Continuous Improvement and the Expansion of Quality Measurement

Transcription

1 Continuous Improvement and the Expansion of Quality Measurement T h e S t a t e o f H e a l t h C a r e Q u a l i t y

2 Continuous Improvement and the Expansion of Quality Measurement T h e S t a t e o f H e a l t h C a r e Q u a l i t y

3 2 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E This Report and the data contained herein are protected by copyright and other intellectual property laws or treaties. Unauthorized copying or use is prohibited. HEDIS is a registered trademark of NCQA. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. Portions of this report were prepared using select data provided by the Centers for Medicare & Medicaid Services (CMS) pursuant to a data use agreement. The contents of the report represent the sole views of NCQA and have not been approved, reviewed or endorsed by CMS or by any other federal agency by the National Committee for Quality Assurance. All rights reserved. Printed in the U.S.A. To order this or other publications, contact NCQA Customer Support at or log on to

4 T h e S tat e o f H e a l t h C a r e Q u a l i t y ta b l e o f c o n t e n T S 3 President s Message Introduction Executive Summary HEDIS Measures of Care Safety and Potential Waste Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Use of Imaging Studies for Lower Back Pain Relative Resource Use Wellness and Prevention Adult BMI Assessment Flu Shots for Adults Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening Medical Assistance With Smoking and Tobacco Use Cessation Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack Comprehensive Diabetes Care Controlling High Blood Pressure Cholesterol Management for Patients With Cardiovascular Conditions Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis Use of Appropriate Medications for People With Asthma Use of Spirometry Testing in the Assessment and Diagnosis of COPD Pharmacotherapy Management of COPD Exacerbation Annual Monitoring for Patients on Persistent Medications Antidepressant Medication Management Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Measures Targeted at Children and Adolescents Appropriate Treatment for Children With Upper Respiratory Infection* Lead Screening in Children* Ambulatory Care: Emergency Department Visits Prenatal and Postpartum Care & Frequency of Ongoing Prenatal Care Chlamydia Screening in Women Follow-Up After Hospitalization for Mental Illness Appropriate Testing for Children With Pharyngitis Well-Child Visits in the First 15 Months of Life and in the Third, Fourth, Fifth and Sixth Years of Life Adolescent Well-Care Visits Children and Adolescents Access to Primary Care Practitioners Follow-Up Care for Children Prescribed ADHD Medication Childhood Immunization Status Immunizations for Adolescents Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents * As part of the Pediatric Quality Measures Program, states are working with AHRQ and CMS to report Children s Initial Core Set measures at the state level in order to assess the quality of Medicaid and CHIP. All measures in this section except the two noted are in the Children s Initial Core Set.

5 4 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Measures Targeted at Older Adults Fall Risk Management Medication in the Elderly Management of Urinary Incontinence in Older Adults Physical Activity in Older Adults Glaucoma Screening in Older Adults Osteoporosis Testing in Older Women Osteoporosis Management in Women Who Had a Fracture Consumer and Patient Engagement and Experience Methodology Overview Appendices HEDIS Effectiveness of Care Measures: 2010 National HMO Averages HEDIS Effectiveness of Care Measures: 2010 National PPO Averages CAHPS Member Satisfaction Measures: 2010 National HMO Averages CAHPS Member Satisfaction Measures: 2010 National PPO Averages Accredited vs. Nonaccredited Plans: 2010 Commercial HMO Averages Accredited vs. Nonaccredited Plans: 2010 Commercial PPO Averages Accredited vs. Nonaccredited Plans: 2010 Medicaid HMO Averages Accredited vs. Nonaccredited Plans: 2010 Medicare HMO Averages Accredited vs. Nonaccredited Plans: 2010 Medicare PPO Averages Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial HMOs Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial PPOs Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicaid HMOs Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare HMOs Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare PPOs HMOs vs. PPOs, Commercial Plans HMOs vs. PPOs, Medicare Plans HMOs vs. PPOs, Commercial Plans HMOs vs. PPOs, Medicare Plans Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial HMOs Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial PPOs Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicaid HMOs Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare HMOs Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare PPOs References Acknowledgments

