1. Using Patient Experiences Surveys in Health Plan and Practice Evaluation Sarah Hudson Scholle Assistant Vice President, Research AHRQ 2009 Conference September 15, 2009

2. 2 AHRQ Research Conference 9/15/09 Agenda NCQA Health plan accreditation model and CAHPS Incorporating patient experiences surveys into evaluation of physician practices

3. 3 AHRQ Research Conference 9/15/09 Private, independent non-profit health care quality oversight organization founded in 1990 Committed to measurement, transparency and accountability Unites diverse groups around common goal: improving health care quality NCQA: A Brief Introduction

4. 4 AHRQ Research Conference 9/15/09 NCQA Health Plan Accreditation Key Components –Rigorous on-site review of key systems and processes –Evaluation of clinical performance through HEDIS ® measures –Member experience surveys - CAHPS ® 4.0H for adults and children

5. 5 AHRQ Research Conference 9/15/09 NCQA ACCREDITATION: BASED ON PERFORMANCE Clinical Performance (HEDIS) Member Experience (CAHPS) += 43% Health Plan Systems (Accreditation Standards) = 57% Accreditation is Performance-based: NCQA Accreditation is the only health plan Accreditation that requires reporting on clinical performance

6. 6 AHRQ Research Conference 9/15/09 What is NCQA’s HEDIS? The Healthcare Effectiveness Data and Information Set: Process and outcomes measures Standardized member experience surveys Used by commercial, Medicare, and Medicaid plans alike Allows plan-to-plan comparisons by quality, not just by price

7. 7 AHRQ Research Conference 9/15/09 CAHPS ® 4.0H Surveys Development and Reporting Quality Compass ® (plan-to-plan comparisons) State of Health Care Quality Report National CAHPS Benchmarking Database (NCBD) Other products—report cards, Quality Dividend Calculator, etc.

8. 8 AHRQ Research Conference 9/15/09 >14,000 physicians Recognized nationally across all Recognition programs Clinical programs – Diabetes Recognition Program (DRP) – Heart/Stroke Recognition Program (HSRP) – Back Pain Recognition Program (BPRP) Medical practice process and structural measures – Physician Practice Connections – Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) NCQA Recognition Programs 7534 physicians*2072 physicians*3440 physicians* 254 practices* 121physicians* 24 practices* 1001 physicians* 178 practices* * As of 7 /31/09

9. 9 AHRQ Research Conference 9/15/09 Goals for Physician Practice Connections (PPC) Evaluate systematic approach to delivering preventive and chronic care (Wagner Chronic Care Model) Build on IOM’s recommendation to shift from “blaming” individual clinicians to improving systems Create measures that are actionable for physician practices Validate measures by relating them to clinical performance and patient experience results

10. 10 AHRQ Research Conference 9/15/09 Theoretical Frameworks Informing Development of PPC-PCMH Based on best available empiric evidence in each area and on testing of reliability and validity of elements in field tests using on site audit as “gold” standard Chronic Care Model Patient Centered Care Cultural Competence Medical Home Clinical information Systems Decision Support Patient Self- Management Delivery System Redesign Community Linkages Health Systems Respect Patient Values Accessible Family-Centered Continuous Coordinated Community Linkages Compassionate Culturally Appropriate Emotional Support Information and Education Physical Comfort Quality Improvement Culturally competent interactions Language services Reducing disparities Personal physician Physician directed team Whole person orientation Care is coordinated and integrated Quality and safety Enhanced access PRIMARY CARE First contact-comprehensive-continuous-coordinated

11. 11 AHRQ Research Conference 9/15/09 Adapting PPC for the Patient-Centered Medical Home New PPC-PCMH version released in January 2008 – Aligned standards with Joint Principles – Incorporated critical attributes of PCMH – Defined foundational elements (“must pass” requirements) PPC-PCMH endorsed by ACP, AAFP, AAP, AOA, other specialties and PCPCC for use in demos Endorsed by National Quality Forum Sept 2008 (as “Medical Home System Survey”)

