1. Holding Health Plans & Providers Accountable for High-Quality, Patient-Centered Care January 23, 2015

2. 2 NCQA History NCQA – a non-profit that since 1990 has worked with federal, state, consumer & business leaders to improve quality Our Mission – To improve health care quality Our Vision: Transform health care through: – Measurement – Transparency – Accountability

3. 3 Holding Plans & Providers Accountable Health Plan Accreditation Clinical Quality Measures (HEDIS) Patient Experience Measures (CAHPS) Pay-for-Performance Patient-Centered Medical Homes Patient-Centered Specialty Practices Accountable Care Organizations

4. 4 Health Plan Accreditation NCQA accredits plans with strong consumer protections & high quality – Access/experience of care – Quality improvement initiatives – Verifying proper provider credentials – Appropriate denial & appeal practices – Helping enrollees understand/use coverage & manage their own health & health care NCQA “look-back period” ensures that policies are enforced, not just on paper Must Pass!

5. 5 Performance-Based Accreditation HEDIS & CAHPS quality scores calculated for each plan & then: – Determine accreditation level Accredited, Commendable, Excellent – Translate to report cards for comparing plans http://www.ncqa.org/ReportCards.aspx – Support pay-for-performance Medicare Advantage, many states & employers pay plans & providers based on quality scores – Determine annual Consumer Reports ratings

6. 6 HEDIS Clinical Measures Healthcare Effectiveness Data & Information Set® The most widely used & respected tool for measuring quality 70 + measures of proven, effective care – Wellness and prevention – Chronic disease management – Children, adults and older adults – Overuse, waste/resource use Continuously updated for new scientific evidence and to “raise the bar”

7. 7 CAHPS Patient Experience Measures Consumer Assessment of Health Providers & Systems Survey asks how well plans & providers meet patient needs (‘experience of care’) – How often did you get appointments/care as soon as you thought you needed? – Did customer service give you help you needed? Treat you with courtesy and respect? – Did your doctor listen carefully? Explain things in a way that was easy to understand? Spend enough time with you?

8. 8 Quality Measures & Physician Payment Reform How Measures are Used Pay for Performance – MA Stars, most Medicaid, many private plans Accreditation Scoring – 50% of NCQA plan ratings – Required for Marketplace/Exchange plans ID, prioritize & target improvement efforts – Critical for ACOs, other delivery system reforms Always evolving! – For new evidence & to raise the bar – Moving toward patient-reported outcomes

9. 9 Pay-for Performance (P4P) Payment based on quality & service as in Medicare Advantage – Bonuses to highest-rated 4/+ Star plans Total $2.2B in 2015 for better benefits/lower costs 5 Star plans get continuous enrollment – New enrollees outside open enrollment Poor performers (<3 stars) – Flagged on plan finder – No enrollment via plan finder – Enrollees encouraged to switch plans – Plans can be terminated from the program

10. 10 ACA Bonuses Drive both Enrollment & Improvement 40% of Medicare Advantage plans have 4 Stars or more for 2015 – Significant improvement on many measures :  Advising smokers to quit, body mass index, colorectal cancer screening, controlling high blood pressure 60% of enrollees will be in 4+ Star plans – A 31% increase since 2012 when P4P began – Average premium paid rising just $1.30 as enrollees move to bonus-fueled low cost plans

11. 11 Quality Measures & Physician Payment Reform Colorectal Cancer Screening

12. 12 Quality Measures & Physician Payment Reform Patient-Centered Medical Home Transforming Primary Care Into What Patients Want It To Be Long-term partnerships, not hurried visits Coordinated care among providers Better access - expanded hours and online Shared decisions so patients make informed choices, get better results Lower costs from reduced ER/hospital use More satisfied patients and providers

13. 13 Quality Measures & Physician Payment Reform Patient-Centered Specialty Practice Compliments PCMHs to improve often weak primary/specialty care coordination: – Timely access to care/same-day appointments – Agreements on sharing information with primary care providers – Managing care for individuals & populations – Coordination with facilities on care transitions and post-discharge follow-up

14. 14 Quality Measures & Physician Payment Reform Accountable Care Organizations Builds on PCMH foundation to coordinate care across all health care settings – Payment based on both quality & efficiency, instead of just the volume of services Accreditation assesses essential core capabilities for ACO success – Standards are prescriptive when essential, i.e. patient privacy – Otherwise flexible to accommodate different types of ACO structures

15. 15 NCQA’s ACO Accreditation We specifically score ACOs on: – PCMH foundation – Patient protections, including privacy – Ensuring access to & availability of care – Care management & coordination capabilities – Monitoring practice patterns & using data to improve quality – Decision support to help patients/providers ID best care – Stakeholder participation, structure, contracting, payment arrangements