6 T H E S TAT E o f H E A l T H C A R E Q U A L I T Y P R E S I D E N T s M E S S A G E 5 PRESIDENT s MESSAGE Dear Colleague: Every autumn, NCQA updates the nation on how consistently health plans deliver high-quality care. This, our 15th State of Health Care Quality Report, is a snapshot of an industry that is moving in the right direction, but has opportunities for further improvement. We find encouraging signs of rising quality. Across diverse measures of care, performance is improving, and insurers can be proud of what they have accomplished. We also note that some insurers are not reporting and that for some measures, we have not seen the gains in performance we would like. Three features distinguish this year s report. First, it is longer than in past years because it includes, for the first time, comparisons between HMOs and PPOs across all measures. That we are able to fill a report with PPO data tracked over time is a significant step in quality s story. Not long ago, few PPOs quantified or disclosed results. Now, measurement and transparency are more common, though there is room to add more PPO reporting. The rising tide of PPO reporting is a credit to PPOs that have worked hard to fashion themselves into data-driven organizations that collect and report results. Their willingness to evaluate themselves and be transparent is a boon to consumers, a third of whom are enrolled in PPOs. A second distinct feature of this report is a focus on longer-term trends a departure from our usual concentration on one-year changes in performance. In a fast-paced society where attention spans seem to grow ever shorter, it s easy to overlook the cumulative benefits of determined, incremental gains. Yet stepping back to look at the long term confirms that the industry has come far. The data show that insurers commitment to measurement, transparency and accountability has, over the years, improved care, saved lives and reduced suffering. Finally, this report looks ahead to consider how quality measurement can help address what is arguably our country s most ominous long-term threat ballooning health care costs. It is important to grasp that the most insidious cost problems are often problems of quality extra costs resulting from preventable medical errors, overtreatment and ineffective care. An

7 6 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E increasingly common response to the cost crisis is to drop coverage or increase deductibles, a reaction that can also be understood as a quality issue. After all, not having coverage is the ultimate quality gap. Reducing care as the main strategy for containing costs is a siren s song: it might seem irresistible or inevitable, but it is ultimately destructive. A more sustainable approach is to stretch our health care dollars and get better results by emphasizing a value agenda. This report identifies ways that health plans can be catalysts to transform health care from a system that prizes volume to one that emphasizes value. In particular, we call on health plans to redefine their roles to take advantage of existing tools that can spur and complement delivery system reforms. These changes are important because value s delicate intersection of cost and quality is no longer just nice to have; it s a necessity. Thank you for your interest in these vital topics. And thank you for doing all you can to improve the state of health care quality.

8 T H E S TAT E o f H E A l T H C A R E Q U A l I T y I N T R o D U C T I o n 7 INTRoDUCTIon NCQA produces The State of Health Care Quality Report every year to call attention to key quality issues the United States faces and to drive improvement in the delivery of evidence-based medicine. This report documents performance trends over time, tracks variation in care and recommends quality improvements. Thousands of consumers, health insurance executives, benefits managers, policy makers, academics, consultants and journalists read this report. More than 1,000 health plans voluntarily disclose the clinical quality, customer experience and resource use data that are the report s foundation. All data are rigorously audited. Consumer experience information is independently collected and verified. We commend all the health plans that contributed data for this report, and for the commitment to accountability and quality improvement that they show in opting to disclose their performance results publicly. Electronic copies of this report are available free of charge at NCQA s Web site, Printed copies are available for purchase by calling We appreciate your interest in these topics and welcome your feedback. You can reach us at communications@ncqa.org.

9 8 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E E x E C U T I V E S U M M A Ry The Healthcare Effectiveness Data and Information Set (HEDIS ) continually changes to capture better information and new medical knowledge and to reflect purchaser and consumer needs. HEDIS was developed by forward-thinking employers and quality experts in the late 1980s; since the early 1990s, it has been the national standard for health plan performance reporting. NCQA s goal is for HEDIS measures to have strong evidence and be meaningful, valid and practical. With the addition of preferred provider organization (PPO) performance results to HEDIS, we can now compare PPOs with HMOs. We consider these comparisons some surprising, many encouraging to be the key findings of this year s State of Health Care Quality report. PPOs on the Rise, Show They Improve by Measuring, Too With some exceptions, commercial HMO performance is typically higher than PPO performance. One reason may be that HMOs have traditionally had more tools to manage care: care coordination processes, selective contracting and more bargaining power over providers. Differences in information collection or populations could be factors, as could benefit design. HMOs usually have lower cost sharing for services than PPOs, and higher PPO cost sharing might reduce use of recommended services. That said, some PPOs offered by health plans that also offer HMOs perform very well. Differences between HMOs and PPOs in how they collect data for hybrid measures have traditionally made it difficult to compare results. But there are indicators where PPOs perform at virtually the same level as HMOs for example, in the Use of Appropriate Medications for Asthma measure. PPOs are catching up on other measures, as well, by making bigger year-toyear gains. Interestingly, there are also performance differences between commercial HMOs and PPOs for some patient experience measures. Many readers will recall that health plan members preferred PPOs to HMOs because of fewer restrictions and larger networks. In 2005, PPO members were more likely to give a high rating than HMO members were. But times have changed, and there is a widening gap in performance: in 2010, HMO results were 6 percentage points higher than PPO results. The gap might be related to the rise in cost sharing including deductibles for PPOs.

