introduction to ncqa & snp assessment june 25 and 27, 2013

Introduction to NCQA & SNP Assessment

June 25 and 27, 2013

2SNP Training – Intro to NCQA & SNP Assessment Program

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 - Celebrating 23 years

• Committed to measurement, transparency and accountability

• Unites diverse groups around common goal: improving health care quality


NCQA: Mission and Vision

• Mission–To improve the quality of health

care

• Vision–To transform health care

through measurement, transparency and accountability


NCQA: COMMITTED TO MEASUREMENT, TRANSPARENCY,

ACCOUNTABILITYQuality measurement means:

• Use of objective measures based on evidence

• Results that are comparable across organizations

• Impartial third-party evaluation and audit

• Public Reporting

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• ACOs


Achieving the Mission• Over 70 percent of all Americans

enrolled in health plans that are accredited by NCQA

• More than 90 percent of managed care organizations report HEDIS® quality data

• 41 states and the federal government rely on NCQA Accreditation and HEDIS

• More than 42,846 clinicians and 5,804 practices* have earned NCQA Recognition; 6 programs form the basis of quality improvement programs and P4P nationwide

*As of 5/31/13


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


SNP Assessment Process• Year-to-Year 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


Year-to-Year StrategyFY 2008 FY 2009

SNPs Effective as of January 2007 SNPs Effective as of January 2008

HEDIS 2008 HEDIS 2009

Measure Development Measure Development

• 13 existing measures • 13 existing measures

• Introduced 2 new measures

-- Care for Older Adults

-- Medication Reconciliation Post-discharge

Structure & Process Measures Structure & Process Measures

• SNP 1: Complex Case Management • SNP 1-3

• SNP 2: Improving Member Satisfaction • SNP 4: Care Transitions

• SNP 3: Clinical Quality Improvements • SNP 5: Institutional SNP Relationship with Facility

• SNP 6: Coordination of Medicare & Medicaid


Year-to-Year Strategy

FY 2010 FY 2011




Same as 2009 • 15 existing measures

In development for 2011

Plan all-cause readmissions

Introduced 1 new measure

-- Plan all-cause readmissions

Structure & Process Measures Structure & Process Measures

Refinement of existing measures: SNP 4 & 6

Increased focus on evidence of implementation

Clarified requirements Moved analyses to separate elements


Year-to-Year Strategy FY 2012 FY 2013




• 16 existing measures • 16 existing measures Includes 14 Effectiveness of Care Measures plus:

--Plan all-cause readmissions

--Board Certification

Includes 14 Effectiveness of Care Measures plus:

--Plan all-cause readmissions

--Board Certification

• Clarified reporting requirements and methodology

Structure & Process Measures Structure & Process Measures Enhanced documentation requirements Clarified measure language Strengthened focus on quality

improvement and implementing interventions

• Changed requirements for SNP 1 from Case Management to Care Management—focus on assessment and individualized care plans

• Revised some existing requirements for SNP 2, SNP 3 and SNP 4


Project Time Line 2013

• June 17 – HEDIS submissions due to NCQA

• June & July – NCQA Releases 2013 Structure and Process measures in hardcopy and in ISS

• June through September– S&P Training for SNPs

• October 15, 2013 – S&P Measure submissions due to NCQA

• October 15, 2013 to April 30, 2014 - S&P reviews conducted by NCQA and Surveyors

• June 2014– NCQA Delivers Final Report to CMS

HEDIS 101


What Is HEDIS?

HealthcareEffectivenessData &InformationSet

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 causesof death and morbidity

• Includes information on quality, utilization and cost


How Are HEDIS Data Used?• Federal, state and

other regulatory requirements

• Performance-based accreditation

• Health plans use for RFP/RFI preparation

• Quality improvement activities and health plan operations


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 2013 data are reported in June 2013

–Data reflects events that occurred January–December 2012 (per specs)

–HEDIS 2013 = 2012 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 SourcesAdministrative

Medical Records

Surveys

Claims Encounter Eligibility Provider


Selecting an Eligible Population• Member ID • Age (DOB)• Enrollment date and type• Dates of service• Diagnosis and procedure

codes• Provider specialty• Pharmacy


• Defining the denominator is critical

• Administrative: Claims and encounter data– Denominator: Based on all eligible

members of the population

Clinical Measures Data Collection

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 measure development

• Initial literature review and evidence

• Geriatric Measurement Advisory Panel (GMAP)– Diverse set of expert

stakeholders– Technical expert panels

also formed, if necessary

• Pilot Tests/Public Comment– Determine

feasibility/burden– Input from

stakeholders• Final approval from

GMAP and CMS


Components of the S&P Measure

Components of the S&P Measure• Standard Statement

A statement about acceptable performance or results


Components of the S&P Measure

Intent Statement A sentence that describes the importance of the S&P measure


Components of the S&P MeasuresComponents of an S&P Measure

ELEMENT

FACTORS

SCORING

DATA SOURCES


Components of an S&P Measure

The period of time for which NCQA evaluates the SNPs documentation to assess performance against an element

The extent of the organization’s services evaluated during an NCQA survey.


Components of an S&P Measure

Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

Guidance for demonstrating performance against the element


Data Source Types

Documented Process

Reports

Materials


Data Source Types--Process

This policy applies to all ABC Health staff unless otherwise noted.

