National Council on Aging Leveraging Quality Metrics to Increase … · 2019. 2. 4. · •...

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Improving the lives of 10 million older adults by 2020 © 2014 National Council on Aging

Leveraging Quality Metrics to Increase CDSME Sustainability

April 22, 2014

Howard Bedlin, JD, MPS

NCOA Vice President, Public Policy & Advocacy Kata Kertesz, JD

NCOA Legal Fellow

National Council on Aging

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Quality Health Care

• Right care in right amount at right time Right care: Safe, effective, fits patient

values & situation Right amount: What you need without

waste Right time: To stay healthy, get well, avoid

preventable problems • Quality problems are widespread Underuse – People don’t get needed care Misuse – People get the wrong care Overuse – People get care that doesn’t help

or costs more than effective options Source: NCQA

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Importance of Quality Measures

• In order to know where and how to improve, first you need to know how you are doing

• Shows where providers/plans can improve • Transparency helps foster accountability-

patients/payers can hold providers/plans accountable for quality

• Movement toward pay for performance leads to improvements in quality of care through financial incentives

• We need to expose quality To facilitate consumer/patient choice To incentivize improvement To manage costs Source: NCQA

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Importance of Quality Measures (Continued)

• Move away from current incentive structure in predominant FFS (rewards providers for the volume and complexity of services, not quality and outcomes)

• PFP: Rewards doctors and hospitals for improving the quality, efficiency, and overall value of health care (% of physician compensation can be tied to achieving specific clinical benchmarks) bonus to health care providers if they meet or exceed

agreed-upon quality or performance penalties on providers that fail to achieve specified goals or

cost savings

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Quality Metrics Gaps

• Quality Metrics for adults with Multiple Chronic Conditions (MCC) are severely lacking.

• Christine Cassell, President and CEO of the National Quality Forum (NQF): “[D]espite the growing prevalence of people with MCCs, existing quality

measures typically do not address issues associated with their care.” • Robert Berenson, Urban Institute:

“The changing demographics call for much more attention…shared patient-clinician decision-making, teaching patient self-management skills, medication management, counseling, [and] care coordination…in the [physician] fee schedule.”

• Mary Tinetti, Yale Program on Aging Director: “CMS and private insurers should eventually link payment in their value-

based purchasing initiatives to metrics relevant to multiple chronic conditions.”

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Types Of Quality Measures

• Access measure: Ability to get timely, appropriate care

• Structural measure: Capacity to provide good care through facilities, personnel,

equipment • Process measure: Actions known to support good outcomes (ex: patient

counseled to quit smoking) • Patient experience measure: Patient’s self reported observations (ex: patient perception of

communication with doctor) • Outcome measure: Ultimate (Death/recovery); Intermediate (BP control)

• Resource use/efficiency: Amount of services used or costs incurred

Source: NCQA

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Structure & Process Standards

• Health plans (from accreditation) Do plans provide accurate marketing material? Do they give clear information to members on coverage and

denial decisions? Do the providers in their networks have proper credentials?

• Primary care practices (from patient-centered medical home recognition) Do practices provide access after hours? Do they track patients with chronic conditions? Do they coordinate care with specialists?

Source: NCQA

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Example: Care Coordination

Structure PRACTICE Uses a standard referral form Tracks referrals

Process PRIMARY CARE % of referrals where information was sent to specialist % of referrals where specialist report was returned

Outcomes PATIENT “provider was informed & up to date” Able to return to work/social activities SYSTEM: Readmissions

Source: NCQA

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Who Develops and Uses Quality Measures?

Source: NCQA

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National Committee on Quality Assurance (NCQA)

• A non-profit that for over 20 years has worked with federal, state, consumer and business leaders to measure, improve and hold plans accountable for quality

• Mission: Improve healthcare quality • Vision: Transform healthcare through measurement,

transparency, and accountability

Source: NCQA

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NCQA’s Role In Quality Arena

• NCQA has established a process to evolve the measurement set each year: NCQA’s Committee on Performance Measurement (CPM) debates and decides collectively on the content of HEDIS This group determines what HEDIS measures are

included and field tests determine how it gets measured

HEDIS quality measures are reevaluated about every 3 years

Managed by NCQA Recommends measures to NCQA for inclusion in HEDIS

Source: NCQA

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Measure Development Process

Source: NCQA

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National Quality Forum (NQF)

• NQF was created in 1999 by a coalition of public- and private-sector leaders.

• NQF promotes and ensures patient

protections and healthcare quality through measurement and public reporting.

• NQF receives funding from both public

and private sources, including grants from foundations, corporations, and the federal government.