10 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 9 One example where HMO results are higher than PPO results is in the share of members who rated their health plan a 9 or 10 on a 10-point scale. Figure 1. PerCEntage of CoMMErCIal HMO and PPO MEMbers Who Rate their Plan 9 or 10, HMO PPO Performance patterns between Medicare HMOs and PPOs are quite different. While HMOs outperform PPOs on some measures, PPOs outperform HMOs on several others, notably on measures related to drug therapy and monitoring. For example, on Pharmacological Management of COPD Systemic Corticosteroids, the average Medicare PPO rate is 69.6 percent and the average Medicare HMO rate is 66.6 percent. Medicare has required HMOs and PPOs to report the same quality measures. The Medicare star rating system that will send additional payments to high-performing plans is neutral to whether a plan is a HMO or PPO. These policies may be driving higher PPO performance in Medicare. Other reasons for higher PPO performance could be geographic differences or variations in the nature of the participating PPOs.

11 10 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Comparisons across product line Commercial, Medicaid and Medicare product measures reflect varying policy and population differences, but we can compare performance on measures reported by all product lines. On these measures, Medicaid performance tends to be worse than commercial or Medicare performance. Exceptions are Chlamydia Screening for Women and Persistence of Beta-Blocker Treatment After a Heart Attack. One reason for Medicaid s lower performance might be that its population faces challenging economic circumstances; for example, transportation to doctor appointments may be an issue. Even though this pattern holds for the overall population, we do see some Medicaid plans with very high performance, suggesting that some of the challenges of caring for this population may be surmountable. Medicare and commercial performance relative to each other varies by measure. Medicare outperforms commercial plans on several intermediate outcome measures and process measures. Comparison With Last Year s Findings Childhood immunizations In last year s State of Health Care Quality report, NCQA noted a significant drop in childhood immunizations in commercial health plans. This drop also appeared in the Centers for Disease Control and Prevention s national data. Reasons for the drop include widespread concern about the (disproven) potential for some immunizations to lead to autism; other explanations were the rise in cost sharing and the economic downturn. The 2010 data do not show a full recovery for commercial health plans. The Combination 2 Childhood Immunization Rate for commercial HMOs had a slight uptick, but the numbers were not statistically significant. Medicaid results held steady. There was a drop in the H influenza type B (HiB) immunization rate, which might have been caused by a temporary shortage of vaccine, and a small gain in the polio (IPV) immunization rate. Overall pattern 2009 to 2010 Although several measures showed important gains including Colorectal Cancer Screening, Use of Spirometry Testing in the Assessment and Diagnosis of COPD and Pharmacotherapy Management of COPD many measures showed little meaningful change. Commercial and Medicare PPOs displayed significant performance improvement and showed progress in closing the performance gap with HMOs.

12 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 11 HEDIS: Responding to Evidence and to Purchaser Needs Early quality measures were developed specifically for HMOs, and focused on use of recommended services. Today, measures are reported by other types of health plans, as well as some fee-for-service (ffs) programs like Medicaid. Public payers (Medicare, Medicaid and the Federal Employees Health Benefit [FEHB] program) and private payers (including those in the Evalu8 tool) use HEDIS measures. Figure 2. Eye Exams for diabetics MedICare Screening Rate HMO PPO NCQA now specifies HEDIS measures for individual clinician and clinician groups, using both conventional data sources and electronic health records (EHR). HEDIS the most widely used measures for ambulatory care includes measures of outcome; measures of overuse and resource use; and measures of care coordination. Outcome measures NCQA measures of outcome include intermediate outcome measures that reflect test results, as well as patient experience. They capture cholesterol control, blood pressure control and blood sugar (HbA1c) control in diabetics. Patient experience of care measured through the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) is another important measure of outcome.

