1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

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1 Comments on Framework for Reform of Sustainable Growth Rate To House Energy & Commerce Committee And House Ways & Means Committee By National Committee for Quality Assurance Chairman Upton, Chairman Camp, Subcommittee Chairman Pitts, Subcommittee Chairman Brady and Subcommittee Vice Chairman Burgess, thank you for the opportunity to comment on your Committees framework for reforming the Sustainable Growth Rate (SGR). The National Committee for Quality Assurance (NCQA) is a private, non-profit organization that for more than 20 years has worked to improve health care quality and value through measurement, transparency and accountability. Our Health Care Effectiveness Data and Information Set (HEDIS ) 1 is one of the most widely used health plan and provider quality measurement tools in the nation. SGR Conundrum and Support for Medical Homes. We agree with your Committees conclusion that reoccurring SGR fixes are not sustainable and could undermine provider and beneficiary confidence in the Medicare program. We also agree that the underlying fee-for-service payment system is a driver of fragmented care and high costs, and that over time providers should be encouraged to move toward payment and delivery models that reward high-quality, efficient care. You have proposed a phased approach that would: Phase 1: Establish updated payment rates and repeal the SGR. Phase 2: Alter provider payment to reflect higher quality care. Phase 3: Alter provider payment to reward providers that deliver care more efficiently. We strongly recommend building federal financial support for Patient-Centered Medical Homes into Phase 2 research shows it is a proven model of primary care that improves coordination and patient satisfaction and lowers costs. We also have a new program to recognize specialty practices that demonstrate good care coordination and patient-centered care. Although this is a new program, you could ask the Secretary to explore including financial incentives for specialists who participate in it, perhaps through a pilot that could become permanent if proven successful. Under fee-for-service, Medicare has not paid clinicians to collaborate with patients, engage staff in a team-based approach or coordinate across the spectrum of health care. It is essential for Congress to revise Medicare s physician payment system to reward clinicians who show that they coordinate care by become a Patient-Centered Medical Home and deliver high-quality, efficient care. 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2 Specific Payment Changes and Medical Homes. There are different ways to support PCMHs through the proposed changes to the SGR. Clinicians in recognized PCMHs could receive higher annual payment updates following the stabilization of rates in Phase 1. Another option is to create a code to make annual or monthly per capita payments to practices, similar to what many privatesector PCMH initiatives do now. These policies could be coupled with an existing incentive program like the value-based payment modifier or the physician quality reporting system as long as those programs continue. We encourage your Committees to identify ways Medicare could pay updates, bonuses or other quality-related payments to practices instead of to individual clinicians. Good care is a team sport that includes all members of a care team working together at a practice. This is why NCQA s PCMH program evaluates practices rather than individual clinicians. Your Committees should also consider similar payment adjustments to the Medicare and Medicaid Electronic Health Record Incentive programs, which pay eligible providers bonuses for adopting and meaningfully using Health IT. Deeming PCMHs for Meaningful Use. NCQA PCMH standards are carefully aligned with meaningful use requirements. We have written many elements of meaningful use directly into our program: both help improve quality and efficiency through better coordination and data sharing. However, current statutory requirements for meaningful use bonuses are specific to individual providers, whereas NCQA PCMH Recognition is specific to clinical sites. We encourage Congress to revise current law to allow deeming of all providers in a recognized PCMH as meeting meaningful use requirements and to allow for the payments (or penalties) to be administered at the practice level. This would reduce burden on both providers and regulators and encourage more providers to transform their practice into PCMHs. Verifiable Quality Measurement System. As your Committees explore new quality and efficiency measurement programs under Phases 2 and 3, we strongly encourage you to emphasize the development of systems that are verifiable or auditable. Many private-sector physician and health plan measurement programs include audit processes that increase the reliability, accuracy and, in turn, usefulness of quality data for things like pay-for-performance. NCQA has learned this through years of experience rigorously auditing quality measurement data from health plans, and we firmly believe that quality-reporting systems can be accurate but streamlined, to limit the reporting burden. Recognizing the potential for error and variation, it is important to use independent, external audits and to install safeguards for training, certification and supervision of auditors to ensure the integrity and overall utility of measurement programs. Increasing Payment for Primary Care. We urge your Committees to investigate raising payment for primary care services in such a way that would align it with payment for specialty care. The country is facing a significant primary care provider shortage moving into the 2014 expansion of coverage. Inadequate payment is not the only cause of this problem, but it plays a key role. Additional money for primary care through PCMH-like programs are a good start, but we also encourage your Committees to strongly consider broader reforms that would raise payment for primary care services across the board. 2

3 3 NCQA PCMH Recognition. Our PCMH recognition program is by far the most successful tool for improving the quality and efficiency of primary care. In its first 3 years it has helped more than 25,000 clinicians at more than 5,300 sites transform their practices into what patients want primary care to be. That means: Patients have long-term partnerships with clinicians and enhanced access during and after office hours and through online communication, instead of a series of sporadic, hurried visits. Patients collaborate in their care, which makes care more patient-centered and sensitive to culture and language, and based on shared decisions, so they make more informed choices and get better results. Clinician-led teams coordinate care, with an emphasis on preventing and managing chronic conditions across settings, including specialty clinicians, facilities such as hospitals and emergency departments, and community supports, as needed. Public and private organizations in more than 35 states and the District of Columbia already use our PCMH program as a basis for rewarding physicians who deliver high-quality, patient-centered and efficient care. There are three levels of NCQA Recognition; they are based on how well practices meet our rigorous yet practical criteria. Many insurers pay additional fees based on recognition level, and some sponsor practices in their networks to become NCQA-Recognized PCMHs. 36 States* Have Public and Private PCMH Initiatives That Use NCQA Recognition * Includes the District of Columbia

