Introduction to NCQA & SNP Assessment Brett Kay Director, SNP Assessment Casandra Monroe Assistant...

Introduction to NCQA & SNP Assessment

Brett KayDirector, SNP Assessment

Casandra MonroeAssistant Director, SNP Assessment

2SNP Training – Intro to NCQA & SNP Assessment Program

Purpose of Training

• Provide brief overview of NCQA• Describe the SNP assessment

program NCQA is executing on behalf of CMS

• Give a general understanding of main components of SNP assessment– HEDIS® measures– Structure & Process measures


A Brief Introduction to NCQA

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

• Committed to measurement, transparency and accountability

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


NCQA: Mission and Vision

• Mission– To improve the quality of health

care • Vision

– To transform health care through measurement, transparency and accountability


NCQA: COMMITTED TO MEASUREMENT, TRANSPARENCY,

ACCOUNTABILITYQuality measurement

means:• Use of objective measures

based on evidence• Results that are comparable

across organizations• Impartial third-party

evaluation and audit• Public Reporting

NCQA’s quality programs include:

• Accreditation of health plans using performance data

• HEDIS clinical measures• CAHPS consumer survey• Measurement of quality in

provider groups• Physician Recognition


Achieving the Mission

• 3 out of 4 Americans enrolled in an HMO are in an HMO accredited by NCQA

• More than 90 percent of managed care organizations report HEDIS® quality data

• 38 states and the federal government rely on NCQA Accreditation and HEDIS

• More than 12,000 physicians have earned NCQA Recognition; programs form the basis of quality improvement programs and P4P nationwide


SNP Assessment: How did we get here?

• Existing contract with CMS to develop measures focusing on vulnerable elderly

• Revised contract to address SNP assessment– 1st year—rapid turnaround, adapted

existing NCQA measures and processes from voluntary Accreditation programs

– 2nd year—focus on SNP-specific measures– 3rd year—Refine measures; identify new

SNP-specific measures, where appropriate


Objectives of SNP Assessment Program

• Develop a robust and comprehensive assessment strategy

• Evaluate the quality of care SNPs provide

• Evaluate how SNPs address the special needs of their beneficiaries

• Provide data to CMS to allow plan-plan and year-year comparisons


Three-Year StrategyPhase 1 - FY

2008 Phase 2 - FY 2009 Phase 3 - FY 2010

SNPs Effective as of January 2007



HEDIS 2008(13 measures)

HEDIS 2009(15 measures)•Addition of two 1st year measures: Care for Older Adults; Medication Reconciliation Post-Discharge

HEDIS 2010 • Measure development:

–Potentially Avoidable Hospitalizations–Inpatient Readmissions–MDS measures (I-SNPs)–Disease-specific measures (C-SNPs)

Structure & Process Measures

• SNP 1: Complex Case Management

• SNP 2: Improving Member Satisfaction

• SNP 3: Clinical Quality Improvements


• SNP1 – 3• SNP 4: Care Transitions• SNP 5: Institutional SNP

Relationship with Facility• SNP6:Coordination of

Medicare & Medicaid


•Refinement of existing S&P measures, includes the potential development of new elements

•Potential development of new measures


SNP Assessment: Phase I • 2008 SNP Data Collection Successfully

Completed – 340 HEDIS submissions – 432 Structure & Process submissions

• Draft SNP Report sent to CMS September 30– Final Report to CMS—April 2009

• Reassessment – Plans with 50% or less on any element– 72 plans requested reassessment– Revised scores sent to CMS

• SNP specific HEDIS measures released in HEDIS 2009 Volume 2


Project Time Line – Phase II

• March - Release final S&P measures• March 30 - Release ISS Data

Collection Tool– S & P Measures

• April - Release IDSS Data Collection Tool– HEDIS Measures

• June 30 - HEDIS submissions and S&P measures submissions due to NCQA

• October 30 - NCQA delivers SNP Assessment Report to CMS


Training & Education

• Five training topic areas, focus is on content and data submission– Introduction to NCQA & SNP Assessment

Program– SNP Subset of HEDIS Measures– Interactive Data Submission System

(IDSS)– Structure & Process Measures

• Phase I (SNP 1-3)• Phase II (SNP 4-6)

– Interactive Survey System (ISS)

HEDIS 101


What Is HEDIS?

HealthcareEffectivenessData &InformationSet

HEDIS is an evolving set of standard specifications for measuring health plan performance


Where Did HEDIS Come From?

