Implementation of Section 2717: Ensuring the Quality of Care

Transcription

1 Implementation of Section 2717: Ensuring the Quality of Care The Affordable Care Act includes many provisions to improve the quality of health care received by Americans. One of the key provisions is Section 2717, which directs the Secretary of Health and Human Services to develop reporting requirements for health insurers on benefits, structures and activities that work to improve quality of care. With an increasing number of Americans covered by health insurers because of the Affordable Care Act, insurers have an important role in ensuring and improving the quality and affordability of care. The National Committee for Quality Assurance (NCQA) has worked for over 20 years to improve the quality of health care through measurement, transparency and accountability. NCQA develops quality standards and performance measures for a broad range of health care entities, including health insurers. These measures and standards are the tools that insurers use to identify opportunities for improvement. The public reporting of these measures encourages improvement and holds organizations accountable to consumers and purchasers. We recommend that the Secretaries build the implementation of Section 2717 on existing NCQA Accreditation requirements and HEDIS and CAHPS measures that are, by far, the most widely used for health insurers by other public and private programs. Given the many implementation activities that need to occur around the Accountable Care Act, it strikes us as practical to start with existing standards and measures and build from these over time. This will allow consistency and comparisons across payers and around the country, reduce unnecessary burden and most importantly -- provide a measurement foundation to drive improvements in care. We urge the Secretaries to avoid directing health plans to write narratives of how they say they will improve quality and instead capture dimensions of performance improvement in actual measures and standards that can allow comparison among plans and over time. NCQA can provide additional information, examples of quality standards and measures and expertise in reviewing health insurer quality improvement activities. Improving Health Outcomes Section 2717 (a)(1)(a) requires the development of health insurer reporting requirements on coverage benefits and health care provider reimbursement structures that improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Affordable Care Act, for treatment or services under the plan or coverage. Quality reporting: The Healthcare Effectiveness Data and Information Set (HEDIS ) consists of 75 quality measures across 8 domains of health care. The measures identify how well an insurer s benefits, processes and services meet evidence-based guidelines and improve health outcomes. The HEDIS measure set includes specific health outcome measures, such as HbA1c levels in diabetics and blood pressure for those with hypertension. Many health insurers covering more than 118 million lives - already collect and report audited HEDIS measure results to NCQA. Because so many insurers report HEDIS data to NCQA, and because the measures are so specifically defined and independently audited, HEDIS makes it possible to accurately compare the performance of insurers on an "apples-to-apples" basis. NCQA s public reporting of results and regular updates of HEDIS measures drives insurers to continuously focus on greater quality improvement efforts, and not just check-a-box on quality measurement. Page 1 of 7

2 The Secretaries should use the opportunity offered by Section 2717 to drive reporting on quality by requiring health insurers to report results of care through audited HEDIS measures, not through a written quality improvement activity (QIA) report. Our long experience in reviewing health insurer quality tells us that assessing the level and improvement in quality through standardized measures is much more meaningful than QIA reports. NCQA s experiences with QIA evaluation demonstrate that meaningful improvement can be difficult to determine, the reports are resource intensive for health insurers and reviewers and not effective for consumer reporting. Effective case management: Health insurers can use case management services to improve the health outcomes of their enrollees. NCQA s Health Plan Accreditation program already contains a comprehensive evaluation of case management that includes factors that have been shown to make these programs effective. The evaluation includes not just a review of documented processes, but also actual enrollee case management files for the specified items. NCQA recommends that the Secretaries allow health plans to use the results of our accreditation program review to show their work on case management. Health insurers provide complex case management to coordinate care and services to enrollees who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system. The goal of complex case management is to help enrollees regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. It involves comprehensive assessment of the enrollee s condition; determination of available benefits and resources; and development and implementation of a case management plan with performance goals, monitoring and follow-up. NCQA s standards on case management call for health insurers to evaluate enrollee satisfaction with the program, program staff, and the usefulness of the information disseminated by the organization and enrollee s ability to adhere to recommendations. Also, insurers should measure effectiveness of the program by identifying appropriate process and outcome case management measures, analyzing measure results, identifying opportunities for improvement and developing interventions. Care coordination: People with multiple health conditions typically receive care from different systems and different providers. By administering health benefits, insurers have information at their disposal to facilitate continuity and coordination of medical care across its delivery system. NCQA s Health Plan Accreditation evaluates insurer processes and evidence of implementation for work to improve enrollee coordination and continuity of care. NCQA does not prescribe specific care coordination activities, but does evaluate that the organization works to improve coordination. NCQA recommends that the Secretaries allow health plans to use the results of our accreditation program review to show their work on care coordination. Improved care coordination ensures that services are consistent and that providers are aware of the services received from all other providers and systems. Insurers should help with an enrollee s transition to other care, if necessary, when benefits end. Since enrollees with behavioral health disorders often receive care from multiple providers, it is important that insurers collaborate with its behavioral healthcare delivery systems on behavioral and medical care. Insurers should monitor data and take action, as necessary, to improve continuity and coordination of care across the health care network. Chronic disease management: Disease management is an approach to health care delivery that continuously evaluates clinical, humanistic and economic outcomes with the goal of improving overall health. Insurers possess data about the health status of its enrollees and therefore have a responsibility for meeting their health needs by intervening to help enrollees and providers manage chronic conditions. NCQA s Health Plan Accreditation evaluates insurer disease management program structures and processes for identifying and assessing enrollees and developing plans and interventions. NCQA s Page 2 of 7