12. 12 AHRQ Research Conference 9/15/09 PPC-PCMH Content and Scoring Standard 1: Access and Communication A.Has written standards for patient access and patient communication** B.Uses data to show it meets its standards for patient access and communication** Pts 4 5 9 Standard 2: Patient Tracking and Registry Functions A.Uses data system for basic patient information (mostly non-clinical data) B.Has clinical data system with clinical data in searchable data fields C.Uses the clinical data system D.Uses paper or electronic-based charting tools to organize clinical information** E.Uses data to identify important diagnoses and conditions in practice ** F.Generates lists of patients and reminds patients and clinicians of services needed (population management) Pts 2 3 6 4 3 21 Standard 3: Care Management A.Adopts and implements evidence-based guidelines for three conditions ** B.Generates reminders about preventive services for clinicians C.Uses non-physician staff to manage patient care D.Conducts care management, including care plans, assessing progress, addressing barriers E.Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Pts 3 4 3 5 20 Standard 4: Patient Self-Management Support A.Assesses language preference and other communication barriers B.Actively supports patient self-management** Pts 2 4 6 Standard 5: Electronic Prescribing A.Uses electronic system to write prescriptions B.Has electronic prescription writer with safety checks C.Has electronic prescription writer with cost checks Pts 3 2 8 Standard 6: Test Tracking A.Tracks tests and identifies abnormal results systematically** B.Uses electronic systems to order and retrieve tests and flag duplicate tests Pts 7 6 13 Standard 7: Referral Tracking A.Tracks referrals using paper-based or electronic system** PT 4 4 Standard 8: Performance Reporting and Improvement A.Measures clinical and/or service performance by physician or across the practice** B.Survey of patients’ care experience C.Reports performance across the practice or by physician ** D.Sets goals and takes action to improve performance E.Produces reports using standardized measures F.Transmits reports with standardized measures electronically to external entities Pts 3 2 1 15 Standard 9: Advanced Electronic Communications A.Availability of Interactive Website B.Electronic Patient Identification C.Electronic Care Management Support Pts 1 2 1 4 ** Must Pass Elements

13. 13 AHRQ Research Conference 9/15/09 Examples of Initiatives Using PPC-PCMH Multi-payer - Colorado, Pennsylvania, Rhode Island State-wide – Pennsylvania, Vermont, Maine Single payer – EmblemHealth, Humana Government – Medicare, New York City, Louisiana

14. 14 AHRQ Research Conference 9/15/09 “Measures of Meaningful Use” inside How to further assess patient-centeredness, including patient survey results? – How to engage patients? – How to make name resonate positively? When should performance results be part of scoring? How to adapt to promote quality and cost gains across settings? – Primary care—subspecialty – Physician—hospital, other facilities How to streamline requirements, documentation? – For all practices – For practices renewing Significant PPC-PCMH Issues for Future

15. 15 AHRQ Research Conference 9/15/09 Timeline, Evolution of PPC-PCMH 2009 2010 Convene Advisory Committee; develop draft changes Solicit input: Website, calls, meetings Review draft changes with CPP; Public Comment Advisory Committee Rec’s CPP, BOD approval OctAprilJulyOctDec

16. 16 AHRQ Research Conference 9/15/09 Barriers to Incorporating Patient Experiences Results Lack of agreement on core content Whether existing tools are able to detect change in performance The burden of conducting patient experiences surveys Conflicting priority of accountability versus quality improvement goals Structure/process versus outcome scoring

17. 17 AHRQ Research Conference 9/15/09 Aims of Proposed Research Identify a core set of survey items Explore feasibility of alternative sampling and other data collection strategies Examine the impact of alternative scoring approaches in blending results from the PPC-PCMH and patient experience surveys

18. 18 AHRQ Research Conference 9/15/09 Getting to Core Set of Measures Identify possible domains/items – Access – Communication – Coordination – Shared decision-making – Self Management – Whole person orientation Ranking exercise involving broad stakeholder participation Review of psychometric properties Recommendations to PPC-PCMH review panel

19. 19 AHRQ Research Conference 9/15/09 Getting to Standardized Data Collection Profiles of existing efforts to collect, analyze and report patient experiences survey results – Purpose of survey – Unit of Analysis – Sampling – Data collection – Analysis – Quality assurance – Tool – Cost/Finance Review of literature on impact of different methods Recommendations to PPC-PCMH review panel

20. 20 AHRQ Research Conference 9/15/09 Summary Patient’s views are critical to evaluations of health care, both at health plan and physician level Standardized tools and methodology needed to allow fair, national comparisons Feasibility and relevance to key stakeholders must be addressed

21. 21 AHRQ Research Conference 9/15/09 For more information: Sarah Hudson Scholle, MPH, DrPH scholle@ncqa.org 202 955 1726 http://www.ncqa.org