•Originally developed by employers and the HMO group in 1991; NCQA took charge of HEDIS in 1992

•Expanded in 1996 to cover all three product lines: commercial, Medicare and Medicaid

•Addresses the leading causesof death

•Includes information on quality, utilization and cost


How Are HEDIS Data Used?•Federal, state and other regulatory requirements

•State of Health Care Quality report•Performance-based accreditation•Health plans use for RFP/RFI preparation

•Quality improvement activities and health plan operations

•Quality Compass, Quality Dividend Calculator

•US News and World Report - Ranking of Health Plans


Data Reporting

•Data are reported to NCQA in June of the reporting year

•Data reflect events that occurred during themeasurement year(calendar year)


Data Reporting

•Example:– HEDIS 2009 data are reported in

June 2009– Data reflects events that occurred

January–December 2008 (per specs)

– HEDIS 2009 = 2008 data


Effectiveness of Care Measures

•Clinical quality of care •Focus

– Preventive care– Up-to-date treatments for acute

episodes of illness– Chronic disease care– Appropriate medication

treatment

Collecting HEDIS Data


Three HEDIS Data Sources

Administrative

Medical records

Surveys

Claims Encounter Eligibility Provider


Data Sources

•Administrative– Membership data– Provider data– Claims/encounter data

– Hospital discharge data

– Pharmacy data– Carve-out data


Selecting an Eligible Population

• Member ID

• Age (DOB)

• Enrollment date and type

• Dates of service

• Diagnosis and procedure codes

• Provider specialty

• Pharmacy


• Defining the denominator is critical

• Administrative: Claims and encounter data– Denominator: Based on all eligible

members of the population

Clinical MeasuresData Collection

Clinical MeasuresData Collection

HEDIS Compliance Audit


•A standardized audit methodology for verifying the reliability of HEDIS data collection and rate calculation processes

•Outcome is whether or not a measure is reportable

NCQA HEDIS Compliance Audit

NCQA HEDIS Compliance Audit


•Data collection and calculation methods can vary across plans

•A standardized audit identifies, quantifies and converts errors

•The audit reduces bias

Why a Standardized HEDIS Audit?

Why a Standardized HEDIS Audit?


What is a S&P Measure?

• A statement about acceptable performance or results

• Assesses a plan’s ability to comply with specific requirements

• Focus on systems necessary for quality care– Policies & procedures, reports,

materials


How are S&P Measures Developed

• Similar to HEDIS measures development• Initial literature review and evidence• Measurement Advisory Panel (GMAP)

– Diverse set of expert stakeholders– Technical expert panels also formed, if

necessary

• Pilot tests to determine feasibility, burden

• Public comment• Final Approval from GMAP and CMS


Components of the S&P Measures

• Standard statement: a statement about acceptable performance or results

• Intent statement: A sentence that describes the importance of the S&P measure

• Element: The component of the measure that is scored and provides details about performance expectations. NCQA evaluates each element within the measure to determine the degree to which the SNP has met the requirements within the S&P measure.


Components of an S&P Measure

• Factor: An item within an element that is scored (e.g., an element may require an organization to demonstrate that a specific document includes 4 items. Each item is a factor).

• Scoring: The level of performance the organization must demonstrate to receive a specific percentage on each element (100%, 80%, 50%, 20%, 0%)

• Data source: Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA requires 3 types of data sources for S&P assessment:


Data Source Types

• Documented Processes: Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization

• Reports: Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports of analysis; system output giving information; minutes; and other documentation of actions that the organization has taken

• Materials: Prepared materials or content that the organization provides to its members and practitioners, including written communication, Web sites, scripts, brochures, review and clinical guidelines


Components of an S&P Measure

• Scope of Review: The extent of the organization’s services evaluated during an NCQA survey. Scope of review may vary

• Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element

• Explanation: Guidance for demonstrating performance against the element

• Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive


Look-Back Period FAQs

• Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within that this timeframe?– The look-back period is the three-month period

prior to survey submission—March 31, 2009 to June 30, 2009. All documentation must be current as of the look-back period but it could have been developed before that time.

– For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.

2009 SNP Measures Requirements


SNP Assessment Process

• Phased Approach– Defining and assessing desirable

structural characteristics– Assessing processes– Assessing outcomes

• Two main components – HEDIS Measures-focus on clinical

performance– Structure & Process measures-focus on

structural characteristics and systems


SNP Assessment Process

• S&P Measures assessment– Data collection through Web-based

Interactive Survey System (ISS) data collection tool.

• Several levels of review:– Off-site Review (Level 1)– Executive Review (Level 2)– Final Eyes (Level 3)


S&P Assessment: What’s New for 2009

• Plan Comment Period– b/w level 2 & 3 review– Plans will have an opportunity to provide

additional information to clarify issues from original submission materials

– Quick turnaround: plans will have to respond to NCQA requests for more information rapidly

– One-time opportunity: Only chance plans have before data is finalized and sent to CMS. There will not be a reassessment like Phase I.


