A DECADE OF HEDIS ® : CELEBRATING SUCCESS, SHAPING THE FUTURE MARGARET E. O’KANE PRESIDENT.

A DECADE OF HEDIS®:CELEBRATING SUCCESS, SHAPING THE

FUTURE

MARGARET E. O’KANEPRESIDENT

2A DECADE OF HEDIS: SHAPING THE FUTURE

MARGARET E. O’KANE

TODAY’S DISCUSSION

• NCQA: A Brief Introduction• Defining the Stakes• A Decade of Improvement:

Quantifying the Impact• Assessing Special Needs Plans• The Quality Agenda At a

Crossroads:Shaping the Future



NCQA: A BRIEF INTRODUCTION

• Private, independent non-profit health care quality oversight organization founded in 1990

• Mission: To improve the quality of health care

• Committed to measurement, transparency and accountability

• Unites diverse groups around common goal: improving health care quality



NCQA ASSESSES HEALTH PLAN SYSTEMS & PROVIDERS

• NCQA Accreditation– 2/3 of HMOs in U.S. are NCQA-Accredited

• Covering 75% of HMO lives

– Only Accreditation program that scores programs on quality of care

• Physician Recognition Programs– Assesses for diabetes, heart/stroke, back

pain care, office care systems– Recently recognized 10,000th physician– New program identifies “medical homes”



WHAT DO WE MEASURE?

• HEDIS®

– Cancer screening, diabetes, cardiac care– Measures of effective, appropriate care– HEDIS measure criteria: valid, relevant,

feasible– Specifications vetted by committee of health

care stakeholders, thought leaders– Results are rigorously audited

• CAHPS®

– Access, timeliness, satisfaction– Independently collected



THE WAY OUR SYSTEM OUGHT TO WORK

A value-based health care system

20% of peoplegenerate

80% of costs

Healthy/Low Risk

At-Risk

HighRisk

ActiveDisease

Health care spending

Early Symptoms

Source: HealthPartners



DEFINING THE STAKES



KATHLEEN CASEY-KIRSCHLING

Photo: USA Today



KATHLEEN CASEY-KIRSCHLING:THE FIRST BABY BOOMER

• By 2030, 1 in 5 Americans will be 65 or over

• An estimated 80 million Americans will sign up for Medicare over the next 20 years – That works out to one new Medicare

beneficiary every ten seconds of every day



MEDICARE HOSPITAL INSURANCE TRUST FUND

ASSETS AS A PERCENTAGE OF OF EXPENSES, 1970-2025 (PROJ.)

Source: “Status of the Social Security and Medicare Programs,” ssa.gov

0%

20%

40%

60%

80%

100%

120%

140%

160%

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

2022

2024

Projected Medicare Hospital Insurance Trust Fund Assets



A DECADE OF MEASUREMENT:QUANTIFYING THE IMPACT



IN THE BEGINNING...• Quality widely assumed to be high• Measurement regarded as a novelty• Health plans went first

– Purchaser demand, threat of regulation were key

– CMS was a key supporter

• Strong provider resistance• Performance gaps revealed, quality

improvement efforts launched• Patient safety story unfolded• Notion of ‘cost/quality tradeoff’

exploded



0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006

Cholesterol Screening

MEASUREMENT DRIVES IMPROVEMENT:

CHOLESTEROL SCREENING, MA PLANS, 2000-06

NO

DA

TA

/ S

PEC

. C

HA

NG

E



0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006

Hypertension


BLOOD PRESSURE CONTROL, MA PLANS, 2000-06

SPECIFICATIONCHANGE



30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006

Beta-Blockers After a Heart Attack


POST-MI BETA-BLOCKER TREATMENT, 2000-06



30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006

HbA1c control (<9.0)

MEASUREMENT IDENTIFIES OPPORTUNITIES

FOR IMPROVEMENT:HbA1c CONTROL (<9.0 mg/dL), 2000-06



IMPROVEMENTS SAVE LIVES

Cumulative Lives Saved Due to Commercial and Medicare Quality Improvement, 2000-2006

Measure Lives Saved

Beta-Blocker Treatment 4,400 – 5,600

Cholesterol Management 10,100 – 17,000

Controlling High BP 56,800 – 98,600

Poor HbA1c Control 2,000 – 3,400

TOTAL 73,300 – 124,600



BUT WE STILL HAVE FURTHER TO GO

HEDIS Performance, 2005-2006: • Commercial plans improve in 30 of 44 measures• Medicaid plans improve in 34 of 43 measures• Medicare plans improve in 8 of 21 measures

