National Council on Aging Leveraging Quality Metrics to Increase … · 2019. 2. 4. · • Medicare publishes quality ratings of Medicare health and prescription drug plans which
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• 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
• 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
• 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.”
• 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?
• 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
• 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
• 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)
• 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.
• 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
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)
• 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.
• 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
• 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.
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
• 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.
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
• 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