13 12 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Top 10 and Bottom 10 States Location, location, location is not only the mantra of the real estate industry it s relevant to health care, too. Past editions of the State of Health Care Quality Report showed that quality varies by Census Bureau region. This year s analysis of top 10 and bottom 10 states is more specific: it shows that some states are outliers within their own regions. Cohort calculations of top 10, bottom 10 and middle 32 states include Puerto Rico and Washington, D.C. The calculations are based on mean rates of four measures: Comprehensive Diabetes Care (nine indicators), Controlling High Blood Pressure (one indicator), Persistence of Beta-Blocker Treatment After a Heart Attack and Cholesterol Management for Patients With Cardiovascular Conditions (two indicators). No state went from the top cohort to the bottom cohort (or vice versa) from 2009 to Top 10 cohort Middle 32 cohort bottom 10 cohort d Rose to 2010 cohort from 2009 fell to 2010 cohort from 2009 d d d d d d d d! d d d d d d d d

14 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 13 Quality Measurement and the Million Hearts Initiative Gains in HEDIS measures relevant to heart disease provide momentum for CDC s Million Hearts initiative. Millions Hearts launched in September 2011 and aims to prevent 1 million heart attacks in five years. Performance on six heart-related measures improved in the four years the measures held their current specifications five improved by almost three percentage points. These steady gains confirm that what gets measured gets improved, especially when measurement becomes a habit that insurers sustain. IMProvEMEnt in Measures related to Heart disease CoMMErCIal HMOs Mean Rate Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Persistence of Beta-Blocker Treatment After a Heart Attack Controlling High Blood Pressure* Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) Physical Activity in Older Adults Advice (MEDICARE HMOs) * Measure respecification in 2005 accounts for some of the performance change. Overuse and resource use HEDIS emerged during an era when consumers were concerned that HMOs would deny needed care. Initial HEDIS measures focused on transparency around the use of proven therapies and preventive care.

15 14 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E As health care spending skyrocketed and recognition of wasteful spending caught the nation s attention, NCQA invested in measures to prevent overuse. Examples of these measures are Imaging Studies for Low Back Pain and Avoidance of Antibiotic Treatments in Adults With Acute Bronchitis. NCQA s Relative Resource Use measures help purchasers determine which plans provide the highest quality of care with the lowest use of resources. Care coordination Many experts point to duplicate procedures and poor transitions between providers and settings as examples of wasteful spending and poor quality. Several HEDIS measures capture the results of care coordination and chronic disease management: Annual Monitoring of Patients on Persistent Medications and Follow-Up After Hospitalization for Mental Illness are two of them. NCQA is also developing measures, standards and programs to assess and recognize care coordination and case management. NCQA s Patient-Centered Medical Home (PCMH) program and new Accountable Care Organization (ACO) program aim to improve care coordination. They target the clinical practices and delivery system levels. Responding to the evidence NCQA works with clinical experts to develop and revise HEDIS measures based on evidence. Measures start with guidelines grounded in robust findings. When the evidence base changes, so do the measures. HEDIS measures for clinicians In response to requests for measures below the health plan level, NCQA collaborated with the American Medical Association to develop HEDIS physician measures that assess clinical performance of ambulatory practices. These measures are widely used in the Medicare Physician Quality Reporting System, the Meaningful Use programs and NCQA s Clinical Practice Recognition programs. The NCQA Diabetes Recognition program is supported by private sector initiatives, including the New York State Diabetes Campaign, led by the New York State Health Foundation. EHR measures NCQA is working closely with the Office of the National Coordinator for Health Information Technology, the Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum (NQF) to translate HEDIS measures into electronic formats. EHRs will simplify reporting of quality measures. They have the potential to apply clinical logic, based on quality measures, to improve care in different settings. They also create opportunities for developing measures that were previously set aside because of the burden of data collection.

16 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 15 Figure 3. Trends in ColorECtal CanCEr screening for CoMMErCIal HMOs, The Importance of Public Reporting in Improving Health Plan Performance Many health plans have stepped up to the challenge of collecting, reporting performance data and being held accountable. Plans disclosure of quality information using reliable, audited, standardized measures helps purchasers and consumers learn which plans and clinicians have the best results. NCQA credits public reporting and plans commitment to improving for the progress we have seen overall. The next section highlights significant gains in performance over time. Our discussion focuses on commercial HMOs, for which we have the longest series of data. We compare trends across plan types and product lines. Of the 32 HEDIS Effectiveness of Care measures, 23 show clear trends of improvement. While year-to-year gains are often quite small, they are steady over time. Only one measure showed unmistakable signs of worsening Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis. One example of progress is Colorectal Cancer Screening, with an almost 2 percentage point increase (to 62.6 percent) between 2009 and 2010 for commercial HMOs. Introduced in 2004,

