Introduction to NCQA & SNP Assessment Brett Kay Director, SNP Assessment Casandra Monroe Assistant Director, SNP Assessment

Purpose of Training Provide brief overview of NCQA Describe the SNP assessment program NCQA is executing on behalf of CMS Give a general understanding of main components of SNP assessment HEDIS® measures Structure & Process measures

A Brief Introduction to NCQA 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: Mission and Vision To improve the quality of health care Vision To transform health care through measurement, transparency and accountability 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: COMMITTED TO MEASUREMENT, TRANSPARENCY, ACCOUNTABILITY NCQA’s quality programs include: Accreditation of health plans using performance data HEDIS clinical measures CAHPS consumer survey Measurement of quality in provider groups Physician Recognition Quality measurement means: Use of objective measures based on evidence Results that are comparable across organizations Impartial third-party evaluation and audit Public Reporting

Achieving the Mission 3 out of 4 Americans enrolled in an HMO are in an HMO accredited by NCQA More than 90 percent of managed care organizations report HEDIS® quality data 38 states and the federal government rely on NCQA Accreditation and HEDIS More than 12,000 physicians have earned NCQA Recognition; programs form the basis of quality improvement programs and P4P nationwide

SNP Assessment: How did we get here? Existing contract with CMS to develop measures focusing on vulnerable elderly Revised contract to address SNP assessment 1st year—rapid turnaround, adapted existing NCQA measures and processes from voluntary Accreditation programs 2nd year—focus on SNP-specific measures 3rd year—Refine measures; identify new SNP-specific measures, where appropriate

Objectives of SNP Assessment Program Develop a robust and comprehensive assessment strategy Evaluate the quality of care SNPs provide Evaluate how SNPs address the special needs of their beneficiaries Provide data to CMS to allow plan-plan and year-year comparisons

Three-Year Strategy Phase 1 - FY 2008 Phase 2 - FY 2009 SNPs Effective as of January 2007 SNPs Effective as of January 2008 HEDIS 2008 (13 measures) HEDIS 2009 (15 measures) Addition of two 1st year measures: Care for Older Adults; Medication Reconciliation Post-Discharge HEDIS 2010 Measure development: Potentially Avoidable Hospitalizations Inpatient Readmissions MDS measures (I-SNPs) Disease-specific measures (C-SNPs) Structure & Process Measures SNP 1: Complex Case Management SNP 2: Improving Member Satisfaction SNP 3: Clinical Quality Improvements SNP1 – 3 SNP 4: Care Transitions SNP 5: Institutional SNP Relationship with Facility SNP6:Coordination of Medicare & Medicaid Refinement of existing S&P measures, includes the potential development of new elements Potential development of new measures Phased Approach Phase 1: Development of Structural & Process measures based on existing NCQA Accreditation standards; subset of existing HEDIS measures Phase 2: Development of outcomes measures with a focus on SNP-specific HEDIS clinical measures and S&P measures Phase 3: Refine existing measures; continue to develop SNP-specific HEDIS and S&P measures Focus on key areas for each SNP type

SNP Assessment: Phase I 2008 SNP Data Collection Successfully Completed 340 HEDIS submissions 432 Structure & Process submissions Draft SNP Report sent to CMS September 30 Final Report to CMS—April 2009 Reassessment Plans with 50% or less on any element 72 plans requested reassessment Revised scores sent to CMS SNP specific HEDIS measures released in HEDIS 2009 Volume 2

Project Time Line – Phase II March - Release final S&P measures March 30 - Release ISS Data Collection Tool S & P Measures April - Release IDSS Data Collection Tool HEDIS Measures June 30 - HEDIS submissions and S&P measures submissions due to NCQA October 30 - NCQA delivers SNP Assessment Report to CMS

Training & Education Five training topic areas, focus is on content and data submission Introduction to NCQA & SNP Assessment Program SNP Subset of HEDIS Measures Interactive Data Submission System (IDSS) Structure & Process Measures Phase I (SNP 1-3) Phase II (SNP 4-6) Interactive Survey System (ISS)

HEDIS 101

What Is HEDIS? Healthcare Effectiveness Data & Information Set HEDIS is an evolving set of standard specifications for measuring health plan performance

Where Did HEDIS Come From? Originally developed by employers and the HMO group in 1991; NCQA took charge of HEDIS in 1992 Expanded in 1996 to cover all three product lines: commercial, Medicare and Medicaid Addresses the leading causes of death Includes information on quality, utilization and cost