3 Disease Management Accreditation also evaluates health insurer and other organizations that offer comprehensive DM programs with services to patients, providers or both. NCQA recommends that the Secretaries allow health insurers to use the results of our accreditation programs evaluation to demonstrate their disease management program. Disease management supports the provider-patient relationship and plan of care; emphasizes the prevention of disease exacerbation and complications using cost-effective, evidence-based practice guidelines; and encourages patient empowerment strategies such as self-management. Insurer disease management programs should frequently identify enrollees who would benefit from the program using multiple data sources (e.g., claims, encounter, pharmacy, lab results, EHR, provider referral). The programs should include treatment plans and information and interventions directed at enrollees or providers to improve management of a condition or health maintenance (e.g., materials, enrollee reminders, scripts for phone calls). Care compliance initiatives, such as medical home models: Enrollees are more likely to have better health outcomes if they comply with guidance, medications and referrals given to them by their providers. Health insurers can use particular reimbursement structures that encourage providers to improve enrollee compliance. NCQA s Patient-Centered Medical Home (PCMH) program transforms primary care into what both patients and providers want it to be. It is currently used by insurers to recognize whether providers are working to improve health outcomes through better patient access, coordination, education and support. NCQA recommends that the Secretaries allow insurers to meet requirements if they encourage and incentivize practices to adopt and seek evaluation on medical home processes. It is also important that insurers support and encourage provider reporting of health outcomes and quality measures, such as provider-level HEDIS and CAHPS. A medical home is a health care setting that facilitates partnerships between individual patients, and their personal providers and when appropriate, the patient s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. NCQA s PCMH 2011 program evaluates provider/practice access and continuity, identification and management of patient populations, care management, provision of self-care and community support and quality improvement work. Understanding that the medical home model can improve health outcomes, health insurers are encouraging and incentivizing network providers to adopt NCQA PCMH standards and to seek NCQA evaluation and recognition. For example, insurers are providing additional reimbursement per enrollee, providing consultants and resources needed to adopt medical home processes and facilitating best practice learning collaborative for providers. A key component of NCQA s PCMH evaluation is the use of quality metrics by providers to understand and implement quality improvement activities. Providers can use provider-specified HEDIS measures to understand opportunities for improved health outcomes. For example, comprehensive diabetes care measures demonstrate if diabetic patients need more provider attention to help them control their HbA1c levels. HEDIS measures specified for providers play a part in many current provider incentive programs outside of PCMH. For example, the California Pay for Performance program collects a common provider quality measure set (consisting of some HEDIS measures), publicly reports the results and provides payments for improved quality to approximately 35,000 physicians in 221 physician groups. Some HEDIS provider level measures are also accepted as part of the Centers for Medicare and Medicaid Services Physician Quality Reporting System (PQRS) that promotes provider quality reporting. Page 3 of 7

