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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. HEDIS 101

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

15. 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

16. 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

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

18. 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

19. 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

20. Collecting HEDIS Data

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

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

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

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

25. HEDIS Compliance Audit

26. 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

27. 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

28. Structure & Process Measures

29. 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

30. 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

32. 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.

33. 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:

34. 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

35. 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

36. 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, 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.

37. 2009 SNP Measures Requirements

38. 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

39. 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)

40. 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.

41. 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

42. 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.

43. 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

44. SNP Data & Reporting

45. 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

46. 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

47. 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)

48. 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

49. And now…
Questions?

50. Contacts
Brett Kay Director, SNP Assessment Casandra Monroe Assistant Director, SNP Assessment

51. 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)
Login.asp
HEDIS Audit information

52. Additional Information
HEDIS 2008 Volume 2 Publication Purchase
October Specifications Update

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

54. 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 :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

55. 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 :30 – 2:00 pm
April 7th :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