How Are HEDIS Data Used? Federal, state and other regulatory requirements State of Health Care Quality report Performance-based accreditation Health plans use for RFP/RFI preparation Quality improvement activities and health plan operations Quality Compass, Quality Dividend Calculator US News and World Report - Ranking of Health Plans

Data Reporting Data are reported to NCQA in June of the reporting year Data reflect events that occurred during the measurement year (calendar year)

Data Reporting Example: HEDIS 2009 data are reported in June 2009 Data reflects events that occurred January–December 2008 (per specs) HEDIS 2009 = 2008 data

Effectiveness of Care Measures Clinical quality of care Focus Preventive care Up-to-date treatments for acute episodes of illness Chronic disease care Appropriate medication treatment

Collecting HEDIS Data

Three HEDIS Data Sources Claims Encounter Eligibility Provider Medical records Surveys Administrative

Data Sources Administrative Membership data Provider data Claims/encounter data Hospital discharge data Pharmacy data Carve-out data

Selecting an Eligible Population Member ID Age (DOB) Enrollment date and type Dates of service Diagnosis and procedure codes Provider specialty Pharmacy

Clinical Measures Data Collection Defining the denominator is critical Administrative: Claims and encounter data Denominator: Based on all eligible members of the population

HEDIS Compliance Audit

NCQA HEDIS Compliance Audit A standardized audit methodology for verifying the reliability of HEDIS data collection and rate calculation processes Outcome is whether or not a measure is reportable

Why a Standardized HEDIS Audit? Data collection and calculation methods can vary across plans A standardized audit identifies, quantifies and converts errors The audit reduces bias

Structure & Process Measures

What is a S&P Measure? A statement about acceptable performance or results Assesses a plan’s ability to comply with specific requirements Focus on systems necessary for quality care Policies & procedures, reports, materials

How are S&P Measures Developed Similar to HEDIS measures development Initial literature review and evidence Measurement Advisory Panel (GMAP) Diverse set of expert stakeholders Technical expert panels also formed, if necessary Pilot tests to determine feasibility, burden Public comment Final Approval from GMAP and CMS

Components of the S&P Measures Standard statement: a statement about acceptable performance or results Intent statement: A sentence that describes the importance of the S&P measure Element: The component of the measure that is scored and provides details about performance expectations. NCQA evaluates each element within the measure to determine the degree to which the SNP has met the requirements within the S&P measure.

Components of an S&P Measure Factor: An item within an element that is scored (e.g., an element may require an organization to demonstrate that a specific document includes 4 items. Each item is a factor). Scoring: The level of performance the organization must demonstrate to receive a specific percentage on each element (100%, 80%, 50%, 20%, 0%) Data source: Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA requires 3 types of data sources for S&P assessment:

Data Source Types Documented Processes: Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization Reports: Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports of analysis; system output giving information; minutes; and other documentation of actions that the organization has taken Materials: Prepared materials or content that the organization provides to its members and practitioners, including written communication, Web sites, scripts, brochures, review and clinical guidelines

Components of an S&P Measure Scope of Review: The extent of the organization’s services evaluated during an NCQA survey. Scope of review may vary Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element Explanation: Guidance for demonstrating performance against the element Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

Look-Back Period FAQs Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within that this timeframe? The look-back period is the three-month period prior to survey submission—March 31, 2009 to June 30, 2009. All documentation must be current as of the look-back period but it could have been developed before that time. For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.

2009 SNP Measures Requirements

SNP Assessment Process Phased Approach Defining and assessing desirable structural characteristics Assessing processes Assessing outcomes Two main components HEDIS Measures-focus on clinical performance Structure & Process measures-focus on structural characteristics and systems

SNP Assessment Process S&P Measures assessment Data collection through Web-based Interactive Survey System (ISS) data collection tool. Several levels of review: Off-site Review (Level 1) Executive Review (Level 2) Final Eyes (Level 3)

S&P Assessment: What’s New for 2009 Plan Comment Period b/w level 2 & 3 review Plans will have an opportunity to provide additional information to clarify issues from original submission materials Quick turnaround: plans will have to respond to NCQA requests for more information rapidly One-time opportunity: Only chance plans have before data is finalized and sent to CMS. There will not be a reassessment like Phase I.