4 Preventing Hospital Readmissions Section 2717 (a)(1)(b) requires the development of health insurer reporting requirements on coverage benefits and health care provider reimbursement structures that implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional. NCQA s HEDIS measurement set includes a new Plan-All Cause Readmissions measure that identifies the percentage of acute inpatient stays that were followed by an acute readmission for any diagnosis within 30 days, for enrollees 18 years of age and older. We recommend that the Secretaries require reporting on this measure as a way to track readmissions at the plan level. Care Transitions: To provide quality care and increase patient safety, health insurers should make a special effort to coordinate care when enrollees move from one setting to another, such as when they are discharged from a hospital. NCQA s Care Transitions standard evaluates insurer processes for coordinating patient care during transitions. NCQA recommends that the Secretaries allow health insurers to use the results of evaluation against this standard as a way to report health insurer activities to prevent readmissions. Health insurers should identify and plan for transitions by monitoring all enrollees through risk assessment, utilization management and case management. Insurers can manage transitions by informing the enrollee s usual provider of the transition and communicating to the enrollees their plan of care. NCQA currently evaluates Medicare Special Needs Plans under contract with the Centers for Medicare and Medicaid Services (CMS). NCQA reviews the insurer s documented processes and evidence of implementation for managing the process of care transitions, identifying problems that could cause transitions and where possible prevent unplanned transitions. Improving Patient Safety Section 2717 (a)(1)(c) requires the development of health insurer reporting requirements on coverage benefits and health care provider reimbursement structures that implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage. Errors in health care occur too frequently and result in unneeded costs, reduced quality of life and death. Currently, much of the patient safety quality reporting and improvement work is done at the hospital level, for example postoperative infections. NCQA recommends that more research and work be done to specify health insurer patient safety measures, but that patient safety HEDIS measures are a strong start for reporting requirements. In order to understand opportunities for improvement and drive improvement through public reporting, health insurers should first measure areas that adversely affect patient safety. NCQA s HEDIS measurement set includes measures to understand how insurers manage fall risk and manage medications to reduce errors. The Fall Risk Management measure is collected using survey methodology (Health Outcomes Survey) and measures the percentage of Medicare enrollees who discussed their fall risk and interventions to prevent falls with their providers. An example of a medication management measures includes the Medication Reconciliation Post-Discharge measure that evaluates whether medications were reconciled on or within 30 days of discharge. Over time, we would recommend that the Secretaries support development of measures of inpatient safety that can be applied at the health plans level. Page 4 of 7

5 Implementing Wellness and Health Promotion Activities Section 2717 (a)(1)(d) requires the development of health insurer reporting requirements on coverage benefits and health care provider reimbursement structures that implement wellness and health promotion activities. For purposes of subsection (a)(1)(d), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program's participants, and which may include the following wellness and prevention efforts: (1) smoking cessation, (2) weight management, (3) stress management, (4) physical fitness, (5) nutrition, (6) heart disease prevention, (7) healthy lifestyle support, (8) diabetes prevention. By encouraging people to make changes in their daily habits -- such as eating healthier foods or quitting smoking -- insurers can work to improve their enrollee's health and productivity. NCQA s Accreditation programs review for key aspects of an insurer s health promotion program including health appraisals, self-management tools and encouraging wellness. The Accreditations also score insurers on wellness and prevention quality measures, such as advising smokers to quit. NCQA recommends that the Secretary allow health insurers to use accreditation and HEDIS results to demonstrate their wellness and health promotion activities. Employers and health insurers are increasingly offering wellness and health promotion programs to employees and enrollees. These programs encourage healthy behavior to lower health risks for chronic conditions and other diseases. A wellness and health promotion program should include administration of a health appraisal to identify at-risk and high-risk individuals, determine focus areas for timely intervention and prevention efforts and monitor risk change over time. It is also an educational tool that can engage enrollees in making healthy behavior changes. A health insurer also has a unique opportunity to use additional data beyond appraisals to identify health needs and risks (e.g., claims, pharmacy, utilization management). A wellness and health promotion program should use the information obtained to offer appropriate and targeted self-management tools, reminders for missed appointments, treatment options and community based resources. Insurers can distinguish their wellness and health promotion benefits and services through the comprehensive accreditation program that includes reporting of standard process and outcome measures. NCQA s Health Plan Accreditation evaluates insurer structures and processes including provision of a health appraisal, disclosure of how the information will be used and protection of it in accordance with privacy policies. The evaluation also includes review of evidence-based selfmanagement tools available to help enrollees manage their health. NCQA also reviews how insurers promote enrollee wellness and prevention of illness and measures access to wellness and prevention services. A portion of Health Plan Accreditation scoring includes performance on wellness and health promotion HEDIS quality measures. These scored HEDIS measures include advising smokers to quit and preventative services such as immunizations and cancer screenings. Some non-scored HEDIS measures that health plans use to track and report quality are Body Mass Index assessment and wellchild visits. NCQA s Wellness and Health Promotion Accreditation program is a broad-based accreditation program for organizations, such as insurers, that offer comprehensive wellness and health promotion services. The program evaluates additional components of a wellness and health promotion program including how wellness and health promotion programs are implemented in the workplace, how services such as coaching are provided to help participants develop skills to make healthy choices and how individual health information is properly safeguarded. The program also requires insurers to report standardized Page 5 of 7