Source: NQF

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NQF’s Role in Quality Arena

• Sets standards (nearly all NQF endorsed measures are in use)

• Recommends measures for use in payment and public reporting programs( NQF-convened Measure Applications Partnership advises the federal government and private sector payers on the optimal measures)

• Identifies and accelerates improvement priorities • Advances electronic measurement • Provides information and tools to help healthcare

decision makers, like reports, tools, events (i.e. NQF Framework on MCC)

Source: NQF

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NQF Multiple Chronic Conditions Framework

• Developed May 2012 • Acknowledged that patients with MCC are largely not

addressed by available quality measures • Report identified measurement areas that are highly

valued by patients are likely to reduce disease burden and cost, while improving patient well-being

• The framework will serve as a guide for future NQF-endorsement decisions for measures that address the MCC population

• http://www.qualityforum.org/Publications/2012/05/MCC_Measurement_Framework_Final_Report.aspx

Source: NQF

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Qualities of Good Measures

Source: NCQA

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Limitations on Quality Measures

• Lack of solid science/consensus Can’t measure if correct action not clear

• Measures not meaningful ‘Did dermatologist look at skin’

• Too hard to get information -Or audit to verify accuracy

• Results do not show where action needed Or show all doing well

• Population too small for valid results Rare conditions

Source: NCQA

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What is HEDIS?

• Healthcare Effectiveness Data & Information Set® (Clinical )

• HEDIS is a tool used by more than 90 percent of America's health plans

• HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis

• The most widely used and respected tool for measuring quality

• 70+ measures of proven, effective care • Continuously updated for new scientific evidence

and to “raise the bar”

Source: NCQA

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HEDIS Measures Multiple Dimensions

• Effectiveness of care: Do hypertension patients have their blood pressure under control?

• Access: Were patients able to get an appointment with their Primary Care Physician?

• Utilization: What was the average length stay in a hospital for a chronic condition?

• Relative Resource Use (RRU): Measures examine the intersection of quality and cost to measure value and efficiency

Source: NCQA

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What is CAHPS?

Consumer Assessment of Health Providers & Systems® (Patient Survey) • Survey asks how well plans and providers meet patient needs

(‘experience of care’) • Agency for Healthcare Research and Quality (AHRQ) collects

CAHPS survey data How often did you get appointments/care as soon as you

thought you needed? Did customer service give you help you needed? Treat you

with courtesy and respect? Did your doctor listen carefully? Explain things in a way that

was easy to understand? Spend enough time with you? Source: NCQA

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Star Ratings for Medicare Parts C and D

• Medicare publishes quality ratings of Medicare health and prescription drug plans which can be used to compare plans. A plan can get a rating from one to five stars. A 5-star rating is considered excellent.

• Beginning in 2012, the ACA required the ratings to be used to award Quality Bonus Payments (QBPs) to Part C Medicare Advantage (MA) plans.

• In 2013, moving from a 3 to 4 star MA plan was worth roughly $50 per member per month.

• MA-PDs receive an overall rating that summarizes quality and performance for all Part C and D measures combined.

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MA Star Ratings Incentives

• The Affordable Care Act established CMS’ Star Ratings as the basis of Quality Bonus Payments (QBPs) for Part C MA plans 5-star Plans can market year-round. Beneficiaries can

join at any time via a special enrollment period (SEP). The Medicare Plan Finder (MPF) blocks enrollment into

plans with the Low Performer Icon (those with less than 3 stars for at least the last 3 years in a row) CMS can terminate Low Performer Plans, beginning in

2015.

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2012 Star Rating Bonus Payments

Plan Rating Bonus (ACA) Bonus (CMS demo) 5 star 1.5% 5% 4 to 4.5 star 1.5% 4% 3.5 star None 3.5% 3 star None 3% 2 and 2.5 star None None 1 star None None Unrated 1.5% 3% (plans too new, or with too few enrollees)

MA Plan Rating Bonus (ACA) Bonus (CMS demo)

5 star 1.5% 5%

4 to 4.5 star 1.5% 4%

3.5 star None 3.5%

3 star None 3%

2 and 2.5 star None None

1 star None None

Unrated 1.5% 3% (plans too new, or with too few enrollees)

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ACA Bonus Payment Increases

Plan Rating 2012 Bonus Payment

2013 2014

4 or more Stars

1.5% 3.0% 5.0%

Unrated 1.5% 2.5% 3.5%

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Health Plan Ratings Measures

• The Plan Ratings measures span five broad categories: Outcomes Intermediate Outcomes Patient Experience Access Process measures

• Outcomes and intermediate outcomes are weighted three times as much as process measures, and patient experience and access measures are weighted 1.5 times as much as process measures.

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Medicare Part C and D Star Rating Domains

Ratings of Health Plans (Part C) Ratings of Drug Plans (Part D) Staying healthy: screenings, tests, vaccines

Drug plan customer service

Managing chronic conditions Member complaints, problems getting services, and improvement in the drug plan’s performance

Member experience with the health plan

Member experience with the drug plan

Member complaints, problems getting services, and improvement in the health plan’s performance

Patient safety and accuracy of drug pricing

Health plan customer service

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MA Domain 2: Managing Chronic Conditions

• Care for older adults: medication review; functional status assessment; Pain screening

• Osteoporosis management in women who had a fracture • Diabetes care: eye exam; kidney disease monitoring; blood

sugar controlled; cholesterol controlled • Controlling blood pressure • Rheumatoid arthritis management • Improving bladder control • Reducing the risk of falling • Plan all-cause readmissions

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Care Coordination in Medicare Part C

• In 2013, a new care coordination metric was included for Medicare Part C, made up of six questions from the CAHPS survey focusing on: Whether the doctor had medical records and other information

about the enrollee’s care Whether there was follow-up with the patient to provide test

results How quickly the enrollee got the test results Whether the doctor spoke to the enrollee about prescription

medicines Whether the enrollee received help managing care Whether the personal doctor is informed and up-to-date about

specialist care.