17 16 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E this measure has shown steady gains. Similar gains have transpired for Medicare HMOs, although they have not reached the same level overall. Figure 4. Trends in HbA1c screening for People With diabetes for CoMMErCIal HMOs, HbA1c Screening for People With Diabetes, introduced with a suite of diabetes measures in 1999, is another example of growth. The screening rate has risen steadily over the past 11 years, progressing from 75 percent in 1999 to almost 90 percent in 2010 for commercial HMOs. We have seen similar gains across HMOs, PPOs and product lines, with Medicare performing best. Performance on Medical Attention for Nephropathy has more than doubled for commercial HMOs. From 36 percent in the first year, it rose to almost 84 percent in (The 2005 addition of ACE/ARB therapy to the measure s qualifying criteria accounts for some of the performance gain.) Like the HbA1c screening measure, all plan types, in all product lines, have experienced gains. Medicare HMOs had the strongest performance of all groups (89.2 percent) in 2010.

18 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 17 Figure 5. Trends in MedICal Attention for nephropathy for People With diabetes for CoMMErCIal HMOs, Health plans have shown steady increases on most consumer experience measures, which are based on a rating scale of Of seven CAHPS indicators, six showed consistent, gradual improvement. Health plans that report quality publicly and have earned NCQA Accreditation based on their performance should be applauded for achieving these gains. Public and private purchasers, including Medicare, have contributed to this effort by offering incentives for plans and providers to report and improve quality. Complementary policies can create even stronger improvement incentives. NCQA incorporates HEDIS results into accreditation levels and health plan rankings. Differentiating among health plans gives credit to the work of excellent performers and signals the results to consumers and purchasers. Even stronger incentives can flow from pay-for-performance programs, which are used by many Medicaid agencies and the Medicare Advantage (MA) program. Health plans with the best performance on quality might win additional payments; Medicaid plans might be assigned more

19 18 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E members. Purchasers that want to expedite performance gains may want to create incentives around measures where there has been little progress. Public reporting alone might not be a strong enough incentive to lead to change. The record on overuse measures is disappointing, and suggests other factors are at play. For example, we have seen virtually no change during the six-year history of Use of Imaging Studies for Low Back Pain. And although overuse of antibiotics leads to development of antibiotic-resistant strains of bacteria, performance on Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis has worsened, falling from almost 29 percent (successful avoidance) to 22.5 percent for commercial HMOs in One reason for this might be that providers have difficulty resisting patients demand for a pill to address symptoms. Implications: A Vision of High-Value Health Plans In the 1990s, many policy makers thought health plans were the vehicle to better quality of care and lower costs. The notion of managed competition underpinned the Clinton health reform proposals. Proponents envisioned that health plans would compete on cost, and drive consumer choice through transparency. HMOs would combine their insurance function with active management of patient care. Advocates saw opportunities to avoid emergency room use and hospital care by improving benefit design, networks and other programs. What happened instead was managed care backlash : members rebelled against limited provider networks and utilization review. 1 And the rise of self-insured employers led to increased contracting with PPO networks, rather than with full-risk-bearing HMOs. One big difference between earlier ideas about health reform and the 2010 Patient Protection and Affordable Care Act (PPACA) is an expectation that change should happen in the health care delivery system. The locus is the clinician s office and, to a lesser extent, the hospital. Programs like PCMH and the Meaningful Use of Health Information Technology (HIT) initiative push small practices to track patients care over time and across settings and to report and benchmark their performance against quality measures derived from medical evidence. The ACO program reflects this vision on a larger scale. The model involves a collection of clinician practices (and possibly hospitals) taking collective responsibility for improving patient care and lowering costs.

