Measuring Measuring Quality In Quality In

Health CareHealth Care

Linda K. SheltonAssistant Vice

PresidentProduct Development

OverviewOverview

• Who is NCQA

• Ways We Assess Quality

• How We Develop Measures

• What Measurement Can Do

• 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

NCQA Assessment ProgramsNCQA Assessment Programs

• Managed Care Organizations

• Preferred Provider Organizations

• Managed Behavioral Healthcare Organizations

• Disease Management Organizations

• Physician Organizations

• Credentials Verification Organizations

NCQA Assessment ProgramsNCQA 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

Ways We Assess Quality: Standards

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.

Ways We Assess Quality: Measures

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.

How We Select MeasuresHow 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

What Makes a Good MeasureWhat Makes a Good Measure

RelevanceMeaningful

Health importance

Financial importance

Cost-effectiveness

Strategically important

Controllability

Variance among systems

Potential for improvement

FeasibilityPrecisely specified

Reasonable cost

Confidential

Logistically feasible

Auditable

Scientific Soundness

Clinical Evidence

Reproducible

Valid

Accurate

Case-mix Adjustment/Risk Adjustment

Comparability of data sources

What Measurement Can DoWhat Measurement Can Do

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

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

39.5

51.6

63.870.5

75.3

0

20

40

60

80

100

1997 1998 1999 2000 2001

Chicken Pox Immunization Rates: 1997 - 2001

Chicken Pox Immunization Rates: 1997 - 2001

Accredited vs. Non-Accredited Plans

Accredited vs. Non-Accredited Plans

7772 79

72

5850

8378

0

20

40

60

80

100

Breast CancerScreening

CholesterolScreening

Controlling HighBlood Pressure

Diabetes Care:HbA1c Testing

2001 Clinical Performance, Accredited vs. Non-Accredited:

Commercial Sector

Accredited Non-Accredited

Measurement Leads to Improvement Measurement Leads to Improvement DPRP-Recognized Physicians vs. the MCO Average

Percent of patients receiving recommended test, level of control

71

43

78

8

98

48

43

41

68

72

84

0 20 40 60 80 100 120

Eye Exam

Lipid Control (<130mg dl)

Monitoring forNephropathy

Poor HbA1c*Control (>9.5%)

HbA1c Testing

DPRPHealth plan averageMedicare FFS

* A lower percentage is better for this measure

IncentivesIncentives

• 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

What Are the Benefits of Public Reporting?

What Are the Benefits of Public Reporting?

46

25

70

48

61

4754

36

0

20

40

60

80

AdolescentImmunizations

ChildhoodImmunizations

Cholesterol Control Diabetes Care: EyeExams

2001 Clinical Performance, Public Reporters vs. Non-Public Reporters: Commercial Sector

Public Non-Public

HealthChoices™ Health PortalHealthChoices™ 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

Health Plan Report CardHealth Plan Report Card

• Recognized physicians receive:

– A certificate of recognition

– Performance reports with comparative data

– Referrals through 1-800-DIABETES; NCQA, ADA Web sites

– Preferential reimbursement?

Financial Rewards for QualityFinancial 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

NCQA’s Quality Dividend Calculator

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