1. Measuring Quality In Health Care Linda K. Shelton Assistant Vice President Product Development

2. Overview Who is NCQA Ways We Assess Quality How We Develop Measures What Measurement Can Do

3. Private, non-profit health care quality oversight organization Measures and reports on health care quality Unites diverse groups around common goal: improving health care quality

4. NCQA Assessment Programs Managed Care Organizations Preferred Provider Organizations Managed Behavioral Healthcare Organizations Disease Management Organizations Physician Organizations Credentials Verification Organizations

5. NCQA Assessment Programs Privacy Certification for Business Associates HEDIS Auditors and Software Vendors Organizations Providing Utilization Management or Credentialing Services Human Research Protection Diabetes Physician Recognition

6. Ways We Assess Quality: Standards On-site surveys: Reviews of the clinical and administrative systems necessary for quality care and service Web-based tools: Readiness evaluations and submissions of documents online, for efficient surveys We grade on performance against standards.

7. Ways We Assess Quality: Measures HEDIS ® : Specified, audited key measures of clinical effectiveness for health plans Diabetes Physician Recognition Program: Specified, audited key measures of diabetes care for physicians CAHPS ® 3.0H: A specified, audited survey used to measure members’ experience with the care and service they receive from health plans We grade on quantitative measures.

8. How We Select Measures Practice Guidelines Evidence-based medicine Minimum 2 years after recommendation to allow time for implementation Committee on Performance Measurement (CPM): includes industry, health plan, consumer and purchaser representatives Measurement Advisory Panels (MAPS): population and disease-specific experts

9. What Makes a Good Measure Relevance Meaningful Health importance Financial importance Cost-effectiveness Strategically important Controllability Variance among systems Potential for improvement Feasibility Precisely specified Reasonable cost Confidential Logistically feasible Auditable Scientific Soundness Clinical Evidence Reproducible Valid Accurate Case-mix Adjustment/Risk Adjustment Comparability of data sources

10. What Measurement Can Do

11. Chaos Gets Headlines... But It’s Not the Whole Story

12. Chicken Pox Immunization Rates: 1997 - 2001

13. Accredited vs. Non-Accredited Plans

14. Measurement Leads to Improvement DPRP-Recognized Physicians vs. the MCO Average Percent of patients receiving recommended test, level of control * A lower percentage is better for this measure

15. Incentives Public reporting—comparable measures on report cards Market share—purchasers demanding a level of measurable quality Financial rewards—direct payments for quality Competition—within and between organizations

16. What Are the Benefits of Public Reporting?

17. HealthChoices™ Health Portal Easy interface with the corporate intranet Customized version of the HPRC Listing of doctors and hospitals affiliated with health plan options Comprehensive, reliable health content Specific company benefit information

18. Health Plan Report Card

19. Recognized physicians receive: –A certificate of recognition –Performance reports with comparative data –Referrals through 1-800-DIABETES; NCQA, ADA Web sites –Preferential reimbursement?

20. Financial Rewards for Quality Performance guarantees Return on investment Payments from purchasers to Providers Bridges logo here Bonuses from health plans to providers— California Pay for Performance

21. NCQA’s Quality Dividend Calculator Free, Web-based utility User enters general information about employee population, overall revenues Generates projected productivity gains (in terms of sick days, sick wages) from contracting with accredited plans