20 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 19 Changes to payment incentives will allow organizations to share savings for reducing unnecessary care. Proponents hope ACOs will invest in strategies and technologies to help patients manage chronic disease. The goal is to avoid emergency room and hospital care. Some might ask, if the delivery system embraces better coordination, patient management and integration, why do we need health plans? How do health plans add value if physicians and hospitals deliver better care? What can health plans do? It is worth noting that health plans will continue to be the entities holding insurance risk. Organizations committed to delivery system innovations will likely be wary of holding full insurance risk and managing population health. Thus, health plans will continue to serve this important purpose for some payers. Health plans have experience managing insurance risk and are regulated by states to ensure stability and financial soundness. They hold reserves and have processes to account for claims that have been incurred but not recorded; they can pool risk and access commercial reinsurance policies. They have data that enable analysis of services and use predictive modeling to target interventions like case management to high-risk populations. Health plans offering coverage in Medicaid, Medicare and Exchanges (2014) will have to bear financial risk. They also will have roles in benefit and coverage design, as well as collecting and reporting quality results. The following section describes a value agenda for health plans and suggests a vision for highvalue health plans. NCQA sees a strong role for health plans to nurture and promote changes at the delivery-system level. Fostering delivery-system reforms Health plans can lead or partner with other payers (employers, Medicaid, Medicare) to sponsor PCMH and ACO projects. They can change payment methods to encourage these programs, set participation standards and offer technical support. Health plans can also work with hospitals to implement safety initiatives and reduce readmissions. Health plans can provide data to practices to help them manage and coordinate care. They can offer incentives to invest in and use HIT, can explain the benefits of these innovations to members and can identify participating providers.

21 20 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Designing benefits and coverage Most recent changes in benefit design have involved setting coverage limits and increasing cost sharing through higher deductibles. However, health plans and purchasers can collaborate to develop benefits that encourage members to select care that improves their health and deter members from using services that are dangerous or ineffective. An application of this idea is value-based insurance design. It reduces cost sharing for services with the greatest value; for example, proven preventive care and maintenance therapies for chronic conditions. Another example is reference pricing, which steers physicians and patients to the most effective treatments by tying reimbursement for an item or service to the price of the most effective treatment. Less effective treatments are still covered by the plan, but members pay more for them. Collecting data from claims, enrollment, patients and medical records Health plans ability to aggregate data creates opportunities to report on care for their populations and for practices. Because of their size and experience, health plans can manage a diverse group of patients across sites of care. 2 George Isham, medical director of Health Partners in Minnesota, identified key areas where health plans contribute: Paying, collecting and aggregating bills. Billing records describe patients conditions and the care they received. Combined with enrollment information from pharmacies and laboratories, and extracts from medical records, these records form the basis of quality measurement. Collecting data and using it to inform the three-part aim in the National Quality Strategy (better care, healthy people/healthy communities and affordable care). Plans know how to turn information into quality measures. Cultivating transparency and displaying information for the public. Hospitals and nursing homes are becoming accustomed to transparency, but it is still rare among physicians and in outpatient settings. Small numbers and a lack of specialty care measures have hindered progress. Physicians and their representatives have not embraced public performance reporting. Developing quality improvement projects. Health plans have significant experience helping providers improve care. Collaborating to develop innovations in performance measurement and data analysis. Health plans have had success identifying high-risk patients and deploying inventive case management.

22 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 21 Putting the network together ACOs may eventually become health plans. Short of that, they may serve as the provider network for an employer- or provider-sponsored Medicare Advantage or Medicaid plan. But many purchasers need to offer coverage across a state or even across the country and health plans must assemble entire networks to meet this need. Health plans can use cost sharing to guide patients to high-value hospitals and providers. They can identify hospitals that are Centers of Excellence for treating high-cost or high-risk conditions. Then, they can make them preferred providers with the lowest cost sharing for patients. This approach could also reward hospitals or other providers that have strong patient safety records. The high-value plan of the future should rely heavily on value metrics to select its network. Ensuring that members have access to physicians with good credentials is an important part of consumer protection and of NCQA Health Plan Accreditation. But excellent health plans must also measure the performance of providers. They must use that information to build networks and report the information to consumers. Activating patients Because health plans will continue to hold risk and enroll members, they are uniquely situated to connect with patients and make them active partners in their health and wellness. Plans could pursue the following strategies to engage patients. Conduct wellness and health promotion through health appraisals and other strategies. Use financial incentives to encourage participation in programs designed to improve health. Smoking cessation and weight loss are two examples. Incorporate benefit design incentives that promote the best care and providers. Publicly report provider performance and involvement in delivery system reforms. Provide members with incentives to use decision aids to choose therapies. Cover palliative and end-of-life care and implement strategies to ensure that providers know and follow patient preferences and decisions. Survey enrollees about their experiences and how they rate providers. Then, use this information to provide feedback to physicians and construct networks. Make other options available to patients who opt out of ACOs.