6 program measures that allows for comparisons across insurers. Examples of the performance measures include health appraisal completion, prevalence of risk and overall risk reduction. How Insurers Can Report Quality Work to the Secretaries and Enrollees Section 2717 reads that a health insurance issuer shall annually submit to the Secretary and to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements. As an organization with experience reviewing quality reports and results and reporting them for the state and federal governments, NCQA is happy to provide suggestions for ways the Secretary can effectively require and review insurer work to ensure and improve quality. Other Approaches to Improving Quality Are More Effective Than Quality Improvement Activity (QIA) Reports Although NCQA has experience with QIA reports (and indeed we review these for some Medicare Advantage plans on behalf of CMS), we would urge emphasis on measures and standards for programs rather than this approach. QIAs include identification of an opportunity for improvement and then interventions to improve. An effective QIA also demonstrates that its activities have resulted in meaningful improvements in the quality of care or service delivered to enrollees. Before standardized performance measures existed, NCQA accreditation evaluated and scored insurer s QIAs. QIAs were a starting approach to quality improvement that we used until we developed standardized measurement. NCQA s experience is that meaningful improvement can be difficult to determine, resource intensive for health insurers to produce, that it is difficult for reviewers to assess these statements reliably and they are not useful for consumer reporting. To demonstrate an effective QIA, an insurer submitted to NCQA a completed QIA form that summarized the activities that show meaningful improvement. The form contains the following five sections. 1. Activity selection and methodology- defines the rational for selecting this activity, uses quantifiable measures that clearly and accurately measure the activity 2. Data/results table includes baseline and remeasurement results 3. Analysis cycle presents the results of the analyses used to interpret the meaning of the results and opportunities for improvement 4. Interventions table lists the interventions taken to overcome barriers identified in the analysis 5. Chart or group clarifies the relationship between the results of the remeasurements and the timing of the interventions As HEDIS and CAHPS measures became part of accreditation, NCQA retired QIAs from the program. Standardized Measurement Is the Preferred Approach For years, health insurers have been using HEDIS and accreditation to improve the quality of care they administer. The Secretaries should allow insurers to report their accreditation status, performance on individual standards and HEDIS measures results to meet reporting requirements. NCQA can also report this health insurer quality information directly to the Secretaries. Overall, allowing insurers to use current quality reporting mechanisms will continue to drive improvement, foster further standardization and comparability, and save resources. When insurers report quality measures and prepare for accreditation review they can find weaknesses and strategies for improvements. We can see these improvements over time by tracking the measure results. For example, in plans that report HEDIS, children today are nearly three times as likely to have all Page 6 of 7

7 recommended immunizations as in 1997; diabetics are twice as likely to have cholesterol controlled as in 1998; and more than 97% of heart attack patients get beta-blockers up from 62% in A value of HEDIS and standardized quality measures is that it provides comparable data for analyzing widespread regional differences in health care quality. For example, NCQA annually calculates benchmarks for HEDIS measures that allow for plan to national and regional comparisons. It helps to identify high performing areas and quality improvement strategies that do work. That, in turn, can help identify and promote best practices that are most successful for improving quality and encourage insurers to constantly search for ways to improve the delivery of health care. Standardized requirements and measurements can also help consumers understand what plans do to improve quality. The apples-to-apples comparisons of quality through HEDIS and accreditation can help consumers choose the best plans. It also provides a solid basis for paying insurers based on how well they do at keeping enrollees healthy instead of just on how much they spend on care. Page 7 of 7