4 4 Our program is practical, consensus based and built on solid research about how to provide the best primary care. It is flexible and applicable to a wide spectrum of practices, regardless of their size. NCQA PCMH Practices by Size and Level as of 2/13/ Total Level Level Level Total Growing Evidence for PCMH Benefits. There is a growing body of evidence documenting that this model of care saves more than it costs. PCMHs are especially good at reducing costly, preventable hospital and emergency department admissions. They also improve both patient and provider satisfaction. Specifically, we have seen that: PCMH initiatives in Colorado, New York and New Hampshire have led to lower costs, improved adherence to evidence-based medicine or a return on investment for the health plan. 2 PCMHs in New York deliver better preventive care and disease management and use resources more efficiently, compared with non-pcmhs. 3 Several other state Medicaid programs are seeing promising costs and quality trends with improved access to care. 4 PCMH improves patient satisfaction and reduces provider burnout. 5 Growing Interest in PCMH Recognition. Because of these results, interest in our program is growing rapidly, with more than 150 additional practices applying for recognition each month. Most states have adopted policies and programs to advance medical homes. 6 A growing number of private insurers United, Aetna, Cigna, Centene, among others offer incentives or sponsor practices in their networks to obtain recognition. 2 Raskas, Latts et al. Early Results Show WellPoint s Patient-Centered Medical Home Pilots Have Met Some Goals for Costs, Utilization, and Quality. Health Affairs September : DeVries et. al, Impact of Medical Homes on Quality, Healthcare Utilization, and Costs, American Journal of Managed Care September 2012, 18(9): Takach, Reinventing Medicaid: State Innovations To Qualify And Pay For Patient-Centered Medical Homes Show Promising Results, Health Affairs, July The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction and Less Burnout for Providers. Soman, Health Affairs, May

5 5 Other parts of the federal government are actively promoting PCMHs: The Department of Defense is helping its primary care practices become NCQA-Recognized PCMHs. The Health Resources Services Administration is helping 2,500 community health centers become PCMHs. The Centers for Medicare & Medicaid Services is rewarding up to 500 Federally Qualified Health Centers to transform into PCMHs. The Center for Medicare & Medicaid Innovation also has two PCMH-related initiatives underway. Options that public and private insurers use to promote NCQA PCMH Recognition include: Paying practices more, based on recognition level. Sponsoring practices to become PCMHs by covering recognition costs. Educating members about PCMH benefits, featuring PCMHs in provider directories and lowering cost sharing when members get care at PCMHs. In fact, many private-sector payers find the medical home concept so successful they are expanding from pilots to full-blown programs. Congress also should make PCHMs a permanent part of Medicare as it revises the physician payment system to get higher quality, efficient care. PCMH 2011: Raising the Bar. NCQA closely monitors all comments and suggestions about our PCMH program so we can continually strengthen it. The PCMH 2011 program incorporates feedback and experience from three years of evaluating practices. It reflects greater clarity, specificity and challenging criteria. These changes raised the bar in several important respects by: Making medical homes more responsive to patient needs by incorporating a PCMH-specific Consumer Assessment of Health Plans Providers and Systems (CAHPS ) 7 survey and other information to engage patients and families in quality improvement. Emphasizing language and culturally sensitive facets of care. Focusing on integrating care management and behavioral healthcare. Helping pediatric practices by addressing such topics as parental decision making, ageappropriate immunizations and teen privacy. Evaluating Specialists Quality. Through our experience with the medical home, we have learned that specialists and primary care providers often do not communicate effectively. This creates a system where tests are duplicated, inappropriate referrals are frequent and patients fall through gaps in care. That is why we are launching a new Patient-Centered Specialty Practice (PCSP) Recognition program in March, which will operate similarly to the PCMH recognition program but will focus on improving communication and care coordination among specialists and other providers. The PCSP program could be a useful tool for your Committees as you consider mechanisms to evaluate specialists quality of care. Strong, evidence-based quality measures do not exist for many 7 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

6 areas of specialty care and the measure development process can take time. Evaluating specialists quality through our rigorous PCSP standards could serve as a bridge until additional standardized measures can be developed. Supporting Medicare Advantage (MA) Plans that Sponsor New Care Models. NCQA recently published preliminary results showing that MA plans are performing better on many HEDIS measures tied to bonus payments. 8 We encourage the Committees to explore ways of supporting MA plans that help providers move to new models of care and deliver higher value for their members. This could include additional financial incentives or highlighting the MA plans that support these new models on the MA plan-finder Web site. Conclusion. NCQA strongly urges the Committees to continue their work to revise Medicare s physician payment system to actively promote and reward recognized PCMHs and PCSPs. The evidence for PCMH success, substantial growth in recognized practices, and broad private-sector interest clearly demonstrates that PCMHs are a powerful way to improve quality while reducing costs. Taxpayers who support Medicare and the beneficiaries who rely on it deserve no less. Thank you again for the opportunity to comment on the proposed framework for reforming the SGR. If you would like more information about the NCQA PCMH Recognition program or about any other NCQA programs, please contact our Vice President of Public Policy and Communications, Sarah Thomas, at thomas@ncqa.org or at (202) Sincerely, Margaret O Kane President 8