf. NCQA and AcademyHealth April 9, 2012 32 Use of Data for Contract Requirements • Incentives for performance related to HEDIS and CAHPS measures have been included in contractual performance guarantees and pay for performance objectives with CalPERS health plan partners. • Efforts continue to more closely align the incentive structures across the plans. Sources: December 14, 2010, CalPERS Health Benefits Committee Agenda Items 3b and 3c at http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201012/item-3b.pdf and http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201012/item-3c.pdf NCQA and AcademyHealth April 9, 2012 33 Other Uses of HCDSS Data: Examples • To support creation of Value Based Purchasing Design (e.g., analysis of hospital charges for hip and knee joint replacement in PPO plans, leading to $30,000 limit for these surgeries) • Stanford/NYU study of how introduction of high-performance networks affects healthcare costs Sources: Attachments 1 and 2 to October 18, 2011, CalPERS Health Benefits Committee Agenda Item 3 at http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201110/item-3-attach-1.pdf and http://www.calpers.ca.gov/eip-docs/about/board-cal-agenda/agendas/hbc/201110/item-3-attach-2.pdf NCQA and AcademyHealth April 9, 2012 34 Contact Information Richard KP Sun, MD, MPH, Medical Consultant Health Plan Administration Division California Public Employees' Retirement System P.O. Box 1953, Sacramento, CA 95812-1953 [email protected] Web: http://www.calpers.ca.gov/ NCQA and AcademyHealth April 9, 2012 35 How Can Exchanges Implement the Quality Requirements? Ledia Tabor, MPH Objectives • Discuss NCQA-recommended phase-in approach for Exchanges to meet quality requirements • Discuss how NCQA’s work in quality can be used in state Exchanges • Provide design principles for implementing decision-support tools • Identify principles to help build Exchanges that promote value NCQA and AcademyHealth April 9, 2012 37 Two Phases of Policies to Move Towards Value in Exchanges Phase 1 - (2013 - 2015) Phase 2 - (2016 and Beyond) Accreditation • Require accreditation Accreditation • Require performance-based accreditation Quality Measures • Collect quality measures (CAHPS) Quality Measures • Create meaningful benchmarks, ratings, & rankings using HEDIS/CAHPS • Report measures at plan & provider level Quality Improvement and Reporting • Provide evidence of quality improvement activities • Consider using past plan results to report to consumers for plans that have similar products in the Commercial or Medicaid market Web Portal/Decision-Support • Display quality information together with cost sharing and premiums • Create a process for mandatory training of navigators and brokers on value Quality Improvement and Reporting • Develop reward/incentive system • Create incentives for plans to engage with consumers • Push aggressively for quality improvement through public reporting of standardized measures, benchmarking against targets and public education Web Portal/Decision-Support • Evolve web portals NCQA and AcademyHealth April 9, 2012 38 Principles for Accreditation • Simple to understand, administer • Level playing field among products • Must include clinical quality measures and patient experience measures • Key challenge is transition – – In 2014 plans will have no quality measures to report for Exchange enrollees – Need a transition strategy until 2015 when first measures, benchmarks can be calculated NCQA and AcademyHealth April 9, 2012 39 Possible Accreditation Timelines 1. Require Accreditation the first year of the Exchange Currently Accredited Plan Plans Qualified Non-Accredited Plan (should start process) 7/2013 2/2012 State Qualifies Plans 2. Allow a year for plans to be Accredited Currently Accredited Non-Accredited (should start process) 2/2012 1/2013 • About 18 months to go through Accreditation process • No matter what report Accreditation status in 2013 Plans Qualified 7/2014 State Qualifies Plans NCQA and AcademyHealth April 9, 2012 40 Quality Measures: A National Starter Set • Use the same quality standards nationally • Start with a feasible set of measures; can add over time • Select measures using defined principles – Aligned with national health improvement goals, Medicaid, Medicare and commercial strategies – Widely used by health plans and national quality reporting initiatives (e.g., HEDIS®) – The same measures for all types of health plans – HMOs and PPOs – Phase in more outcomes measures over time – Require auditing to ensure reliability, validity of results • Require CAHPS, a proven method of gathering patient experience; may need new items NCQA and AcademyHealth April 9, 2012 41 Quality Measures for Exchanges • Various levels of requirements • Waiting for federal and state rules • Quality measure reporting options – Separate Exchange population Small numbers State Required Federal Required Quality Rating • Start with high prevalence measures • Phase in more with time – Combine Medicaid or Commercial with Exchange populations • NCQA will align its data collection, reporting, Accreditation with requirements – Could include non-HEDIS measures NCQA and AcademyHealth April 9, 2012 42 Quality Data Collection Why do Exchanges need quality data? •Qualify plans for Exchange participation •Monitor quality improvement goals and strategies •Create ratings and report cards •Report to consumers How do Exchanges obtain quality data? •Through an efficient and uniform data collection process •Analysis-ready files •Data submission process that health plans already use for NCQA, CMS, and other purchasers NCQA and AcademyHealth April 9, 2012 43 Design Principles for Decision-Support Tools (Refer to NCQA White Paper, Ratings and Decision-Support Tools, for more information) Context • Explain how quality information is meaningful in selection of a high value plan Content • Provide short definition & example of concept • Use filtering to allow consumers to customize the decision process Presentation Ease of Use • Data displays should summarize and interpret data for consumers • Comfortably and quickly navigate through content NCQA and AcademyHealth April 9, 2012 44 Build Exchanges to Promote Value (Refer to NCQA White Paper, Building State Exchanges to Get Better Value, for more information) • Ensure that Web portals, report cards, navigators, brokers and other resources make total cost and quality information easy to see, understand and use – Present information as simply as possible – Build from existing measures and data collection systems – Limit data collection to data that have clear use – Add more information, new measures and quality improvement over time NCQA and AcademyHealth April 9, 2012 45 Questions? For more information, please contact Ledia Tabor ([email protected]) or Kristine Thurston Toppe ([email protected]), or visit NCQA Exchange Quality Solutions at http://www.ncqa.org/tabid/133/Default.aspx NCQA and AcademyHealth April 9, 2012 46