S&P measures: What’s New for 2009

• SNP 1-3: Added 2 new elements– SNP 2C: Improving member satisfaction

•Focus on implementing interventions to address member satisfaction issues

– SNP 3B: Clinical measurement activities•Focus on collecting, analyzing relevant

clinical data• Identifying opportunities for improvement

based on data analysis

– Existing elements: added more examples and clarified explanations


S&P measures: What’s New for 2009

• SNP 4: Care Transitions– All SNP Types– Focus on how SNPs manage planned and

unplanned transitions of care for members

• SNP 5: Institutional SNP Relationship with Facility– (I-SNPs only)– Focus on ensuring SNP members in Institutional

facilities receive comprehensive quality care

• SNP 6: Coordination of Medicare and Medicaid– Different requirements for Duals and I&C SNPs– Focus on helping members obtain benefits/services

regardless of payer.


New Phase II HEDIS Measures

• Measures– Care for Older Adults (COA)– Medication Reconciliation Post-

Discharge (MRP)

• Hybrid Method Collection

SNP Data & Reporting


Data Submissions

• HEDIS measures– Submission date: June 30, 2009– IDSS data collection tool– All data must be audited by NCQA certified

HEDIS auditor

• S&P measures– Submission date: June 30, 2009– ISS data collection tool

• No Fees required to submit


Who Reports

• HEDIS measures– All SNP plan benefit packages with 30+

members as of February 2008 Comprehensive Report (CMS website)

• S&P measures– All SNP plan benefit packages– Plans with no enrollment exempt from

certain elements


What to Report

• S&P measures• Cohort I—All SNPs operational as of

January 1, 2007 and renewed in 2009.– S&P measures 4-7 (SNP 2:C & 3:B)

• Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009– All S&P measures (SNP 1-6)

•Do not report SNP 7 (SNP 2:C & 3:B)


What happens after submission?

• NCQA Analysis of HEDIS and S&P measures– Comparison to MA plans (HEDIS) and

to other SNPs– Demographic (size, type, region)– Statistical significance

• Deliver report to CMS– CMS will make all decisions about how

to use the data– NCQA will not publicly report any of

the SNP data


And now…

Questions?


Contacts

Brett KayDirector, SNP [email protected]

Casandra MonroeAssistant Director, SNP [email protected]


Additional Resources

• NCQA SNP Webpage: www.ncqa.org/snp.aspx– FAQs (HEDIS)– Training descriptions & schedule– Final HEDIS and S&P measures (March 14)

• NCQA Policy Clarification Support (PCS)http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

• HEDIS Audit informationhttp://www.ncqa.org/tabid/204/Default.aspx


Additional Information

• HEDIS 2008 Volume 2 Publication Purchase

http://www.ncqa.org/tabid/78/Default.aspx

• October Specifications Updatehttp://www.ncqa.org/Portals/0/PolicyUpdates/HEDIS%20Technical%20Updates/2008_Vol2_Technical_Update.pdf


Additional SNP Trainings

• Introduction to NCQA & SNP Assessment– March 5th 1:00 – 3:00 pm– March 10th 1:00 – 300 pm


Additional SNP Trainings

• SNP Subset of HEDIS Measures– March 3rd 11:30 – 1:00 pm– March 11th 11:30 – 1:00 pm – March 16th 1:00 - 2:30 pm– March 26th 1:00 - 2:30 pm– April 1st 12:30 - 2:00 pm

• Structure and Process Measures (S&P 1-3)– March 12th 1:00 – 2:30 pm– March 19th 1:00 - 2:30 pm– March 25th 12:30 - 2:00 pm– April 23rd 2:00 – 3:30 pm


Additional SNP Seminars

• Structure and Process Measures (S&P 4-6)– March 17th 2:00 - 3:30 pm– March 24th 2:00 - 3:30 pm– March 31st 2:00 - 3:30 pm– April 2nd 12:30 – 2:00 pm– April 7th 2:00 - 3:30 pm– April 15th 1:00 – 2:30 pm

• Interactive Survey System (ISS)– April 8th 1:00 – 2:30 pm– April 14th 1:00 - 2:30 pm– April 17th 1:00 – 2:30 pm – April 21st 1:00 - 2:30 pm– April 28th 1:00 – 2:30 pm– May 7th 1:00 – 2:30 pm

Introduction to NCQA & SNP Assessment Brett Kay Director, SNP Assessment Casandra Monroe Assistant...

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