23 22 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Health plans serving low-income patients and those with multiple chronic conditions also can invest in care management, which concentrates the focus on providing or connecting patients to health care and other service providers. While some of this work is moving to the delivery system, small clinical practices may not have the resources to invest in dedicated staff to do this work; health plans can either provide it or make available care coordination to share across multiple practices. How do we get health plans to high value? NCQA s experience has demonstrated that what gets measured gets improved. Many of our expectations for health plans could be turned into performance measures or standards, allowing health plans to review programs and policies against clear, detailed program elements. We have developed several programs that let high-performing health plans earn NCQA Recognition or NCQA Distinction. Most recently we created a distinction program for plans committed to improving multicultural care. Pay for performance might be successful in furthering the value agenda by awarding higher payments to plans that demonstrate high value. Many state Medicaid agencies have such programs; the Medicare Advantage program will soon, as well. Measures of health plan value could be added to that program or used to give health plans extra credit. Additionally, the Exchanges created by the PPACA could direct participants into plans that offer value. High-value plans could be visibly rewarded on the Exchanges report cards or listed prominently on the national Web portal. Information about high-value plans could be presented when consumers are first comparing plans. However, Exchanges must be mindful of choice fatigue, which can result from consumers having too much information and too many options. Exchanges can be architects of choice that guide people toward better value and quality, but the success of health reform depends on galvanizing consumers, not overwhelming them. Regardless of the specific approach, policy makers and purchasers should seize opportunities to work with health plans. Collaboration can improve health care and markets.

24 T H E S TAT E o f H E A l T H C A R E Q U A l I T y E x E C U T I V E S U M M A R y 23 Conclusion The Dartmouth Group has shown that cost and quality do not have to be a trade-off, but how do we get to affordable, quality health care? We must focus on buying value in health care, but the politics are challenging. Our current marketplace is fractured; providers have different approaches for working with each sector. Patients are confused and vulnerable, and appeals to their fears have succeeded. It is challenging in this environment to implement strong, synchronized strategies to improve coordination and delivery of care. Health plans can be drivers of improvements to cost and quality in health care markets. As market makers, they should pursue strategies to activate and engage members. Leading-edge health plans devote significant resources to keeping their members healthy. Health plans need to construct value choices at the provider level so patients do not overpay and are not over-treated or victims of medical errors. NCQA s objective in seeking a value agenda is to advance the triple aim improving the individual s experience of care and the population s health, and reducing the overall cost of care. Ultimately, consumers hold the power to reshape insurance markets. The concept of a new insurance marketplace, facilitated by Exchanges, flows from the premise that consumers will be motivated to compare health plans. Measures based on CAHPS and HEDIS are a logical place to start. Endnotes 1. Draper, D.A., R.E. Hurley, C.S. Lesser, B.C. Strunk The Changing Face Of Managed Care. Health Affairs, Jan-Feb;21(1): Enthoven, A The History and Principles of Managed Competition. Health Affairs, Vol 12, Supplement 1,

25 24 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS MEASURES of CARE About HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by most HMOs and PPOs plans to measure performance on important dimensions of care and service. By providing objective, clinical performance data measures against a detailed set of measurement criteria, HEDIS helps purchasers and consumers compare health plans performance. HEDIS measures address a broad range of important health issues: Antibiotic use Asthma Breast, cervical and colorectal cancers Care for older adults Childhood immunizations Cholesterol management Diabetes High blood pressure Medication management Mental illness Smoking Prenatal and postpartum care HEDIS includes the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 4.0 Survey. The CAHPS survey measures members experiences with their health care in areas such as claims processing and getting needed care quickly, and asks them to rate their health plan on a scale of HEDIS 2011 data collected for this report generally reflect services delivered during calendar year To ensure validity of HEDIS results, certified analysts rigorously audit all data, using a process NCQA designed. See the appendices for more details about national averages and performance trends. Hos Measures Medicare Health Outcomes Survey (HOS) measures evaluate the physical and mental health of seniors enrolled in Medicare and are the first patient-based self-report of health status as a measure of quality of care in elderly populations. Including HOS in HEDIS measurement creates a broader scope of measures to evaluate the quality of care provided by health plans for the Medicare population. Included in this report are four HOS measures:

26 T H E S TAT E o f H E A l T H C A R E Q U A l I T y H E D I S M E A S U R E S o f C A R E 25 Fall Risk Management Management of Urinary Incontinence in Older Adults Osteoporosis Testing in Older Adults Physical Activity in Older Adults. Terms NA: Measure rates have no available data. In some instances, data are not collected for a measure in a product line. Rate: The statistical mean for reported data. Each measure is described by an average rate for each applicable product line. A Note on Medicare Survey Data Medicare CAHPS survey data of consumer experience and HEDIS measures collected through the survey (such as Flu Shots for Adults and Medical Assistance With Smoking and Tobacco Use Cessation) are not available when NCQA prints the State of Health Care Quality Report in September. NCQA will issue an updated version of this report that includes those data in November.