S&P measures: What’s New for 2009 SNP 1-3: Added 2 new elements SNP 2C: Improving member satisfaction Focus on implementing interventions to address member satisfaction issues SNP 3B: Clinical measurement activities Focus on collecting, analyzing relevant clinical data Identifying opportunities for improvement based on data analysis Existing elements: added more examples and clarified explanations

S&P measures: What’s New for 2009 SNP 4: Care Transitions All SNP Types Focus on how SNPs manage planned and unplanned transitions of care for members SNP 5: Institutional SNP Relationship with Facility (I-SNPs only) Focus on ensuring SNP members in Institutional facilities receive comprehensive quality care SNP 6: Coordination of Medicare and Medicaid Different requirements for Duals and I&C SNPs Focus on helping members obtain benefits/services regardless of payer.

New Phase II HEDIS Measures Care for Older Adults (COA) Medication Reconciliation Post-Discharge (MRP) Hybrid Method Collection All SNPs operational as of 1/1/08 will have to report the new S&P measures Cohort I SNPs (reported in 2008) will not have to report S&P 1-3 Cohort II SNPs will have to report Phase I and Phase II S&P measures All SNPs that meet enrollment criteria (30+ members as of January 2009

SNP Data & Reporting

Data Submissions HEDIS measures S&P measures Submission date: June 30, 2009 IDSS data collection tool All data must be audited by NCQA certified HEDIS auditor S&P measures ISS data collection tool No Fees required to submit

Who Reports HEDIS measures S&P measures All SNP plan benefit packages with 30+ members as of February 2008 Comprehensive Report (CMS website) S&P measures All SNP plan benefit packages Plans with no enrollment exempt from certain elements

What to Report S&P measures Cohort I—All SNPs operational as of January 1, 2007 and renewed in 2009. S&P measures 4-7 (SNP 2:C & 3:B) Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009 All S&P measures (SNP 1-6) Do not report SNP 7 (SNP 2:C & 3:B)

What happens after submission? NCQA Analysis of HEDIS and S&P measures Comparison to MA plans (HEDIS) and to other SNPs Demographic (size, type, region) Statistical significance Deliver report to CMS CMS will make all decisions about how to use the data NCQA will not publicly report any of the SNP data

And now… Questions?

Contacts Brett Kay Director, SNP Assessment 202-955-1722 kay@ncqa.org Casandra Monroe Assistant Director, SNP Assessment 202-955-5136 monroe@ncqa.org

Additional Resources NCQA SNP Webpage: www.ncqa.org/snp.aspx FAQs (HEDIS) Training descriptions & schedule Final HEDIS and S&P measures (March 14) NCQA Policy Clarification Support (PCS) http://app04.ncqa.org/pcs/web/asp/TIL_Client Login.asp HEDIS Audit information http://www.ncqa.org/tabid/204/Default.aspx

Additional Information HEDIS 2008 Volume 2 Publication Purchase http://www.ncqa.org/tabid/78/Default.aspx October Specifications Update http://www.ncqa.org/Portals/0/PolicyUpdates/HEDIS%20Technical%20Updates/2008_Vol2_Technical_Update.pdf

Additional SNP Trainings Introduction to NCQA & SNP Assessment March 5th 1:00 – 3:00 pm March 10th 1:00 – 300 pm

Additional SNP Trainings SNP Subset of HEDIS Measures March 3rd 11:30 – 1:00 pm March 11th 11:30 – 1:00 pm March 16th 1:00 - 2:30 pm March 26th 1:00 - 2:30 pm April 1st 12:30 - 2:00 pm Structure and Process Measures (S&P 1-3) March 12th 1:00 – 2:30 pm March 19th 1:00 - 2:30 pm March 25th 12:30 - 2:00 pm April 23rd 2:00 – 3:30 pm

Additional SNP Seminars Structure and Process Measures (S&P 4-6) March 17th 2:00 - 3:30 pm March 24th 2:00 - 3:30 pm March 31st 2:00 - 3:30 pm April 2nd 12:30 – 2:00 pm April 7th 2:00 - 3:30 pm April 15th 1:00 – 2:30 pm Interactive Survey System (ISS) April 8th 1:00 – 2:30 pm April 14th 1:00 - 2:30 pm April 17th 1:00 – 2:30 pm April 21st 1:00 - 2:30 pm April 28th 1:00 – 2:30 pm May 7th 1:00 – 2:30 pm