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Documented Process


Data Source Types--Reports

Report


Data Source Types—Reports (cont’d)


Data Source Types--Materials

Materials

2013 Assessment Against S&P Measures


SNP Assessment Process• S&P Measures assessment

– Data collection through Web-based Interactive Survey System (ISS) survey tool.

• Several levels of review:– Off-site Review (Level 1)– Executive Review/Plan Comment (Level

2)– Final Eyes (Level 3)– Final Stage Review (Level 4)


S&P Assessment• Plan Comment Period

– 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 to provide additional documentation before data is finalized and sent to CMS


S&P Assessment• Plan Comment Period (continued)

– If you have questions, please contact a SNP team member immediately

– Please ensure additional data submitted is within the look-back period or it will not meet the requirements


Final Stage Review• Occurs after plans receive

preliminary final scores• One last opportunity for review• Only for scoring inconsistencies

– Radio buttons and support text language differ

– Different scores for similar SNP PBPs • No new documentation will be

reviewed


Look-Back Period• What is the Look-Back Period & how does

it work?– The look-back period is the six-month period

prior to survey submission – April 15, 2013 to October 15, 2013. All documentation must be current as of the look-back period but it could have been developed before that time.

– Data used for reports can go back up to 1 year prior to submission, unless the explanation indicates otherwise.

– 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.


Who Reports• HEDIS measures

– All SNP plan benefit packages with 30+ members as of February 2012 Comprehensive Report (CMS website)

• S&P measures– All SNP plan benefit packages– Plans with zero enrollment are exempt

for certain elements


SNP Reporting• Returning SNPs— all SNPs that were

operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted.– SNP 1-6

• New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time.– SNP 1 A-D, SNP 2, SNP 4-6


2013 S&P Measures• SNP 1: Care Management – Major

changes to measure to align with MOC requirements– All SNP Types– Focus on assessment, individualized care

plans, how SNPs coordinate services and manage care for members

• SNP 2: Member Satisfaction – Added examples– All SNP Types– Focus on monitoring member satisfaction

to identify areas for improvement & take action


S&P Measures: What’s New for 2013

• SNP 3: Clinical Quality Improvement – revised methodology for calculating significant improvement to address small numbers– All SNP types– Focus on demonstrating quality improvement

• SNP 4: Care Transitions – Added new factor in Element E– All SNP Types– Focus on how SNPs manage and support

members through planned and unplanned transitions in care


S&P Measures: What’s New for 2013• SNP 5: Institutional SNP Relationship

With Facility – No major changes– I-SNPs only – Focus on how SNPs communicate with

facilities to monitor services and members’ needs

• SNP 6: Coordination of Medicare and Medicaid Coverage – No major changes– Different requirements for Duals and I & C

SNPs– Focus on coordination and administration of

benefits for Duals

SNP Data & Reporting


Data Submissions• S&P measures

– Submission date: October 15, 2013– ISS data collection tool– No Fees required to submit

– All SNPs that were operational as of January 1, 2012, AND renewed in 2013.

– Plans with zero enrollment are exempt for certain elements

NCQA will verify enrollment using CMS Comprehensive Report—publicly available enrollment data


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 regarding the

use of the data– NCQA will not publicly report any of the

SNP data


And now…

Questions?


ContactsBrett KayAssistant Vice President, SNP [email protected]

Casandra MonroeAssistant Director, SNP [email protected] JonesAssistant Director, SNP [email protected]


Contacts

Anthony DavisAccreditation Manager, SNP Assessment [email protected]

Nidhi DalwadiAccreditation Manager, SNP Assessment [email protected]


ContactsPriyanka OberoiAccreditation Manager, SNP [email protected]

Ling Chen Accreditation Manager, SNP Assessment 202-955-3548 [email protected]

Delia PonceCoordinator, SNP [email protected]


Additional Resources• NCQA SNP Webpage:

http://www.ncqa.org/snp• FAQs

– Training descriptions & schedule– Final HEDIS and S&P measures

• NCQA Policy Clarification Support (PCS)http://ncqa.force.com/pcs/login

• HEDIS Audit informationhttp://www.ncqa.org/tabid/204/

Default.aspx


Additional Information• HEDIS 2013 Volume 2 Publication

http://www.ncqa.org/Publications• Specifications Update

http://www.ncqa.org/Publications


Additional SNP Trainings• Introduction to NCQA & SNP

Assessment– June 25 ~ 2-4:00 pm– June 27 ~ 2-4:00 pm

• Structure and Process Measures (S&P 1-3)– July 9 ~ 2-4:00 pm– July 11 ~ 2-4:00 pm– July 16 ~ 2-4:00 pm


Additional SNP Trainings• Structure and Process Measures

(S&P 4-6)– July 18 ~ 2-4:00 pm– July 24 ~ 2-4:00 pm– July 30 ~ 2-4:00 pm

• Interactive Survey System (ISS)– August 6 ~ 2-3:30 pm– August 13 ~ 2-3:30 pm– September 12 ~ 2-3:30 pm


Additional SNP Seminars

• Open Door Forums– August 15 ~ 2-3:00 pm – September 10 ~ 2-3:00 pm – September 25 ~ 2-3:00 pm

introduction to ncqa & snp assessment june 25 and 27, 2013

Documents

snp assessment introduction

facility snp

snp assessment program

snp training intro

ncqa snp assessmentjune

care transitions snp

institutional snp relationship

member satisfaction