27 26 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E AvoIDANCE of ANTIbioTIC TREATMENT IN ADUlTS WITH ACUTE bronchitis S a f E T y A N D P o T E N T I A l W A S T E Acute bronchitis clinically presents as a cough lasting more than five days (typically, from one to three weeks). About 90 percent of cases are caused by a virus. 1,2 The Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis measure evaluates whether adults were treated appropriately by not receiving antibiotics, which are not indicated and may contribute to antibiotic resistance. Acute bronchitis affects approximately Diminished effectiveness of antibiotics 5 percent of U.S. adults annually and against bacterial infections, particularly continues to rank among the top 10 for use in patients who may need them conditions for which patients seek treatment to fight future, life-threatening bacterial in clinical settings. 1 infections, poses a significant public health concern. When resistance makes widelyused antibiotics ineffective, an alternative Antibiotics are prescribed in more than 60 percent of bronchitis cases; of those, 80 treatment may not be available, 7 or percent were unnecessary, according to the physicians may use more potent antibiotics, Centers for Disease Control and Prevention which are often more toxic and more (CDC) guidelines. 1,2 Antibiotic treatment expensive. This can result in longer hospital is not usually appropriate for acute stays, more serious side effects and bronchitis, with the exception of comorbid increased financial burden on the system diseases requiring antibiotics. 3 and on patients. 8 The Case for Improvement More than $1.1 billion is spent annually on unnecessary antibiotics for respiratory infections in adults. 4 Treating drug-resistant pathogens poses a significant burden on the system through repeated health care visits and greater risk of disease complications and hospitalizations which lead to increased health care costs. 5,6 HEDIS Measure Definition This measure assesses the percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or three days after an episode. A higher rate indicates better performance.

28 T H E S TAT E o f H E A l T H C A R E Q U A l I T y H E D I S M E A S U R E S o f C A R E 27 Results Antibiotic treatment is only infrequently appropriate for acute bronchitis. Misuse or overuse can be avoided by prescribing treatment when necessary, as well as informing patients and clinicians regarding the appropriate use of antibiotics. TreatMEnt Rate Year HMO PPO HMO PPO HMO NA NA NA NA NA NA NA NA NA NA 28.0 S a f E T y A N D P o T E N T I A l W A S T E

29 28 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E USE of IMAGING STUDIES for LoWER back PAIN S a f E T y A N D P o T E N T I A l W A S T E Back pain is one of America s most common medical problems. An estimated 75 percent 85 percent of Americans will experience back pain at some point, 1 and approximately 25 percent of Americans will experience at least one day of back pain during any three-month period. 2 Although imaging is used to diagnose the cause of low back pain, it is costly and ineffective. Less than 1 percent of radiographs identify a specific cause of low back pain. 3 The Use of Imaging Studies for Low Back Pain measure assesses the number of patients with lower back pain who did not get an X-ray, MRI or CT scan as part of their treatment. Although a variety of minor injuries and The Case for Improvement conditions can lead to back pain, most On average, patients with low back pain acute low back pain is benign and selflimiting. Imaging studies are not required with back pain spend an average of have higher overall medical costs. Patients for diagnosis. 8 $7,211, while comparable patients without back pain spend an average of $2,400 Studies have shown that patients treated over a two-year period. Patients with low without imaging experience no difference back pain who opt for surgery incur an in health outcomes. 4,5 Abnormalities average of $34,000 in direct medical costs. 8 discovered through imaging were as common in individuals without back pain According to the Agency for Healthcare as they were in individuals with low back Research and Quality (AHRQ), almost pain. 4 18,000 Americans sought medical attention for low back pain in Additionally, Imaging for early, acute low back pain medical care for these individuals cost can lead to surgery. Complications from approximately $35 billion dollars, with unnecessary surgery can prolong back imaging driving much of the cost. 6,7 pain or lead to permanent disability. 5