– Partly attributable to high number of first-time reporters

– 64 MA plans reported HEDIS for the first time in 2006– Plans reporting in ’05 and ’06 improve on 13 of 21

measures

• We must stay focused on advancing quality



EVALUATING SPECIAL NEEDS PLANS (SNPs)

• Created by MMA legislation of 2003• SNPs serve vulnerable groups of

beneficiaries– Institutionalized– Those with severe or disabling chronic

conditions– Dual eligibles (Medicare and Medicaid)

• NCQA evaluation requirements build on existing Accreditation standards



EVALUATING SPECIAL NEEDS PLANS (SNPs):

A PHASED APPROACH• 2008: Review 477 SNPs

– Evaluate performance on 13 HEDIS measures of care– Assess structure and process, case management,

member experience, quality improvement

• 2009: Review 787 SNPs– Expand suite of HEDIS measures, with focus on

measures of care for older adults; integrate CAHPS, HOS

– Expand structure and process measures to include care transitions, plan design, caregiver experience

– Test benchmark measures

• 2010: Review 787+ SNPs– Refine benchmark measures for collection; expand set

of applicable HEDIS measures



THE QUALITY AGENDA AT A CROSSROADS



ONLY 1 IN 5 MEDICARE BENEFICIARIES ARE ENROLLED IN ACCOUNTABLE

SYSTEMS

Traditional Medicare:74.4%

MA HMO plans: 15.4%

MA PPO plans: 2.4%

MA PFFS plans: 5.1%

SNPs: 2.7%



PRIVATE FEE-FOR-SERVICE PLANS: THE FASTEST- GROWING SEGMENT OF MEDICARE

ADVANTAGEEnrollment in Medicare Advantage as a Percentage of Part A Enrollment

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

0

5

10

15

20

25

30

PFFS Plans

HMOs and PPOs

Source: Congressional Budget Office



WE MUST ASSESS THE VALUE WE’RE GETTING FOR THE TAXPAYER DOLLAR

• Growth in unaccountable PFFS plans is troubling, yet it’s the fastest-growing MA segment– PFFS is reimbursed at a higher rate

than other plan types• MSAs remain small (<250)• Accountability must cut across

plan, payment types– Support in Congress, MedPAC for PFFS

accountability



WHAT’S NEXT?

• Develop and test accountable health care models such as the medical home

• Implement a comprehensive strategy for stewardship of medical evidence

• Develop more bundled, severity-adjusted payment models

• Develop a public-private strategic plan for improving population health



THE AVERAGE MEDICARE BENEFICIARY SEES SEVEN DOCTORS

Dx

Tx

RxTx Rx

DxDx

Dx

Rx

Rx

Dx

Tx

Rx

Tx

Tx

Rx

Dx

Tx

RxDx

Tx

…confusing, dangerous gaps in care often result.



EVIDENCE STEWARDSHIP

• We don’t have evidence to support much of the medical care we deliver

Current model:• Investigator-initiated research• Fragmented by specialty, organ

systems• Repetitive trials in some areas, no

evidence in others



PAYMENT REFORM: TIE IT TO OUTCOMES

• Bundling of payments (partial capitation) desirable to allow integrated systems to gain from their efficiencies

• Performance benchmarking also plays an important role – Facilitates performance comparison– Transparency critical to trust– Allows differential rewarding for superior

care



THE HEALTH OF AMERICANS IS A PRECIOUS NATIONAL ASSET

• We need to treat our collective health as an asset and zealously protect it (e.g., “Gross National Health”)– A comprehensive strategy for population

health stewardship is needed– Stakeholders are preoccupied with rising

costs• Warning signs are there: growing

numbers of uninsured, rising rates of diabetes, obesity



CHALLENGES IN POPULATION HEALTH MANAGEMENT

• Keeping healthy people healthy (e.g., promoting wellness)

• Finding disease early in its course to optimize outcomes

• Keeping the chronically ill as well as possible

• Improving care coordination for patients with complex conditions

• Providing compassionate, coherent end-of-life care

• Identifying, eliminating medical errors



THE THREE DIMENSIONS OF STRONGPOPULATION HEALTH MANAGEMENT

QUALITY

AFFORDABILITYACCESS



For more information:www.ncqa.org

SNP Assessment:www.ncqa.org/snp.aspx

A DECADE OF HEDIS ® : CELEBRATING SUCCESS, SHAPING THE FUTURE MARGARET E. O’KANE PRESIDENT.

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