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Patient Centered Medical Homes (PCMH)

• PCMH is a team-based model for organizing primary care that emphasizes care coordination and communication that can lead to higher quality and lower costs.

• NCQA developed guidelines for becoming a certified medical home.

• The PCMH Item Set in the CAHPS survey includes a new self-management support measure.

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Self Management and PCMH Recognition

• NCQA Standards reinforce the critical role of

patient Self-Management and practice Self-Management Support

• The physician within the PCMH must Document Self-Management capabilities of

the patient Document Self-Management goals; provide

tools and resources Counsel on healthy behaviors Assess/provide/arrange for mental

health/substance abuse treatment Provide community resources

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CDSMP as a Key Component of NCQA PCMH Standards

PCMHI: Access and Continuity D. Use of Data for Population Management F. Culturally and Linguistically Appropriate Services

PCMH4: Provide Self-Care Support and Community Resources (Must Pass) A. Support Self-Care Process B. Document Goals, Ability, Self-Management Tools, Referrals to Community Resources

PCMH2: Identify and Manage Patient Populations C. Patient Panels, Comprehensive Health Assessment

PCMH5: Track and Coordinate Care B. Referral Tracking and Follow-Up C. Coordinate with Facilities/Care Transitions

PCMH3: Plan and Manage Care B. Identify High-Risk Patients C. Care Management, Pre-Visit Planning, Treatment Plan and Goals, Identify Barriers D. Manage Medications

PCMH6: Measure and Improve Performance B. Measure Patient/Family Experience E. Report Performance

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PCMH Self-Management Measure

• One of the required elements for Level 1 PCMH recognition is PPC 4, Element B: Self-Management Support.

• Practices must score at least 50% in this element to achieve Level 1, meaning that 25-49% of patients seen in the last three months must have at least three activities that support patient/family self-management documented.

• This measure could serve as a model for other areas, such as ACOs.

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Accountable Care Organizations (ACOs)

• Network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients

• ACO quality measures include pieces from HEDIS and CAHPS

• 33 quality measures for ACOs Patient/ Caregiver experience (7) Care coordination/patient safety(6) Preventive health (8) At risk populations: diabetes (6), hypertension (1),Ischemic

Vascular Disease (2), heart failure (1), Coronary Artery Disease (2)

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Physician Quality Reporting System (PQRS)

• Uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs)

• EPs must report on a minimum of 3 measures in order to get the PQRS incentive

• EPs may choose from any of the 267 measures in the PQRS program

• The Physician Compare website recently added PQRS quality data

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Physician Quality Reporting System (PQRS)

• EPs now get 0.5% bonus for simply reporting measures – 1.5% cut in 2015 for not reporting in 2013

• Pay-for-performance (P4P) begins 2017 based on 2015 results for groups of 10/+

Source: NCQA

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Legislation on Physician Quality

The Medicare SGR Repeal and Beneficiary Access Improvement Act (S. 2110) • Consolidates three existing quality programs into a

streamlined and improved program that rewards providers who meet performance thresholds, improves care for seniors, and provides certainty for providers.

• Provides critical funding for quality measures development. • Publicizes quality and utilization data to enable patients to

make more informed decisions about their care.

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CDSME Advocacy: Quality

Promote Chronic Disease Self-Management Measures and Standards for: • PCMH (model for others?) • 5 Star • ACOs • PQRS

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CDSME Advocacy: Federal Appropriations

Appropriations Funding • Prevention and Public Health Fund $10m in FY 12, $7.1m in FY13, $8m in FY14 Requesting $16m in FY15 (restore FY10, FY11

ARRA levels) Issue Brief: www.ncoa.org/CDSMEFY15

• OAA Title IIID Stable at $21m, unlikely to increase

http://www.ncoa.org/CDSMEFY15

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CDSME Advocacy: Medicare

Medicare Opportunities • New Senate Finance committee Chairman

Ron Wyden (D-OR) interested in chronic care reforms – S. 1932, S. 1228

• Payment for Diabetes Self-Management • Diabetes prevention legislation (S. 3463,

amend to include SM demo?) • Federally Qualified Health Centers (FQHCs)

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CDSME Advocacy: Medicaid

Medicaid Opportunities • Dual-Eligible Integration Demonstration Profiles:

http://dualsdemoadvocacy.org/state-profiles

• Medicaid Health Home Demonstrations: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html

• State Medicaid CDSMP Activities: http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/NCOA-AoA-Flyer-State-Medicaid-1.pdf

• Managed Long-Term services and Supports (MLTSS)

http://dualsdemoadvocacy.org/state-profiles

http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html



http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/NCOA-AoA-Flyer-State-Medicaid-1.pdf

http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/NCOA-AoA-Flyer-State-Medicaid-1.pdf

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